65 yrs FEMALE HEART FAILURE, HYPERTENSION, DIABETES, TELANGANA PaJR

65 yrs Female patient came with

C/O Difficulty in breathing since 2 months
Left sided chest pain since 2 months
Left shoulder pain since 2 months
Neck pain since 2 months 
Swelling in the neck since 20yrs

HOPI : patient was apparently alright before 6 months since then she had shortness of breath on and off which is mild and doesn't cause any problem in her daily activities, day by day it is gradually increasing and since 2 months she had moderate to severe shortness of breath and it becomes difficult for her to do her daily activities and sob is present with mild exertion., 
PND present
Orthopnoea present
Chest pain is gradual in onset which is increasing while walking and relieved by rest, pain radiating to left shoulder, back and neck
Swelling in the neck is present since 20 yrs which is gradually increasing in size and moving with Diglutation. 

PAST HISTORY : k/c/o.HYPERTENSION using Tab. Amlodepin since 3 yrs
k/c/o. DIABETES MELLITUS using Tab. Metformin 500mg since 3 yrs
No H/O TB / ASTHAMA / CAD / EPILEPSY

PERSONAL HISTORY : Diet - mixed
appetite- poor, no addictions
FAMILY HISTORY : No history of similar complaints in family, no h/o DM/HTN/CAD /ASTHAMA/EPILEPSY

ON EXAMINATION : 
patient Concious, coherant, cooperative
Pallor present
b/l pitting pedal edema present
No cynosis, no clubbing, no lymphedenopathy
Temp - Normal
Pulse - 90, regular
BP - 100/60mm of hg
CVS - S1, S2 present, no murmurs
RS- basal crepts present in left lower segment
PA - Mild distended




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