1601006046 SHORT CASE

 

1601006046 short case



 GENERAL MEDICINE 

 A 46 year old female, resident of Nalgonda, who is a housewife came to the outpatient department with the chief complaint of shortness of breath since 5 days. 

History of presenting illness: 

The patient was apparently asymptomatic 5 days ago and 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 and cough with expectoration since 5 days which was insidious in onset. 

Known case of COPD since 12 years and is on inhaler. 

Personal history- 

Chronic smoker since 20 years.

General Examination: 

Raised JVP

Respiratory System examination: 

• Inspection- normal

• Palpation- normal

• Auscultation- bilateral decreased breath sounds and bilateral rhonchi and crepitations present at infrascapular and infraaxillary areas.


CVS Examination-  

• Inspection- normal

• Palpation-

*left parasternal heave

*palpable P2

*apex beat at 5th intercostal space, lateral to midclavicular line

• Auscultation -S1,S2 heard

Loud P2, No murmurs



Findings- 

• Right atrium and ventricle- dilated

• RVSP- 85 mm of Hg 

• Severe TR with PAH

Provisional diagnosis:
Right heart failure ?secondary to COPD (CORPULMONALE)

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