Joseph Martinez comes to the hospital complaining about his heart: it has been pounding for three weeks. Also, the patient has been feeling tired a lot before his visit and experiencing shortness of breath after doing exercises. Mr. Martinez is a 48-year-old male of 5 feet 9 inches and 165 pounds. This is the first time the patient reports heart issues; he does not report chest pain, dizziness, or cough. The important questions to ask the patient concern his lifestyle and medical and family history. First of all, Mr. Martinez is not overweight; with a BMI of 24.4, he is assessed to have a normal weight (Pursey, Burrows, Stanwell, & Collins, 2014).
The patient has been married for 15 years; he denies smoking or taking any illegal drugs. He works in the area of sales; therefore, the lifestyle does not involve heavy physical exercise. Concerning his personal history, after a series of questions, it is found out that Mr. Martinez has been experiencing hypertension for a few years without receiving any medical treatment for it; however, he has taken some measures in terms of his lifestyle and diet to reduce health risks and started to do exercises. His lifestyle modifications were also due to a high level of cholesterol detected during one of his previous examinations. The patient does not have asthma and only drinks about twice a month in moderate amounts. The only surgery he received was tonsillectomy at the age of five. Questions about family history are asked, too; the patient reports that, to his knowledge, there is no history of diabetes or heart disease in his family.
Concerning physical examination, it is necessary to primarily assess the patient’s vital signs. During his hospital visit, the temperature is 98.6 degrees F (measured by mouth), the pulse is 136 beats per minute, irregular intermittent (irregularly irregular); the blood pressure is 150/100 mmHg; the respiratory rate is 20 breaths per minute (normal); the SpO2 level is 96 percent on room air (normal). The pulse is the sign that is particularly relevant to the patient’s complaints. At the time of examination, the patient is not experiencing shortness of breath; breathing is not labored. The point of maximal impulse is nondisplaced.
Upon the completion of the primary physical examination, several diagnoses can be proposed. Heart pounding, shortness of breath, fatigue, and irregular pulse can indicate atrial flutter, atrial fibrillation, myocarditis, cardiomyopathy (van Riet et al., 2014), and pulmonary edema; the latter is the only condition associated with the patient’s lungs, not the heart like the rest of conditions; however, pulmonary edema is closely associated with heart-related pathologies (Kemp & Conte, 2012). In the presented case, the irregularly irregular pulse is the first sign to diagnose atrial flutter or atrial fibrillation (Camm, 2012).
Atrial fibrillation is “a supraventricular tachyarrhythmia with uncoordinated atrial activation and consequently ineffective atrial contraction” (January et al., 2014, p. 12). To confirm the diagnosis, it is primarily needed to administer an ECG; based on the results and the ventricular response, atrial fibrillation can be observed; particular signs to be considered are irregular R-R intervals (Rix et al., 2012), the absence of distinct repeating P waves (Nielsen et al., 2015), and intermittent atrial activity. If the ECG displays these signs and a high ventricular rate, the patient should be diagnosed with atrial fibrillation. Further treatment will primarily involve administering drug therapy to control the ventricular rate.
References
Camm, A. J., Lip, G. Y., De Caterina, R., Savelieva, I., Atar, D., Hohnloser, S. H., … Ceconi, C. (2012). 2012 focused update of the ESC guidelines for the management of atrial fibrillation. European Heart Journal, 253(1), 1-29. Web.
January, C. T., Wann, L. S., Alpert, J. S., Calkins, H., Cleveland, J. C., Cigarroa, J. E., … Yancy, C. W. (2014). 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation.
Kemp, C. D., & Conte, J. V. (2012). The pathophysiology of heart failure. Cardiovascular Pathology, 21(5), 365-371. Web.
Nielsen, J. B., Kühl, J. T., Pietersen, A., Graff, C., Lind, B., Struijk, J. J., … Nordestgaard, B. G. (2015). P-wave duration and the risk of atrial fibrillation: Results from the Copenhagen ECG Study. Heart Rhythm, 12(9), 1887-1895. Web.
Pursey, K., Burrows, T. L., Stanwell, P., & Collins, C. E. (2014). How accurate is web-based self-reported height, weight, and body mass index in young adults?. Journal of Medical Internet Research, 16.
Rix, T. A., Riahi, S., Overvad, K., Lundbye-Christensen, S., Schmidt, E. B., & Joensen, A. M. (2012). Validity of the diagnoses atrial fibrillation and atrial flutter in a Danish patient registry. Scandinavian Cardiovascular Journal, 46(3), 149-153. Web.
Van Riet, E. E., Hoes, A. W., Limburg, A., Landman, M. A., van der Hoeven, H., & Rutten, F. H. (2014). Prevalence of unrecognized heart failure in older persons with shortness of breath on exertion. European Journal of Heart Failure, 16(7), 772-777. Web.