A 55 year old businessman, a smoker, non diabetic and non hypertensive presented to the OPD with complaints of headache and vertigo for 2 weeks which was not associated with vomiting and blurring of vision.
He had fatigability with lack of concentration on daily activities for 4 years, bluish discoloration with swelling of fingers and toes for 10 years and exertional shortness of breath since childhood.
Initially it was during severe exertion and relieved by rest and later it became continuous. It was not associated with seasonal variation
He had H/O repeated attack of cough with scanty amount of hemoptysis which wasn’t foul smelling and did not change with posture and there was no seasonal variation.
He did not give any history of pain and swelling of the joints, calf muscle, syncopal attack, chest pain, prolonged fever except occasional palpitations.
conjunctiva: Suffused,non-icteric, central cyanosis and clubbing present.
Oedema absent. JVP not raised.
Pulse 92/min , BP 120/70 mm Hg
RR 18/min T -98°F
There was no chest-wall deformity, apex beat was in the left fifth intercostal space just lateral to the mid-clavicular line and normal in character.
Palpable P2, left parasternal heave, epigastric pulsation were present but no thrill.
S1 normal ; P2 loud with narrow fixed splitting;
Ejection systolic murmur (2/6) in pulmonary area, no other added sounds.
All other systems were normal