58M with 3 episodes of syncope

 NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT. 

PATIENT HISTORY: Pt is a 58 old male, working as an accountant.

At 22-23 yrs age, he used to c/o cough with little sputum (white), nasal discharge with blockage, headache, and fatigue. These symptoms used to occur twice a year, lasting for 15 days, after the rainy season. Dr. diagnosed it as acute bronchitis and the symptoms resolved within wks with antibiotic treatment. 

In 2006, he c/o high fever (103-104F) lasting for 15-20 days with night sweats and body weakness, and no relief with paracetamol. Mantoux test was +ve. USG abd was done which detected retroperitoneal lymph node enlargement. FNA of the retroperitoneal lymph node revealed granulomatous inflammation. Dr. diagnosed it to be TB. 2 antibiotics (isoniazid and rifampicin) for 6 months. 2 additional antibiotics (pyrazinamide and ethambutol) for the first 2 months of the 6-month treatment period were completed. 

In 2014, pt w/c/o hematuria (blood clots with urine) almost always while urinating, dysuria, frequent urination, dribbling or hesitant urination, and pain in and around the penis, and testicles. Biopsy from verumontanum showed papillary hyperplasia and cystitis cystica. CT urology revealed prostatomegaly and a diagnosis of BPH was made. Taking 1 tab of Veltam F (Tamsulosin and Finasteride) to date. 1 more incident of hematuria in 2022 Jan.

In Jan 2021, while coming downstairs he felt a slight heaviness in his legs and missed steps falling down. He lost consciousness for 1 min. Cold sweats after he became conscious. ECG and Echo (mild TR) were done. Dr. said nothing significant. 

In Oct 2021, while standing for 10 mins he felt a heaviness and generalized body weakness. Realizing he is about to faint he sat on a bench. Soon after lost consciousness. After 10 mins he became conscious and was profusely sweating. CT, MRI brain, and EEG were done. MRI detected ischaemic changes in bilateral periventricular white matter. Dr. prescribed no medication and said no problem. 

In Dec 2022, again while standing still for 10 mins he felt heaviness and lost consciousness for 15 mins. Dr. did a head-up tilt table test which was positive for evidence of provocable neuro-cardiogenic syncope. Dr. made a diagnosis of it to be vasovagal response and prescribed Frolicot 100mcg (fludrocortisone) for 14 days (no improvement seen). After taking it for a few days his BP became high (160/110 mmHg) and since then always remains 150+/90+ (earlier his BP used to be low). He had stopped Frolicot on his own accord. 

Pt reports since those incidents he never stood still for more than a few mins and feels if he does so he may faint.

For the past 1wk c/o breathlessness on walking for 200 mt.

Pt denied any history of DM

Addiction - smoking since age of 20, 3-4 cigarettes/day

CHIEF COMPLAINT AND Pt REQ.: 1) syncope 3 times in the past 1 yr

2) SOB for past 1 wk.

FAMILY HISTORY: Father - had TB

Mother - HTN, heart ailments, kidney failure

Sister - 3 seizures at age of 4-5 yrs.

REPORTS: 

PROVISIONAL DIAGNOSIS: Vasovagal syncope, BPH