1801006147 CASE OF 27 YEARS OLD MALE WITH HEADACHES AND SYNCOPE

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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 

CHIEF COMPLAINT : 

A 27 year old male resident of dachenpally working as a designer in printing press presented with the complaints of -

1) Headache since 5 years 

2) fainting episodes since last 5 years - last episode was 10 days back.

HISTORY OF PRESENTING ILLNESS :

The patient was asymptomatic 4 years back then he met with a RTA bike to bike collision in which he fell on the divider and impact was on his occipital region, as soon as he fell he had an episode of seizure. Many months after this episode he developed headache which was sudden on onset, gradually progressive. He explained it as pulsating type and starts from occipital region and radiates till frontal lobe. The headache is not associated with nausea and vomitings. It’s aggravates on climbing stairs ,lifting heavy weights and waking for long distances and is relived in some hours spontaneously.

Fainting episodes which were about 1 or 2 in a year since 5 years. His reason of admitting to our hospital was one such attack which he got 10 days back and lead to unconsciousness (syncopial attack ? ). 

H/o palpitations since 1 year associated with sweating. He first felt the palpitation around 1 year back and went to the hospital to get diagnosed where his reports came normal and indicated by doctors as stress related. He was prescribed pranolol BD taking which his symptoms got relived after 3-4 days. Then he again came across palpitations in feb this year for which he visited our hospital and the diagnosis was same as above. 

H/o stomach pain in left quadrant of stomach ( left hypochondirium ) and Epi gastric region since 1 and half year which was of burning type and aggravated just after taking food and got relived after 1-2 hours. 

H/o of occasional bleeding per anus which he described as due to body heat and dehydration.

On a whole the patient during the whole of history taking just pointed out on just three symptoms again and again which where headache stomach pain and palpitations. There was no particular order in their occurance but they would always be accompanied together whenever the patient felt uneasy.

PAST HISTORY :

Not a known case of diabetes,htn,epilepsy,tb or asthama.

The patient has a history of RTA 4 years back where he was hit by a speeding vehicle coming from opposite side. He felt on the divider with his occipital region as the area of impact. He felt unconscious for about 2 hours and was shifted to hospital during this time. He was said to have issues in any of the reports and was discharged a day after.

He got contracted with COVID-19 in JAN 2022 and got treated at home.

FAMILY HISTORY : 

He has no family history of DM OR HTN OR ANY OF ABOVE MENTIONED PROBLEMS.

He is survived by his mother sister and grandmother. His guardian at the hospital was his paternal uncle.

Upon enquiry I got to know that the patients father passed away at the age of 46years 3 years back due to low heart rate which was around 40-50 bpm usually. 

PERSONAL HISTORY:

Diet - mixed during childhood became vegan in his teens

Appetite - Decreased appetite since 1 year ( only lunch and dinner consumed ).

Sleep - Disturbed Sleep due to thoughts.

Bowel and badder movements - normal

No addictions.

Patient works at a printing press run by his family which was started by his great granddad. Patient studied till 10 class after which he felt ill and was unable to take his intermediate exams and left his studies. Irrespective of his studies he used to be regular at the printing press and continued so on after discontinuing his studies. 

Patient is an introvert has no friends outside his family and when asked about friends he mentioned his 2 cousins with whom he is close. 

The patient is an emotional person as any negative or bad issues happening around him affected his mind and it starts occupying his mind and is the ignition key to his headches. He is a overthinker. His family is a happy go lucky one and doesn’t have him pestered for anything. Patient has no individual or personal life outside home.

He himself described to me that whenever he gets headaches or giddiness he calls his uncle and accompanies with him to the hospital but by the time he reaches the hospital his condition becomes better as he has a good conversation about his thoughts on the way. 

All the syncopial attacks happened when he was on his own or alone.

TREATMENT HISTORY: 

No H/o of any surgeries.

Elbow fracture around 8 years back.

GENERAL EXAMINATION:

Patient is concious ,coherent,cooperative.

Moderately built,Moderately nourished.

No signs of pallor is present

No signs of icterus, clubbing, cyanosis, lymphadenopathy, edema.

BP - 110/70

PR - 90bpm

RR - 15cpm

Temprature - afebrile .

RESPIRATORY SYSTEM: 

PALPATION :

All inspectory findings are confirmed

No rise of temperature

No tenderness 

Trachea is in midline

B/L chest movements are equal

No swelling and palpable masses are felt

vocal fremitus are normal

PERCUSSION.  

     

                                                  RT.            LT

SUPRA CLAVICULAR       resonant.  resonant

INFRA CLAVICULAR.       resonant.  resonant

MAMMARY.                       resonant.  resonant

INFRA MAMMARY.           resonant.  resonant

AXILLARY.                         resonant   resonant

INFRA AXILLARY.             resonant   resonant 

SUPRA SCAPULAR.         resonant   resonant

INFRA SCAPULAR.          resonant   resonant

INTER SCAPULAR.          resonant   resonant

AUSCULTATION:

Vesicular breath sounds 

SUPRA CLAVICULAR NVBS. NVBS

INFRA CLAVICULAR. NVBS. NVBS

MAMMARY. NVBS. NVBS

INFRA MAMMARY. NVBS. NVBS

AXILLARY. NVBS. NVBS

INFRA AXILLARY. NVBS. NVBS

SUPRA SCAPULAR. NVBS. NVBS

INFRA SCAPULAR. NVBS. NVBS

INTER SCAPULAR. NVBS. NVBS

PER ABDOMEN: 

Inspection -

Shape of abdomen : scaphoid

Umbilicus : inverted 

Movements of abdomen wall with respiration 

No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites 

On palpation -

No local rise of temperature 

Inspectors findings are confirmed 

Soft and non tender

No palpable mass 

Liver and spleen not palpable 

On percussion -

Resonance note heard

On auscultation -

Bowel sounds heard

CARDIOVASCULAR SYSTEM :

Inspection- 

No raised JVP

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Auscultation-

S1 and S2 heard, no murmurs are heard .

INVESTIGATIONS : 

      

COMPLETE URINE ANALYSIS:

HEMOGRAM:

FERRITIN:

SERUM ELECTROLYTES:

BLOOD UREA:

SERUM IRON:

RETICULOCYTE COUNT:

PROVISIONAL DIAGNOSIS :

Palpitations due to emotional disturbance ?

Syncope under evaluation 

Nutritional anemia.