History: This is a 56-year-old male who works in a travel agency. He is a smoker for years, and he is still smoking about 10 cigarettes per day. In this presentation, he started feeling breathless with his usual activity about a week back. He stays near his office, and normally he goes to work on foot. Previously he was able to walk to his office in a slower pace without much of discomfort; however, for the last 1 week or so, he is trouble covering this small distance without taking rest midway, and the distance for taking rest is decreasing day by day. Although with rest, the breathlessness seems to wane down, he is worried due to the fact that his feet are swollen, and this time the grade of swelling is much more than earlier ever. EHehHe has noted also that he is coughing a little with expulsion rusty sputum of small quantities. His sleep is disturbed since he can no longer sleep on the bed with usual two pillows that he uses, and of late, he needs to use 4 pillows which makes him reclined on the bed. Over the top of that he can sense his heart is beating faster, and last night he had to wake up from whatever sleep he was having with sudden episodes of acute breathlessness just after midnight. He is feeling fatigued, tired, and exhausted. His appetite is poor, he is having a bloated sensation in the abdomen, and heaviness in the upper part of his abdomen, more on the right hand side. From his previous visit, the doctor asked him to quit smoking, and he did not comply, and now he knows that like previous such episodes, he is going to have another now, and so he decided to visit the clinic.
He has past history of congestive heart failure with ischaemic heart disease. He has no evident drug allergies or drug interactions. He is on diuretic and digitalis. He has associated hypertension. On interrogation, there is no suggestive history of weight loss or blood loss; however, he has gained some weight.
Clinical Examination: On inspection, he was obviously with discomfort, and respiratory distress was obvious with nasal flaring, retraction of the suprasternal notch, moderate use of accessory muscles of respiration, and intercostal retraction. His vital sign examination revealed him to be puffy, with pallor. There was no cyanosis, jaundice, but he had grade 2 clubbing and +4 pitting edema in both the ankles and pretibial regions. There was no cervical lymphadenopathy, thyroid was not palpable, face was puffy. On examination, he had harsh vesicular breath sounds throughout the lung fields, with features of laboured breathing at a rate of 22 per minute at rest. The lungs were otherwise clear except at the bases, there were fine moist rales. There was no dullness to percussion in any lung area including the bases. His pulse rate was 92, blood pressure 100/92, peripheral pulses were equal volume on both the sides with carotids being palpably normal. The jugular venous pressure was elevated in clinical examination with distention up to 12 cm from the suprasternal notch on a 45 degree recline on the examination couch. The apical pulse was located in the seventh intercostal space 1.5 cm lateral to the left midclavicular line, and with close inspection, the apical impulse was visible. There was obviously evidence of cardiomegaly, but it was difficult to discern whether there was any