Reference no: EM133250175

Chief Complaint

"Heart palpitations."

History of Present Illness

A 64-year-old woman presents to her regular PCP complaining of chest palpitations. She was watching TV and suddenly her heart started racing and pounding. She became light-headed and felt a bit better after a while. She reports she hears her heart beating when lying down. She is concerned and now presents for evaluation. She reports having mild palpitations in the past but nothing like this. She has a history of atrial fibrillation and was taken off her blood thinners by her urologist and oncologist. She was diagnosed with kidney cancer 5 months ago and is now 4 months post right nephrectomy. She denies any chest pain or syncope. She reports she never refilled her previous medication and she did not follow up with her PCP post-surgery.

Review of Systems

The patient's ROS is positive for chest palpitations, generalized weakness, and SOB. Her ROS is negative for weight loss or gain, fever, chills, vomiting, diarrhea, constipation, and chest pain.

Relevant History

This patient has a history of hypertension, renal cancer, coronary artery disease, GERD, and a systolic murmur. She also has a new lung lesion. Her surgical history is positive for a nephrectomy 4 months ago. The patient is a widow and lives with her only child, an unmarried son. She denies tobacco use, alcohol use, or any illicit drug use. She has a family history of CAD, hypertension, and type 2 diabetes, but no family history of cancer.

Allergies

No known drug allergies; no known food allergies.

Medication

Diltiazem 180 mg PO QD (empty pill bottle).
Lisinopril 20 mg PO QD.
Metoprolol succinate 50 mg QD (empty pill bottle).
Low-dose aspirin, 81 mg PO QD.
Physical Examination

-Vitals: T 36.8°C (98.3°F), P 130, R 18, BP 110/74, WT 80.7 kg (178 lbs), HT 160 cm (63 in.), BMI 31.5.

-General: Lethargic but not in acute distress.

-Psychiatric: Smiles; is cooperative and answers all questions appropriately though slightly slow to respond but states this is her baseline after the nephrectomy and her surgeon said it is to be expected.

-Lungs: Nonlabored, chest rise symmetrical, lungs clear upon auscultation bilaterally.

-Heart: Irregular rhythm and rapid heart rate, systolic murmur right sternal border grade 3/6.

-Neurologic: Alert awake (GCS = 15), but delayed verbal response; motor and sensory is intact; deep tendon reflex 2+ bilaterally; Romberg is negative.

Clinical Discussion Questions:

Question 1: What is the most likely diagnosis? Why?

Question 2: What is the appropriate patient education for this case?

Question 3: Demonstrate your understanding about the pathophysiology in regard to the most likely diagnosis.