• two months duration.

• two months duration

  • indicate the patient has chronic disease

    
    

DIFFERENTIAL DIAGNOSIS

• valvular heart disease (stenosis - blockage of area of valve will reduce blood flow from left atrium to left ventricle and regurgitation - defects in papillary muscle or connective tissue that cause leaflets flop allowing backflow of blood

  • mitral valve prolapse - a condition where mitral valves cannot close properly

  • mitral valve stenosis (commonly affected valve)

• sinus tachycardia - increase rate of electrical discharge from SA node

• IHD - atherosclerosis can cause IHD

• congestive heart failure - causes by no blood flow

• hyperthyroidism (most common in women due to hormonal causes)

  • affected by early menopause due to drop level of estrogen

  • can affect men but less common (usually caused by grave's disease or other thyroid issues (thyroid nodules / thyroiditis)

• mental health (due to anxiety and depression or panic attack)

• substance use disorder (caffeine is a stimulant that stimulate SNS/ alcohol/ nicotine/ tablet*)

• COPD

• pulmonary

FURTHER QUESTIONING

• HISTORY TAKING (SOCRATES)

  • site - where is the location

  • onset - when the palpitations first felt

  • characteristics - is she has crushing pain / how does it feel

  • radiation - where the palpitation can be felt other than chest

  • associated symptoms - is there any associated symptoms (SOB/cough/wheezing sound/headache/orthopnea/chest pain/night sweats/fatigue/weight loss/cachexia/mental distortion-confusing)

  • time - how long the duration of palpitations / continuous or not

  • exacerbating factor - smoking/physical activity/medication such as b-agonist/dust exposure

  • severity - scale based on 1-10

• SOCIAL HISTORY

  • ask about smoking

  • alcohol intake

  • occupation

  • mental health

  • dietary pattern (coffee addiction)

  • lifestyle (sleep patterns)

• FAMILY HISTORY

  • is there any family members affected by heart disease

  • any members have cancer, DM, hypertension, obesity

• PAST MEDICAL HISTORY

  • does she has any surgery before (pacemaker/Artificial valve/stent)

  • does she had RF or RHD when she was young

  • does she has IHD or heart failure before this

  • does she has chronic disease (DM / hypertension/CKD)

• DRUG HISTORY

  • does she take any medications (B-agonist)

• SYSTEM REVIEWS

  • any joint pain/headache/abdominal pain

-shortness of breath on exertion over the previous week.

-history of recurrent episodes of fever and painful joints and sore throats in the patient’s childhood.

-no history of any psychiatric disorder.

-No history of loss of weight,vomiting or diarrhoea was elucidated.

-no familial history of any inherited arrhythmia disorder.

-no known allergies

-not on any medications.

-She denied any smoking, alcohol or illicit substance abuse

-shortness of breath on exertion over the previous week -increase workload increase o2 demand- heart cannot pump to meet o2 demand so lack of o2 lead to dyspnea. - due to pulmonary congestion ineffective gasses exchange. ventilation perfusion mismatch

1.(blood flow okay but less o2 intake)

2.(o2 intake okay but blood flow disrupt)

-history of recurrent episodes of fever and painful joints and sore throats in the patient’s childhood- pt already experience multiple time (fever -infection,inflammation or any injuries)(painfull joints-due to artritis due to group A b-hemolytic strep)

-no history of any psychiatric disorder- no mental illness

-No history of loss of weight,vomiting or diarrhoea was elucidated- no hyperthyroidism, no GIT problem

-no familial history of any inherited arrhythmia disorder- low risk factor

-no known allergies- not aware about her health status( no chance to allergy induce cardivascular disease)

-not on any medications- no chronic disease

-She denied any smoking, alcohol or illicit substance abuse- no substances induce sympathetic outflow.

