Cardiology Case 1 ... !!!

95 years old male, smoker for 70 years, have chronic bronchitis, grade 3 dyspnea,
Complaints of off and on tachycardia.

On GP examination 

Pulse: 120 bpm
Blood pressure: 118/78

30 minutes later

Pulse: 60 bpm, Irregular rhythm.
Blood Pressure: 132/65
Patient feels weakness in bradycardia.

No clubbing, no splinter hemorhages, no osler's or heberden's nodes or any janeway lesions, no spider neivi, no odema. ( skipped findings are normal)

Chest Examination:

Trachea Midline ... B/L equal entry of air with vesicular breathing. However chest is slightly resembles the condition called pectus excavatum.

CVS Examination;

During Tachycardia: ... Visible pulsations in neck, left para-sternal heave, apex beat at 5th intercostal space mid-clavicular line, S1 and S2 are clear but so close that I can't comment on murmur or S3 or S4.
No basal crepts and no pedal edema.
As abdomeno-jugular reflex was checked for pulsating neck vessels then suddenly neck pulsations vanished.

During Bradycardia: ... Pulse was irregular. No pulsating neck vessels. No Left para-sternal heave. S1 and S2 were weak and again sounds were so muffled that one can't comment about murmurs, S3 and S4.
No basal crepts. No pedal edema.

Normally when patient isn't going through these spells, he does not complain about anything except dyspnea and weakness.

EKG investigation was;

EKG

Echocardiography turned out to be;

Echocardiography

Solve this case ... If you think you can become a cardiologist.

Don't forget to share and take opinion of different consultants and students.

For learning purpose only.