63 year old man with dyspnea and chest pain


Unit 3:

Interns:

Dr .Leela 

Dr Harsha 

Dr Archana

Dr Kalyan 

Dr Jeehariki


Dr Raveen PGY1

Dr Aashitha PGY2

Dr Aravind PGY3

Dr Vamshi PGY3

Dr Hareen SR

Dr Praveen Naik Ass Prof

DR. RAKESH BISWAS HOD


This  is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 


Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidencebased inputs. 



This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.


Here is a case i have seen:

Admission under unit 3: 3/2/2021

63 year old man presented to the causalty with the complaints me

Chest pain since 5 days

Dyspnea at rest since 5 days

Dysphagia since 2 days

Throat pain since 2 days 

Patient was apparently alright 2 years back after which he starting noticing that he would get Dyspneic and fatigued on walking for short distances. He had no complaints of chest pain, bendopnia, orthopnea, reduced urine output back then.

His wife however, tells us that he occasionally had wheeze. 

After an year, he started having bilateral pedal edema extending to knees on and off


One month back, he visited a local hospital as he started having cough associated with blood tinged sputum along with Dyspnea ( no documentation available)


And now he presented to us with Dyspnea at rest since 5 days, along with Left sided chest pain, which is dragging type, on and off, radiating to his throat. He also is complaining of difficulty in swallowing.

General examination:
Patient is conscious,coherent and cooperative. 

Pallor +,clubbing+,

No icterus, cyanosis and clubbing. 

Vitals:
Temp-99.2F
PR-86bpm
BP-110/70mmHg
RR-20cpm
SPo2-98% @room air


CVS EXAMINATION :

Jvp not raised

Apex beat in 6th ICS 1 cm lateral to mcl

Pansystolic murmur 

S1, S2+

R/S - BAE+ B/L ISA,IAA area fine crepts present,Bronchial breaths +

CNS-NAD
P/A - Soft, nontender


Investigations.



DIAGNOSIS:

1. HFrEF secondary to ischaemic heart disease

2. Right sided pleural effusion.


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