A 60yrs old male with progressive breathlessness
DR.NAVYA(INTERN)
DR.CHETANA(INTERN)
DR.ABDUL RAHEEM (INTERN)
DR.ASHFAQ(INTERN)
DR.SRAVYA(INTERN)
DR.GNANADA(INTERN)
DR.CHARAN(PG1)
DR.VAMSI(PG1)
DR.SUSMITHA(PG2)
DR.ADITHYA (PG3)
DR.PRANEETH(PG3)
DR.PRAVEEN NAIK (ASS.PROF)
DR.RAKESH BISWAS(HOD)
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Here is a case i have seen:
A 60 year old man presented with a 1 year history of progressive breathlessness.
Dyspnea - 1 year, progressive, exertional, relieves with rest, initially on activity with farm work and office attender work now incapacitated to Grade 3 NYHA. No associated palpitations, syncope or presyncope. No history of cold sweats or cold hands. Post prandial somnolence +. History of nocturia since 3 months.
Cough - Since 1 month with mild whitish mucoid expectoration. Associated with a low grade fever. Expectoration - Spoonful in quantity, whitish, mucoid, no froth or hemoptysis.
History of low back ache since 1 month. No early morning stiffness. Persistent and only mild relief with rest. No history of loss of appetite or weight loss.
Past Hx - Appendectomy 20 years ago.
Drug Hx - Tab Lasix 40mg , Tab Pantoprazole 40mg, Tab Torsemide 10mg
Type 2 Diabetic since 2 months. Non hypertensive.
Personal History - Sleep - Inadequate, frequently wakes up to urinate. Daytime somnolence + with snoring during sleep. Alcohol consumption upto 90 to 180ml of Imperial Blue for nearly 40 years. Reason for alcoholism - Stresses of family and having 8 kids and death of wife recently 2 months ago. Bowel habits - Normal but having to strain.
Provisonal Diagnosis - Heart Failure with Preserved Ejection Fraction associated with Coronary Artery Disease
? Pulmonary TB.
GENERAL EXAMINATION:
Patient is conscious, coherent, cooperative moderately built and moderately nourished .
Vitals:
Bp:150/80mmhg
PR:90bpm
RR: 20cpm
Temperature: afebrile
No signs of pallor, icterus, cyanosis, clubbing, koilonychia.
No generalized lymphadenopathy
B/L Pedal edema present pitting type
CVS:
INSPECTION:
. elevated JVP
.left parasternal heave
Locomotor brachi
PALPATION:
Apical impulse: 5th ICS lateral to MCL
left parasternal heave present
Palpable A2 in left 2nd ICS
AUSCULTATION:
pansystolic mumur present
S1S2heard
PER ABDOMEN:
INSPECTION:
Soft, distended abdomen with slit like umblicus
Flank fullness present
Cough impulse present at umbilical region
Appedicectomy scar present in RIF
Rectus divertica present
Epigastric aortic pulsations are present
PALPATION:
All inspectory findings are confirmed
Waist circumference:91cms
Hip circumference:94cms
Liver is palpable
Liver span_17cms
PERCUSSION:
Shifting dullness present
AUSCULTATION:
Bowel sounds present
RS:
NVBS heard
B/L Air entry present
No added sounds.
CNS: No focal neurological deficit present
Provisonal Diagnosis - Heart Failure with Preserved Ejection Fraction associated with Coronary Artery Disease
? Pulmonary TB.
INVESTIGATIONS:
LFT:
Total bilirubin: 1.02 mg/dl
Direct bilirubin:0.30 mg/dl
AST: 22 IU/L
ALT:16IU/L
ALP:167 IU/L
Total protein:5.9gm/dl
Albumin:3.8gm/dl
A/G: 1.81
Serum electrolytes:
Sodium:136mEq/L
Potassium:4.3mEq/L
Chloride:97mEq/L
Serum creatinine:1.3 mg/dl
FBS: 119 mg/L
USG ABDOMEN:
Chest X-ray. 
ECG:
2D ECHO:. 
Treatment:
Heamogram:. 
TAB.LASIX 40 MG PO BD
INJ.OPTINEURON ONE AMPOULE IN 100ML NS IV OD
MONITOR BP,PR 4TH HOURLY
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