1601006061 SHORT CASE

 Hall ticket no. 1601006061


"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. 

       

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 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

 



Findings

The right atrium and right ventricle dilated

RVSP 85mmhg

Severe TR with PAH


Provisional Diagnosis

Right heart failure sec to COPD (CORPULMONALE)

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