A 50 year old female 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.

CASE PRESENTATION 

A 50 year old female resident of Narketpally municipality worker by occupation came to the general medicine OPD (15-12-2022) with the chief complaints of
• palpitations since 3 days

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 3 days ago and then she developed palpitations which is sudden in onset,continous,even at rest which aggravates on walking and no relieving factors. 
No history of shortness of breath
No history of chest pain,dizziness 
No history of orthopnea, PND
No history of cough,abdominal distension,pedal edema

PAST HISTORY 
Not a known case of hypertension, diabetes mellitus, CVD,asthma,epilepsy. 

FAMILY HISTORY 
no relevant family history 

PERSONAL HISTORY 
Diet- mixed
Appetite - decreased 
Sleep- regular 
Bladder- regular 
Bowel- constipation (passes stools once in 2-3days)
Addictions- consumes toody occasionally (1litre)

GENERAL EXAMINATION 

patient is conscious, coherent, cooperative and well oriented towards time,place,person and malnourished.

Pallor - present
Right eye
 
left eye

No icterus,cyanosis, clubbing,lymphadenopathy 
vitals
Temperature - afebrile 
Blood pressure - 110/90nn of Hg
Pulse rate- 96bpm
Respiratory rate-18cpm
CVS EXAMINATION 

INSPECTION 
Shape of chest - bilaterally symmetrical 
No visible pulsations 
Keloid noticed over the left breast 

No sinuses

PALPATION 
No thrills,parasternal heaves

AUSCULTATION 
S1, S2 heard
No murmurs heard


RESPIRATORY SYSTEM

Shape of chest - bilateraly symmetrically 
Trachea position- central
Bilaterally air entry - present 
Normal vesicular breath sounds are heard.

PER ABDOMEN

Soft,non tender,no organomegaly 

CNS

No focal neurological deficit 

INVESTIGATIONS 

RBS - 103mg/dl
Uric acid  -5.4mg%
Serum creatinine- 0.8mg/dl
Blood urea - 32mg/dl
ECG on 14/12/2022 
2D ECHO 14-12-2022



15-12-2022 &16-12-2022

ECG ON 16-12-2022


DIAGNOSIS
Atrial fibrillation 
fast ventricular rate
Heart failure with preserved ejection fraction
Chronic AF?
 
TREATMENT 
T.Met xp50mg PO/OD
T.Ecosporin AV
hourly BP and heart rate monitoring 

DAY 3
S
palpitations decreased

O
Patient is conscious, coherent,cooperative 
Bp: 110/70 mm of Hg
PR:74bpm
RR:18cpm
Temperature: afebrile 
RBS: 105mg/dl
CVS:S1 S2 heard
BAE:present 
CVS: no focal neurological deficit 
Per abdomen: no tender,no organomegaly 
A
Atrial fibrillation with fast ventricular rate (resolved)
Heart failure with preserved ejection fraction
Chronic AF?(reverted to sinus rhythm)

P
T.Met xp50mg PO/OD
T.Ecosporin AV
hourly BP and heart rate monitoring 

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