A 55 Yr old man presented with shortness of breath 20 days and swelling of both lower limbs since 10 days

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A 55 Yr old male presented with shortness of breath 20 days back and swelling of both lower limbs since 10 days

History of presenting illness :

Patient was apparently asymptomatic 2 years back then he developed Shortness of breath while lifting weights then 20days back started to develop SOB even while doing normal work and occasionally it used to present while taking rest or on lying down , walking and relieved to some extent in sitting position. 

Patient also complains of Pedal Edema from 10 days back which is insidious in onset gradually progressed till knees 

History of facial puffiness 1 week back and it is resolved .

history of backache for the past 5years which was non radiating ,non progressive relived with rest and started to take NSAID medication every 2-3 days for the past 3years .

No history of chest pain , palpitations , sweating 

No history of fever , cold , cough 

No history of burning Micturition , frothy urine , Hematuria 

No history of decreased urine output 

History of past illness :

Not a known case of Diabetes Mellitus , Hypertension , Asthma , TB , CAD , CVA , Epilepsy 

Underwent surgeries for hernia right side 8 years back and hernia left 4 years back

Personal History : 

Patient takes mixed diet , appetite is good , bowel and bladder movements are regular , sleep is disturbed .

He consumes 90 mL whiskey daily from past 10 years and chewing gutka for the past 15 years

Daily routine : 

Patient wakes up around 6 in the morning and goes out around 7 and has his breakfast around 10 am , continues to work and around 2 am he comes home and sleep for an hour or 2 and resumes his work in vegetable Market till 9 pm . Later he drinks 90 mL whiskey and comes home , have dinner and sleep around 10 pm .

Family history : 

His mother and elder brother had similar complaints of Shortness of breath .

Treatment history : 

Patient used NSAIDS for back pain every 2-3 days for past 3 years . 

GENERAL EXAMINATION 

Patient is examined in well lit area After taking consent 

Patient is conscious , coherent , cooperative , well oriented to time , place , person . 

Patient is moderately built and moderately nourished . 

Pallor - present 

Icterus - absent 

Cyanosis - absent 

Clubbing is present

No generalised lymphadenopathy 

Pedal edema - Grade ll ( Till knees )

                        Pitting type

VITALS : 

Temp - Afebrile 

BP - 130/70 mm Hg

PR - 66 bpm

RR - 18cpm

GRBS - 92 mg/dL

Elevated JVP

CVS EXAMINATION : 

INSPECTION

chest normal in shape

no visible pulsations

no scars 

no dilated veins

AUSCULTATION 

Done in all 4 areas . S1 S2 heard . No murmurs heard 

Apex beat - 6th ICS , 2 cms lateral to Mid clavicular line

Tactile vocal fremitus -decreased on right mammary and axillary area

PERCUSSION 

dullness felt at axillary area on right side

AUSCULTATION

normal vesicular breath sounds heard and diminished sounds at right mammary and axillary areas,

CNS - no focal neurological deficits elicited

PER ABDOMEN - soft , non tender , no hepatomegaly , spleen not palpable 

PROVISIONAL DIAGNOSIS 

Heart failure with reduced ejection fraction , with right sided pleural effusion.

INVESTIGATIONS

X ray

Treatment- 

1.inj lasix 40 mg iv bd

2.fluid restriction <1lt/day and salt restriction <2gm/day.

3.tab.ecosprin po

4. Tab MET-XL 12.5 mg po

5. Inj. Thiamine 200mg direct iv bd

6. Pantop 40 mg po bd

7. Bp charting every 4th hrly and grbs 12th hrly