A 65 YEAR OLD MALE WITH PALPITATIONS
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
A 65 year old male agricultural labourer by occupation came to emergency with chief complaints of palpitation since night.
HOPI: yesterday evening after having dinner
Patient slept in bed, the palpitations started at 8pm which is sudden in onset , persistent until 12 0 clock , aggravated on posture change relieved on it's own.
patient was apparently asymptomatic 25 years ago he developed stabbing type of chest pain localized to mitral and pulmonary area lasting for few minutes which is sudden in onset and diagnosed with heart disease(mitral stenosis) and had penicillin prophylaxis for 1 month , heart surgery was done after few years he had history of exertional palpitations (NYHA class 2) by doing weed cutting or little fast walking or by planting vigorously
H/o shortness of breath since 15 years, insidious in onset, progressive in nature aggravated with cold exposure especially in winter season ( January and February ) associated with dry cough during relieved by medication(inhalers)
Dyspnea is associated with palpitations(Mmrc 2or nyha2)
h/o chest pain from 10 years stabbing in character .
no h/o syncopal attacks
Past history:
History of hypertension since 5 years , stopped using medication since 2years
history of Diabetes since 5 year and stopped using medication since 2years
no previous hospitalizations due to dyspnea
H/o bypass surgery 5 years ago .
Personal history:
Dialy qctivities: patient gets up at 6 O clock eats rice with curry at 8 o clock goes to field which is 3 km away by walk slowly , he does the work( limited work )not as before and eats lunch at 20 clock tea and bun and comes to home at 5 o clock , he relaxes he eats dinner at 8 0 clock mainly rice with curry and sleeps at 9 0clock ., gets up in sleep for urination for 3 times ( no sleep disturbances ) .he eats pan daily from 30 years.
Family : No significant family history
Treatment history:
inhalation medication?( cause of palpitation?)
GENERAL EXAMINATION:
patient was conscious coherent and cooperative well oriented to time place and person
PALLOR: absent
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