52 yr old male with complaint of chest discomfort since 3 months

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Intern : N Joshua Paul

15/9/23

Chief complaints : 52 yr old male came in with the chief complaint of breathlessness since 3 months

HOPI :

A 52 yr old male, woodcutter by occupation and a resident of suryapet presented to the opd with the chief complaint of breathlessness NYHA class since 3 months, which was more during the nights or evenings than in mornings. 

H/o orthopnea, seasonal variation present. It was not associated with chest pain/PND/Syncope. 

No H/o burning micturition/oliguria/pedal edema//palpitations/abdominal pain/nausea/fever/diarrhoea 

It is sometimes associated with excessive sweating + not associated with chest pain/palpitations/breathlessness 

PAST HISTORY :

Patient developed vitiligo 10yrs ago with areas of hyperpigmentation, hypopigmentation and depigmentation.

 







A keloid scar on chest post CABG



  On 4 episodes of palpitations and sweating in a period of 3 months he sought for consultation CAD-TVD S/p - CABG 3 Grafts @ 2021 November 

N/K/C/O HTN/DM2/Epilepsy/TB/CVA/Thyroid disorders/Asthma

TREATMENT HSITORY : treated for CAD-TVD in 2021 November

PERSONAL HISTORY : married

 Occupation - woodcutter

Appetite - normal 

Non vegetarian 

Chronic Alcoholic used to be regular but stopped the intake 4yrs ago

Family history: insignificant 

PHYSICAL EXAMINATION:

A. GENERAL EXAMINATION : 

Pallor - no

Icterus - no

Cyanosis - no

Clubbing - grade 1 





Lymphadenopathy - no

Odema of feet - present bilaterally grade 2 up to knee, pitting type

 

Raised JVP

 

Vitals : 

Pr - 84 bpm

Bp - 130/80 mmhg

RR - 19 cpm

GRBS - 154 mg%

SYSTEMIC EXAMINATION :

CVS : No thrills

          Cardiac sounds - S1 & S2 heard

          Visible raised JVP

RS : Dyspnoea : orthopnea +, NYHA grade 1

        Position of trachea : central

        Breath sounds : vesicular

        Adventitious sounds : b/l rhonchi + in Infrascapular, interscapular and infraaxillary area

  B/L airway entry present

P/A : Soft, non tender abdomen, bowel sounds heard and no organomegaly observed

CNS : No FND

           HMF - intact

           Sensory system - normal

           Motor system - Normal

           No focal neurological deficits

INVESTIGATIONS : 



2D echo: 

The patient was referred to dermatology department in view of vitiligo and cross consultation was done





Diagnosis : 1. Asthma

                   2. CAD-TVD - s/p CABG - TRIPLE GRAFT (2yrs ago)

                         C/o breathlessness of grade 1 NYHA

Treatment : 1. Tab. ECOSPORIN 75mg po H/S

                     2. Tab. MET-XL 12.5 PO/OD (at afternoon)

                     3. Tab. ROSUVASTATIN 20mg po H/S (at night)

                     4. INHALER BECLOMETHASONE DIPROPIONATE 200 mg/ sos