DIFFERENTIAL DIAGNOSIS

• valvular heart disease (stenosis - blockage of area of valve will reduce blood flow from left atrium to left ventricle and regurgitation - defects in papillary muscle or connective tissue that cause leaflets flop allowing backflow of blood

  • mitral valve prolapse - a condition where mitral valves cannot close properly

  • mitral valve stenosis (commonly affected valve)

• sinus tachycardia - increase rate of electrical discharge from SA node

• IHD - atherosclerosis can cause IHD

• congestive heart failure - causes by no blood flow

• hyperthyroidism (most common in women due to hormonal causes)

  • affected by early menopause due to drop level of estrogen

  • can affect men but less common (usually caused by grave's disease or other thyroid issues (thyroid nodules / thyroiditis)

• mental health (due to anxiety and depression or panic attack)

• substance use disorder (caffeine is a stimulant that stimulate SNS/ alcohol/ nicotine/ tablet*)

• COPD

• pulmonary embolism

• SVT

• Rheumatic heart disease (meet 2 minor jones 2015 criteria)

FURTHER INVESTIGATION

• PE -vital sign , auscultation, percussion, palpation (cardiomegaly), inspection

• ECG- ST elevation , prolonged PR interval

• CXR

• echocardiogram

• angiogram

• lab test - lipid profile test (atherosclerosis), fasting blood glucose, cardiac biomarkers, ASOT( antibody for strep infection), FBC, blood culture and sensitivity, electrolyte

• ECG stress test(angina)

• CT scan

DIFFERENTIAL DIAGNOSIS

• valvular heart disease (stenosis - blockage of area of valve will reduce blood flow from left atrium to left ventricle and regurgitation - defects in papillary muscle or connective tissue that cause leaflets flop allowing backflow of blood

  • mitral valve prolapse - a condition where mitral valves cannot close properly

  • mitral valve stenosis (commonly affected valve)

• sinus tachycardia - increase rate of electrical discharge from SA node

• IHD - atherosclerosis can cause IHD

• congestive heart failure - causes by no blood flow

• hyperthyroidism (most common in women due to hormonal causes)

  • affected by early menopause due to drop level of estrogen

  • can affect men but less common (usually caused by grave's disease or other thyroid issues (thyroid nodules / thyroiditis)

• mental health (due to anxiety and depression or panic attack)

• substance use disorder (caffeine is a stimulant that stimulate SNS/ alcohol/ nicotine/ tablet*)

• COPD

• pulmonary embolism

• SVT

• Rheumatic heart disease (meet 2 minor jones 2015 criteria)

Imaging Studies:

Chest radiograph and C.T. scan:

1. Diffuse airspace opacification, bilateral pleural effusions

2. ECG - Atrial fibrillation

3. TEE: The left atrium is severely dilated. The right atrium is moderately dilated.

4. There is moderate to severe tricuspid regurgitation.

5. Right ventricular systolic pressure is elevated at> 60mmHg.

6. Left ventricular systolic function is borderline reduced.

7. The flattened septum is consistent with R.V. pressure/volume overload.

8. The right ventricle is mildly dilated. The right ventricular systolic function is hypokinetic.

9. There was severe mitral stenosis.

10. Rheumatic mitral stenosis, features of congestive heart failure.

11. Treatment: beta-blockers, cardiac glycosides, diuretics, anticoagulants.

12. The patient was transferred to a cardiothoracic evaluation of potential percutaneous balloon valvuloplasty of the mitral valve.

1. Diffuse airspace opacification, bilateral pleural effusions

2. ECG - Atrial fibrillation

3. TEE: The left atrium is severely dilated. The right atrium is moderately dilated.

4. There is moderate to severe tricuspid regurgitation.

5. Right ventricular systolic pressure is elevated at> 60mmHg.

6. Left ventricular systolic function is borderline reduced.

7. The flattened septum is consistent with R.V. pressure/volume overload.

8. The right ventricle is mildly dilated. The right ventricular systolic function is hypokinetic.

9. There was severe mitral stenosis.

10. Rheumatic mitral stenosis, features of congestive heart failure.

11. Treatment: beta-blockers, cardiac glycosides, diuretics, anticoagulants.

12. The patient was transferred to a cardiothoracic evaluation of potential percutaneous balloon valvuloplasty of the mitral valve.