50 Y/M with c/o chest pain and Dyspnoea

 A 50 year old male resident of khasanaguda tailor by occupation came with chief complaints

1)chest pain since 3 years 

2) shortness of breath since  3 years

3) cough since 1 week 


Patient was apparently asymptomatic 5 years ago .

March 2019 

He had c/o fever , high-grade , not associated with child and rigors since 4 days , redness , pain and swelling in rt lower limb since  3 days . Initially it started as a bleb and  it progressed to swelling of limb  associated with pain . He was examined, investigated and diagnosed as Rt lower limb cellulitis with  ulcer over rt dorsum of foot.

S/P - Split Skin Graft 

Stayed at hospital for 3 months and got discharged 





2022 

He went to hospital with c/o dyspnea ( grade 2 mmrc ) since 1 month . No h/o chest pain, palpitations, sweating, pedal edema , pnd , orthopnea . He was started on medication

1) T.Aspirin 75 mg 

2) T.Atorvastatin 20 mg 

3) T.Met xl  15 mg 

4) T Lasix 40mg 

He was on regular follow up and on regular medication since then .


2023 

Patient went with c/o chest pain radiating to the back , left arm since 1 month .

Sob progressed to garde 3 ( MMRC) 

H/o fatigue  

After investigations were done he was notified his creatinine levels were elevated (?CKD) and underwent 2 sessions of  dialysis . Later he was planned for renal biopsy but patient was not willing for it so left the hospital.

From then he is visiting near by government hospital for medication.(monthly) 

But from last few months he couldn't afford for the medication and he has stopped taking few of the above mentioned medication. 

2024 

Patient now complains of chest pain radiating to left upper limb since 3 years aggravating on strenuous exercise and no relieving factors associated with sweating on exertion and  not associated with palpitations .

H/o SOB grade 2 MMRC insidious in onset , gradually progressive since 3 years aggravates on exertion and relieves on taking rest .

H/o cough not associated with expectoration since 10 days aggravates during night and no relieving factors.

No h/o orthopnea and paroxysmal nocturnal dyspnea.

No h/o decreased urine output, burning micturition .

No H/o nocturia, polyuria 

No H/o nausea, vomiting, loose stools, constipation.

No H/o fever,  cold .

No H/o palpitations 

No H/o abdominal distension, abdominal pain.

No H/o hematuria.

No h/o headache,sleep disturbances.

N/k/c/o DM, HTN ,TB, Asthma, Epilepsy, Thyroid disorders 

Personal History 

Appetite - Normal 

Bowel and bladder movement - regular

Sleep - adequate 

Diet - mixed ( stopped intake of meat since 3 years ) 

Alcohol consumption since 20 years stopped intake since 3 yrs 

Smoker since 25 years (1 pack / day )

 Family history: 

No significant family history 


General physical Examination: 

Patient is conscious, coherent and co-operative.

No signs of pallor , icterus , cyanosis , clubbing , clubbing, lymphadenopathy , edema .

Hyperpigmentation seen around the neck 




Vitals 

BP : 110 / 70 mm hg 

PR : 62 

RR : 18

Spo2: 95@ RA

Systemic examination:

Cardiovascular system:

Inspection- 

No raised JVP

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse at 5th intercostal space

Palpation-

Apex beat is felt in the fifth intercostal space, 1 cm medial to the midclavicular line

Auscultation-

S1 and S2 heard, no added thrills a

nd murmurs are heard 

Respiratory system: 

Bilateral air entry clear, Normal vesicular breath sounds heard

Per abdomen:

Shape of abdomen - obese 

Umbilicus - everted 

Soft, non tender, bowel sounds heard







CNS:

No focal neurological deficit found

ECG on 5/2/24 ( date of admission) 




ECG on 6/2/24




ECG on 7/2/24



2d echo 



Lft on 5/2/24

Hemogram on 5/2/24

Rft on 5/2/24


Xray LS Spine 



CXR 



Provisional Diagnosis

? Heart failure 

CKD since 3 years 


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