Case of a 60 year old male

This is the case of a 60-year-old male, a labourer by occupation who presented to the hospital yesterday afternoon with chief complaints 

- Lower back pain since 4 days 

- Chest pain since 4 days 

- Shortness of breath since 4 days 

History of Presenting Illness 

The patient was apparently asymptomatic 6 months ago 

6 Months ago the patient developed pain in the left side of the chest which radiated to the left nape of the neck. 

At this time, the patient visited 3-4 hospitals, but the pain did not reduce, later on the patient was diagnosed to having an MI after the completion of a few tests at another hospital. The patient underwent angioplasty. After 4 days of the surgery, the patient went for a checkup which was concluded normal. 

4 days ago, the patient got drenched in the rain and developed a respiratory tract infection. It lasted for a day. Which led to him experiencing shortness of breath. 

The shortness of breath was insidious in onset, non-progressive. It was aggravating due to sputum (yellowish white in color). There was presence of cough The cough was more at night. Thesputum and shortness of brethe were aggravating at night while sleeping. The cough led to vomiting. 

The contents of the vomitus was water and sputum . There were 4 - 5 episodes, while going to the hospital in the car. 

The patient also complains of chest pain and lower back pain since then. 

The chest pain was insidious in onset, maintaining the same intensity and was described as muscular pain by the patient. It was localised to the left side without any radiation. Lasted till the patient presented to our hospital. There were no aggravating or reliveing factors. 

The lower back pain is bilateral , pricking type of pain, insidious in onset, continuous, aggravated by change of positions , walking and lying supine on the bed. It was relived on sleeping on one side(any). It was not radiating . 

On reaching another hospital (4 days ago) the patient was given oxygen therapy and nebulisation and given some medication afterwhich the vomiting and shortness of breath stopped. 

The patient also complained of green urine with burning micturition with white discharge for one day , with normal frequency of urination , with no blood or suprapubic pain . He was given medication and it was resolved. 

The patient also complains of itching and  skin eruptions bilaterally in the lower limbs since 2 years  without any redness. 

Past History

The patient is a known case of DM since 8 years and is on Tablet metformin 500 mg and glimiperide 1mg . 

6 months ago the patient underwent angioplasty and is on medication for the same since then as he had an episode of MI. 

Not a known case of TB , Hypertension, Epilepsy. 

FAMILY HISTORY 

No similar complaints in the family.

Personal History 

Diet ; Mixed 

Appetite : reduced 

Bowel movements: contipation since 4 days

Bladder : one episode of green urine and burning micturition 4 days ago , since then normal urine (pale yellow urine )with normal frequency and no burning micturition.

Addictions: chronic alcoholic and smoker till 6 months ago

Smoking since 12 years 4 cigarettes a day 

Alcohol 90 ml a day since 12 years .

Previous  investigations - 4 days ago 

Treatment history 

Examination 

General examination 

The patient is conscious,coherent, cooperative, oriented to time place and person.

Absence of pallor , icterus , cyanosis , clubbing , lymphadenopathy, edema. 

CVS EXAMINATION 

On inspection: 

Shape of chest : funnel shaped, pectus excavatum 

No Dilated veins , or scars 

Apex beat not observed. 

On Palpation 

Apical beat normal 

No thrills 

No parasternal heave

On auscultation 

S1, S2 heard- low pitch

No murmurs

Provisional diagnosis - heart failure secondary to myocardial infarction 

lower back ache

Investigations 

Treatment 

 Ultracet , glimiperide, atorvastatan , aspirin.