CME CASE PRESENTATION
49 yr male known diabetic came with the complaints of
Breathlessness since 1 week
B/l swelling of feet since 1 week
Cough since 1 week
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 1 week ago then he developed shortness of breath class II of NYHA insidious onset , gradually progressive a/w profuse sweating ,
a/w paroxysmal nocturnal dyspnea,orthopnea
No diurnal variations
*No h/o chest pain , palpitations ,syncopal attacks
Cough with sputum of mucoid consistency,non blood tinged,non foul smelling
No h/o ,fever,sore throat,hoarseness of voice
No h/o nocturnal cough
B/swelling of lower limbs extending upto knee insidious onset pittting type
No h/o Decreased urine output,burning micturition
No h/o long standing hours
*No h/o abdominal distension ,facial puffiness
HISTORY OF PAST ILLNESS
No h/o similar complaints in the past
Known case of TYPE II DIABETES MELLITUS since 8 yrs
Known case of epilepsy with last episode 40yrs back
Not a k/c/o HTN ,CVA,CAD ,TB ,THYROID DISORDERS,ASHTMA
TREATMENT HISTORY
using tab metformin 500mg BD for diabetes mellitus
PERSONAL HISTORY
patient is a jewellery shopkeeper
Alcoholic and drinks 1 quarter alcohol almost everyday since 15 yrs and every night when he drinks he doesn't eat any food
Non smoker
Mixed diet ,with no bowel and bladder disturbances with normal sleep pattern
No known allergies
NO SIGNIFICANT FAMILY HISTORY
GENERAL PHYSICAL EXAMINATION
A middle aged patient who is thin built ,moderately nourished is conscious coherent cooperative and comfortably sitting on bed
Pallor present
B/l pedal edema present
No icterus, cyanosis , clubbing of fingers and toes ,lymphadenopathy .
Vitals on the day of admission
Temp - 98.7°F
PR -8bpm
Bp - 110/70 mmHg measured in left arm in sitting position
RR- 20 cpm
SPO2 - 95% at room air
SYSTEMIC EXAMINATION
CVS
Jugular venous pressure is not raised
Chest wall - elliptical shape
Bilaterally symmetrical
No Kyphoscoliosis
No Dilated veins, scars, sinuses
Apical impulse not visible
No Pulsations visible in – epigastric, parasternal, pulmonary, aortic, suprasternal, supraclavicular, infraclavicular, suprascapular, interscapular, hypochondrial regions
PALPATION:
Kyphoscoliosis is absent
Apical impulse – normal/absent/tapping/heaving/hyperdynamic/other specific characters
Pulsations – Epigastric pulsations,
Parasternal Heave – Grading,
Palpable Pulmonary valve closure,
Palpable aortic, suprasternal, supraclavicular, infraclavicular, suprascapular, interscapular, right hypochondrial pulsations
Thrills – Precordial/Carotid thrill
Dilated veins – direction of flow
PERCUSSION:
Right Heart Border
Left Heart Border
Gerhardt’s sign
AUSCULTATION:
MITRAL AREA:
S1, S2 heard
TRICUSPID AREA:
S1, S2 +nt
PULMONARY AREA:
S1, S2 heard
AORTIC AREA:
S1, S2 heard
RESPIRATORY SYSTEM
B/l air entry present
Normal vesicular breath sounds
B/l fine crepts present
GASTRO INTESTINAL SYSTEM
Distended soft abdomen
No palpable mass or organs ,non tender
CNS
no focal neurological deficit is present
PROVISIONAL DIAGNOSIS
Congestive cardiac failure 2° to ? Anaemia
