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Mr. Rodriguez’s chief complaint is heart palpitations he described as “a pounding of his heart”. He is also experiencing associated symptoms of dyspnea on exertion and fatigue. Important questions that should be asked to formulate a complete HPI involve asking about what events led up to the palpitations, what things improve or worsen symptoms, and a thorough health and family history, specifically heart health. Social history is also important as drug habits or caffeine intake could cause arrhythmias (Cash & Glass, 2014). The patient relayed that the symptoms started out of nowhere, with no unusual events leading up to the problem. He states that symptoms worsen on exertion and improve when he is at rest. He also states that he does not smoke, drink, or do illicit drugs and does not drink caffeine on a regular basis. His cardiac history is remarkable for hypertension and hyperlipidemia, family history is unremarkable.
Components of the physical exam that will help form a diagnosis are mainly cardiovascular. What are heart sounds is JVD present, what is the heart rate/rhythm. Respiratory should also be thoroughly evaluated to ensure patient is not in need of emergency help. What is respiratory rate, lung sounds, is breathing labored? Endocrine should be evaluated when searching for underlying cause: an enlarged thyroid could indicate hyperthyroidism which could potentially cause the unwanted arrhythmia (Sokmen et. al., 2013)). In this case the patient’s exam revealed an extra heart sound, S3 gallop heard at the apex. His HR was increased at 136 BPM. These two findings alone indicate an irregular rhythm (Cash & Glass, 2014). Because he is symptomatic pharmacological measures should be taken in a timely manner.
Differential diagnoses to be considered in this case are atrial flutter, primary hypertension, and atrial fibrillation. Atrial flutter can be ruled out with a 12- lead EKG. Hypertension should be included because the patient could be symptomatic if his hypertension is uncontrolled. If left uncontrolled hypertension can increase the chance of complication from CHF, CVA, and renal failure. The 12-lead EKG confirms the final diagnosis of atrial fibrillation.
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