1601006009
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A 45 year old gentlemen, from suryapet who owns a travels business , came to OPD with
CHIEF COMPLAINTS :
Palpitations since 3 days
Shortness of breath since 3 days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 3 days back then developed palpitations ,present at rest,fast ,paroxysmal in onset ,irregular lasts for 15 minutes associated with shortness of breath.
Shortness of breath since 3 days sudden in onset, progressed from grade 2 to grade 3 ,no aggravating factors, relieved spontaneously after 5 to 10 minutes
No history of -fatigue, -Cough , hemoptysis, -dysphagia ,hoarseness of voice -fever, sore throat - pain abdomen, vomitings
PAST HISTORY:
Patient had fever 2 months back and went to a local hospital in suryapet for which he was given some medication, after which he developed shortness of breath (grade 2 ), headache ,then he went to a hospital in Hyderabad where he was diagnosed to be having pneumonia and in course of treatment patient developed MI . Coronary angiogram and recanalisation was done and patient was put on anticoagulants, antipalatelets and discharged in hemodynamically stable condition and completely normal after discharge until 3 days back.
History of diabetes and hypertension since 10 years diagnosed on general health checkup for which he is on regular medication .
No history of TB,hypothyroidism,hyperthyroidism,asthma ,epilepsy.
FAMILY HISTORY:
Mother has history of hypertension
PERSONAL HISTORY:
Diet: mixed Appetite:normal Bladder & Bowel movements: regular Sleep : decreased since 20 days Addictions: no addictions
DRUG HISTORY: Antihypertensives: Telvas 40mg since 10 years Anti diabetics: tab metformin 500mg ,voglibose 0.2mg, glimeperide1mg Antiplatelets:aspirin, clopidogrel Statins:atorvastatin
GENERAL EXAMINATION:
A 45 year old patient who is well built and well nourished is conscious ,coherent,cooperative and comfortably seated,well oriented to time,place and person
There are no signs of pallor,icterus,cyanosis,koilonychia,generalised lymphadenopathy and pedal edema.
JVP not elevated.
VITALS:
Temperature:afebrile
Pulse: 90 bpm,regular,normal volume
BP: 100/80 mm hg on right upper arm in sitting position
Respiratory rate : 16 cpm abdominothoracic
SYSTEMIC EXAMINATION:
CVS:
INSPECTION:
Shape of chest: normal
Trachea : central in position
No precordial bulge
Apex impulse visible in left 5th intercostal space medial to midclavicular line
No visible left parastsrnal heave, epigastric pulsations,2nd ICS pulsations
No other pulsations seen
No scars,sinuses or dilated veins seen on any part of thorax
PALPATION:
All inspection findings confirmed.
Trachea central in position.
Apex beat in left 5th ICS 1cm medial to midclavicular line
AUSCULTATION:
MITRAL AREA:
Two heart sounds heard.S1 and S2
TRICUSPID AREA:
Two heart sounds heard,S1 and S2 which are normal
AORTIC AREA:
Two heart sounds are heard. S1 and S2.
PULMONARY AREA:
Two heart sounds heard. S1 and S2.
CENTRAL NERVOUS SYSTEM:
No facial asymmetry ,all reflexes are normal .
RESPIRATORY SYSTEM:
Normal Vesicular breath sounds heard, no adventitious sounds heard.
GIT:
No hepatosplenomegaly, no ascites.
INVESTIGATIONS
- Indirect ophthalmoscopy for hypertensive retinopathy
-Thyroid function tests
-serum electrolytes awaiting for results
ECG:
Chest xray:
PROVISIONAL DIAGNOSIS:
- Secondary to cardiac causes
?arrythmias
- Metabolic cause
?thyroid abnormality
- Neuro psychiatry cause
?anxiety
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