CBBLE UDHC SIMILAR CASES
NEW ADMISSION
UNIT 3 AND 6
32 Years old Male Patient labourer by occupation resident of West Bengal
Came with chief complaints of Palpitations and Giddiness for the past 6 months.
History of Present Illness :
Patient was Apparently Asymptomatic 20 Years Back.Then He developed Headache which initially localised in the Occiput region later Diffused all over which subsided only on taking medication.
Then 6 months back he Developed Palpitation and Giddiness.
Palpitations were sudden in onset ,and aggravated by Strenous Exercise,Anxiety and slightly relieved on Taking Rest.
Giddiness :
Giddiness was present even on lying down and Sitting Position but Relieved on Medication.
Past History :
No Similar Complaints in the Past.
No H/O Diabetes, HTN,Asthma ,TB,Epilepsy ,Thyroid.
Family History:
His Sister also had Complaints of Headache since 5 years.
Personal history:
Diet- mixed
Appetite- normal
Sleep- adequate
Bowel and bladder movements - regular.
Addictions-h/o beedi smoking (5-6 times/day) , tobacco chewing and cigarette smoking occassionally since 15 years.
Alcohol intake - 90 ml /day since 15 years.
But he stopped all those for the past 6 months.
Drug history:
He had taken Metoprolol for palpitations for 2 months. But he stopped the medication due to epigastric pain.
He had taken medication for anxiety
General examination :
Patient is conscious, coherent and cooperative and well oriented to time , place and person.
Well built and wellnourished.
Physical examination :
Pallor - absent
Icterus - absent
Clubbing - absent
Cyanosis- absent
Lymphadenopathy- absent
Edema - absent.
Vitals:
Pulse rate: 76 BPM
BP: 110/70 MMHG
Temperature: 98.2 F
Respiratory Rate: 18 CPM
Systemic Examination :
CVS :
Inspection :
Shape of Chest and Symmetry - Normal
Breast Abnormality - Absent
Spinal Deformities - Absent
Precordial Prominence
Cardiovascular Pulsations :
Apical Impulse:Not visible
Pulsations in A,P area : absent
Sternoclavicular Pulsations : absent
Left Parasternal Pulsations: absent
Epigastric Pulsations: absent
Distended Veins: absent
Palpation :
Confirmation of Shape and Symmetry
Palpation of Precordium
Palpation of Cardiovascular Pulsation for Sound ,Thrills and Rubs:not heard
Apical Impulse felt on Palpation
Plaption of Left Parasternal Area - Heaves Absent
Percussion:
Dullness corresponding to Right Heart Border is normal
Dullness Corresponding to left Heart Border is normal
Auscultation :
S1,S2 Heard
No Murmurs
RS: BAE + , CLEAR
CNS : NAD
P/A : Soft , Non Tender
Investigations:
DRUGS :
Provisional Diagnosis : Panic attack 2⁰ to Anxiety disorder
PSYCHIATRY REFERRAL DONE ON 28/3/22:
DAC REFERRAL DONE ON 29/3/22 :
