Dr. Piyush Chopra presented a case of a 47-year-old female homemaker who has experienced gradual onset of progressive breathlessness over the past 2 years, as well as chest pain and decreased appetite for 1 year. On examination, she had pallor and epigastric pulsations. Her liver was palpable 3 fingers below the costal margin and was pulsatile. The differential diagnoses considered were serum anemia with heart failure, valvular heart disease, adult congenital heart disease, and pulmonary hypertension.

1. CASE PRESENTATION
Presented by – Dr. Piyush Chopra
Junior Resident 3
Department of Internal Medicine
HIMS, Sitapur
Moderator- Dr. Nishant Kanodia
HOD & Professor
Department of Internal Medicine
HIMS, Sitapur

2. • Patient name Mrs. Ram rati 47 year old female resident of sitapur,
hindu by religion. She is a homemaker. History has been given by the
patient herself.
• Chief complain of – Breathlessness since 2 years
Chest pain since 2 years
Decreased appetite since 1 year

3. • HOPI- Patient was apparently well 2 years back then she started
developing Breathlessness which was insidious in onset, gradually
progressive from NYHA CLASS I to III i.e. earlier she used to had
breathlessness on exertion i.e. on climbing stairs , carrying something
heavy to now on daily routine activities like bathing etc. This
progression occurred over 2 years . History of pedal edema on & off
but not present at time of presentation. No history of orthopnea
/PND .
• No history of cough , no seasonal or diurnal variation of
breathlessness. No history of fever. Breathlessness relieved on rest
which is associated with easy fatiagability

4. • Patient also complained of chest pain ,which was diffuse and on left
side of chest pain, was on /off and associated with palpitations . No
radiation to arm, neck or jaw. Relieved by taking rest . Patient
complained of decrease in appetite since 1 year
• Earlier she used to take 2 chapatis with a bowl of fal/ sabzi but now
reduced to ½ or 1 chapatti , not associated with any fever, nausea ,
vomiting , diarrhoea , constipation.
• No history of syncope or dizziness , no history of squatting episodes .
• No history of sweating , no history of heat intolerance, no history of
any bleeding in stools or black colour stools .No history of recurrent
respiratory Infections . No history of decreased urine output , rashes
or joint pain

5. • No history of any sudden onset exacerbation of breathlessness, no
history of any stroke in past.

6. • Past History – No History of T2DM, HTN ,ATT, Any thyroid disorder
• Menstrual History- Menarche at 14 years , 28 days cycle , normal flow
• Obstetrics History- P3L3A8
All 3 male delivered by normal vaginal delivery at home,
the youngest son is of 22 years . All pregnancies were uneventful.
• Personal History- Mixed Indian diet
Normal sleep 6-8 hours with no night awakening episodes.
No addiction
Normal bowel and bladder habits
• Surgical History- No history of any surgery in past.

7. • Summary- 47 years old female resident of sitapur , homemaker, known
case of presented to hospital with chief complain of gradual onset ,
progressive breathlessness since 2 years with no orthopnea /PND. She
also complained of chest pain , left sided with no radiation to any area,
associated with palpitations on /off and decrease in appetite

8. Differential Diagnosis
• Serum Anaemia with heart failure
• Valvular heart disease with RHD
• Adult presentation of congenital heart disease
• Pulmonary hypertension

9. Examination
• Patient is calm, quiet , conscious well oriented to time place, person
• Patient is lean and undernourished
• Ht-160 cm
wt-43.7 kg
BMI -17.1
Pulse – 95 bpm, regular , low volume , no radioradial or radiofemoral
delay . All distal pulses palpable

10. BP- Rt Arm 98/66 mmHg Rt leg -122/78 mmHg
Lt Arm 100/64 mmHg Lt leg – 120/76 mmHg
Taken in supine position
RR-14/min , temp -98.6 F , SPO2- 99% @ RA
thoracoabdominal axillary

11. • Hair – Normal , no sign of alopecia
• Eyes- No Icterus, pallor present , proptosis +
• Nose- No cyanosis,
• Nails – clubbing absent
• Lips – No cyanosis
• Mouth – No ulcers, glossitis
• Neck- No swelling, Neck veins not engorged
JVP not raised
No palpable Lympnode

12. • CNS
Inspection –
Chest wall- B/L Symmetrical , no scar marks, no visible veins , no spine
deformities
Palpiataion – Apical impulse-5th intercostal just lateral to medial to
midclavicular line
No parasternal heave
Epigastric pulsations present (felt on tip of finger)

13. • ABDOMINAL
- Soft non tendeer on superficial palpation
Palpation
- Tenderness present in right hypochondrium on deep palapation
- Liver was palpable and finger below lower costal margin in mid
clavicular line.
-Live span -18cm. Pulsatile liver present
Spleen – palpable 3 finger below lower costal margin
No shifting dullness, no fluid thrill.

14. THANK YOU