Madhavan
58/M
Thrissur
Farmer by occupation, currently unemployed for 3 years
Studies till 10th standard
Informant is patient himself and history is reliable
Date of admission :
Date of examination :
C/o worsening of dyspnea* 1 week
C/o worsening of pedal edema *1 week
History of Presenting Illness
Patient was in his usual health 7 days back, when he started to experience worsoning of dyspnoea.
Patient could initially walk around 1 km without breathlessness, but for the past 7 days patient finds it difficult to walk around his home and feels breathlessness even while walking to bathroom.
Patient has associated palpitations on exertion, relieved by rest. Patient has worsoning of dyspnoea on lying down and prefers to lie on either side than lie flat. Patient could not appreciate the regularity of palpitations and no h/o post palpitation diuresis. Patient had sudden onset dyspnea yesterday night which woke the patient from sleep and he was unable to lie down at the time.
No h/o chest pain/excessive sweating/vomiting/syncope
Patient also gives history of worsoning pedal edema for the past 7 days. Initially patient had on and off pedal edema often during evening time and edema rarely extending above the ankle joint. But for the past 1 week edema has increased, present at all times but more during evening and edema upto knee joint present.
No h/o abdominal distention or facial puffiness
No h/o decreased urine output/oliguria/hematuria
No h/o yellowish discoloration of eyes and urine
No h/o nausea/vomiting/right upper quadrant pain
No h/o altered bowel habits/bleeding manifestations
No h/o heat/cold intolerance
No h/o joint pain/skin rash/oral ulcers/genital ulcers
No h/o any altered behaviour/seizures/weakness of limbs
Past History
Patient has h/o dyspnoea on exertion for the past 5 years, initially noticed on heavy exertion or lifting weights later gradually progressed over 5 years and had breathlessness even on walking for a distance of less than a km. It was associated with exertional palpitations. Patient was evaluated for the same and found to have valvular heart disease and was on regular medications. 3 days prior to symptoms patient has drug default following which symptoms appeared.
H/o diabetes for the past 2 years following which patient was on insulin and OAD.
H/o systemic hypertension for the past 1 year on regular medications.
No h/o TB/CAD/CVD in past
No h/o allergies/surgery in past
Personal History
Smoker for past 40 years- 80 pack years
Predominantly vegetarian diet
Normal bowel and bladder movements
Normal sleep and appetite
Family History
H/o CAD for father, started at the age of 70
No h/o TB/Respiratory diseases/malignancies/sudden death in family
Socioeconomic History
Patient lives with his wife and 2 children
Patient has own house/adequate sanitation/drinks boiled water/no overcrowding
Summary
K/c/o valvular heart disease detected 5 years back/T2DM/S.HTN now presented with complaints of worsening dyspnea associates with orthopnoea and pedal edema.