49 Male with c/o palpitations
NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.
This is a case of 49 year old gentleman who came to OP with c/o palpitations since 7 years
BIRTH HISTORY:
Patient was born to non consanguinous marriage and at Gestational age of 7 months due to unknown complicationsand delayed labour , section was done and delivered.
And he's the eldest with two siblings.
CHILDHOOD HISTORY:
Since childhood, patient is having recurrent URTI for which his father(renowned cardiologist) used to give some bronchodilators and relieves within 3-4 days and these episodes occurs once in a while (3-4 months mostly) and more frequent and aggravates during winter season.
And at the age of 15 years, due to these recurrent URTI and recurrent(? Chronic) sinusitis , DNS surgery septoplasty was done. Since then his complaints were relieved.
20 years back, during a routine check up incidentally he was found to be having daibetes and since then he was started on Metformin 500mg twice daily
And around same time he was also found to be having high BP recordings and since then he was started on olmesartan 20mg once daily and atorvastatin 10mg once daily at night.
15 years back, patient complained of left sided parotid swelling for which he hasn't used any medication for 2-3 daily late which he gradually progressed to fever with chills, cough and landed in ? septicemia and also acute renal failure(serum creatinine of 1.9) for which he consulted and advised for IV antibiotics and given for one day and late shifted to oral amoxy clavulanic acid.
10 years back, patient had complaints of B/L loin pain for which he went to hospital and diagnosed with renal caliculi. He will be having these pain for 2-3 days once in every year.
8 years back, patient c/o pain during micturition, pubic pain, increased frequency, urgency +, but no incontinence or dribbling for 1 month and diagnosed to have ? BPH
Due to caliculi lodging at VUJ lead to moderate hydroureteronephrosis which was removed through cystoscopy under general anesthesia which was uneventful.
7 years back, when he was posted for exam paper evaluation , due to strenuous work, one day he felt like feverish and had feeling of shock through out the body which was first time in his life time and went to hospital due to this inconvenience ecg was recorded and diagnosed as Atrial fibrillation lasted for 15 mins and was given verapamil. Later after subsiding of episode he was discharged with amiodarone of 100mg twice daily for 3 days followed by 100mg once daily for 6 months and also clopidogrel 75mg was started.
Later he used to have this palpitations like episodes once in every 6 months which gradually increased frequency to once in every 3months
In 2019 , he consulted cardiologist as it is intervening with his routine life style, Ecg was taken and diagnosed as paroxysmal AF and started him on Tab flecanide 20mg twice daily, metoprolol 25mg which has been gradually increased to 100mg over a gradual course of time and Tab rivoroxaban 10mg once daily around 8pm.. With this medication too he used to have palpitation episode once in every 6 months.
From 1 year, when he is having this palpitation like episode he used to do vagal maneuver later which it subsides within 2 mins and no requirement of medication ( he won't take his regular medication if subsides)
4 months back, patient complained of burning micturition, hematuria and fever episode of 102°F and diagnosed as UTI and taken Amoxy clavulanic acid 625mg tablets for 5 days and all these symptoms were resolved.
ROUTINE LIFE STYLE :
His routine life style used to be, wakes up at 5:30 am which he completes his daily routine such as brushing teeth and gets ready by 6 am to go for Gym or walking for approximately 1 to 1:30 hr and lunch form 8-8:30 ,by 8:30 comes to college and till 1pm takes classes for students and at 1pm he will have lunch, he will have nap for 30mins and for 2-4 he will be attending practicals at lab, by 4pm he will reaches home, and 4-5pm takes dog for a walk, and come home at 5pm and watches TV for 1-1:30 hr, by 7pm he will get freshen up and have dinner by 8pm and goes to sleep by 9/9:30pm.
DIETARY LIFE STYLE:
morning for breakfast - he will have south Indian style such as idly, dosa, poori, uthappam etc.
Around 11am - for snacks he will have tea biscuit, fruits, etc
Around 1pm for Lunch: 2 roti, 1 cup of rice, 1 cup of dal, 1 vegetable curry and curd
He consumes Non veg diet for 3-4 times a week.
Around 5pm again he will have snacks such as biscuits, fruits etc
Around 8pm for dinner
For lunch - 2 roti, 1 cup of rice, 1 cup of dal, 1 vegetable curry and curd.
PRESENT COMPLAINTS:
Since 3 months, patient is complaining of tachycardia / palpitations around 5-5:30 am while waking up from sleep, Pulse rate will be around 110-120 for which he consumes medication and subsides with in 15mins Or when he do meditation, his palpitation episodes also reduced without any medication.
While having this episode of tachycardia he used to have 1-2 episodes of loose stools which subsides after episode was subsides.
And since 3 months he is complaining of reduced sleep duration of only around 4-5 hrs.. Difficulty in falling asleep though he goes to bed by 9pm .
He is also complaining of anxiousness while waking up from sleep and while passing urine at early morning there is a sudden rise in pulse rate and having palpiation episode. Though he is not complaining of any tremors, he is having a inner feeling of body shaking and generalised weakness of body. And also he is complaining of incomplete sensation of voiding of urine, dribbling of urine one exertion+ , no urgency , no hesitancy.
No c/o chest pain, sob, orthopnea, PND, syncopal episodes.
No H/o alchol, smoking.
FAMILY HISTORY :
FATHER - type 2 diabetes present
MOTHER - Type 2 diabetes, ? AF, CAD, CABG was done and also pacemaker implantation was also done.
General examination :