1601006040 SHORT CASE

FINAL YEAR MBBS SHORT CASE - GENERAL MEDICINE (1601006040).



I'm a final year medical undergraduate bearing the hall ticket number-1601006040. I've been allotted with this following de-identified case to present on the day of the final practical exam, so I've contacted the patient and took the verbal consent to take the history and to examine the patient. 

This E log also reflects my patient center’s online learning portfolio and valuable inputs on the comment box are welcome.

here are the few incites which I have noticed

A 46yr old female, housewife resident of Nalgonda came to the hospital with chief complaints of shortness of breath since 5days 

History of present illness

  She was apparently asymptomatic 5days back then she developed shortness of breath which was insidious in onset, gradually progressive, aggravated on lying down, and relieved on medication.

Associated with orthopnea, wheeze, paroxysmal nocturnal dyspnea 

Anasarca since 5days and cough with expectoration since 5days which is insidious in onset

Past history

K/c/o Copd since 12yrs and is  on inhaler

 General examination 

Raised JVP 

Respiratory examination 

Inspection-normal

Palpation- normal

Auscultation - bilateral decreased breath sounds and bilateral rhonchi and crepitations present at infrascapular, infra axillary areas\




Cvs examination 

Inspection -normal

Palpation

*left parasternal heave

*Palpable p2

*apex beat 5th ICS lateral to the midclavicular line

Auscultation

*S1, S2 present

*Loud p2

*no murmurs 




Findings

The right atrium and right ventricle dilated

RVSP 85mmhg

Severe TR with PAH

Provisional diagnosis

Right heart failure ?secondary to COPD (CORPULMONALE) 

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