A&E referred me this 57 year old lorry driver presented with so called chest pain during my on-call hour.

I reviewed A&E notes, blood test results, ECG and CXR before seeing the patient. All routine blood tests were normal and admission Troponin was negative. ECG was normal sinus rhythm with no T/ST change. CXR unremarkable.

When I chatted with patient properly, it was not really a chest pain.

He expressed he never experienced such a strange feeling while watching tele. Patient described it as "Bang" "Bang" twice from his heart, followed by pounding heart. The attack last about 30 mintues.

At this point, I got a clue. So I asked the patient to tap the bed with his hand as he felt duing the episode. It was revealed that he tapped with vearying rates and varying intensity.

Interestingly, this patient has a knowledge how to feel his radial pulse. He said he felt his pulse that time,which was sometime fainting and sometime strong.

So my management was Telemetry to detect further arregular rhythm. He will probably needs 24/48 hour out-patient ECG if nothing showing off on Telemtry. Basically he can go home after 12 hour Tropnonin.

Yes, 12 hour Trop is also required in this case, in light of this episode and a srong family history (Father and brother died of MI). He also had border line diabetes and high cholesterol on diet control.

My diagnosis of Paroxymal AF might be wrong at the end. But I think it's a good history, isn't it?

Update: 23/12/2009

I forgot to tell. Of couse, we added Thyroid function test.