A 54year old male patient Came to the OPD
Chief complaints - cough with expectoration since 6 days and low-grade fever since 6 days.
Patient was apparently asymptomatic 3yrs back and then he developed shortness of breath initially of GRADE II which progressed to grade IV at present
B/L pedal oedema of pitting type since 18 months
PND since 6months.
Palpitations since 6 months.
Orthopnea Since 3months.
Nocturia since 2months
6 days back he developed cough with expectoration of insidious onset along with low grade fever which is intermittent
No H/O chest pain, haemoptysis, vomiting, abdominal pain, Burning micturition and No h/o increased frequency, urgency.
History of TB 16 years back for which he was treated.
Not a k/c/o DM/HTN/Asthma/Epilepsy/CAD
Mixed diet, loss of appetite, regular bowel & bladder movements.
Consumption of 180 to 360 ML of alcohol daily for the past 10 years.
No known allergies
General examination-
Patient is conscious, coherent, cooperative.
Pallor +, B/L pedal edema +
No signs of icterus, cyanosis, clubbing, generalised lymphadenopathy
Vitals-
Bp: 110/60 mm hg
PR:118 bpm
RR:16cpm
Spo2:82% @ RA - 100% @ 4 lit O2
Temp : Afebrile
Cardio Vascular System -
Jvp raised
Precordial pulsations +
RV type apex
Epigastric pulsations +
Palpable P2 + and parasternal haeve of Grade III
s1 s2 + , no murmurs
Respiratory system -
Dyspnea present
Centrally positioned trachea
Reduced chest movement on left side
BAE+ Decreased BS on Left side
NVBS heard
Crepts heard at inter-scapular, infra scapular areas
ABDOMEN -
Soft, non-tender, bowel sounds heard.
CNS -
No abnormality detected.
0
Provisional diagnosis -
Heart Failure with Mid range Ejection Fraction secondary to ? Old pulmonary TB (cor pulmonale)
Treatment -
TAB.LASIX 40mg BD
O2 Supplementation @ 4 lit
BP/PR/Temp/ SpO2 monitering 4th hourly
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