1601006166 SHORT CASE

 

1601006166 SHORT CASE - GENERAL MEDICINE

 This is an online elogbook to discuss our patient's deidentified health data shared after taking her/guardian's informed consent.



SHORT CASE :

A 46 yr old female, a labourer by occupation hailing from Nakirekal came to the hospital with Chief complaints of 

Shortness of Breath since 5 days and 
Generalized edema since 5 days. 

HOPI : 
      Patient was apparently asymptomatic 5 days back then she developed Shortness of Breath which was insidious in onset, gradually progressed from Grade 2 to Grade 4 (NYHA grading), aggravated on exposure to dust,cold,lying down and wakes up in the middle of the night and relieved on medication, associated with chest discomfort and Generalized Swelling  since 5 days, started in legs first then progressed to entire body.

Associated with cough with mucoid expectoration and wheeze since 5 days.

PAST HISTORY : 
Similar complaints in the past every 6-8 months
K/c/o COPD since 8 yrs and on inhalers
K/c/o HTN since 2 yrs and on medication (Telmisartan 80 mg OD)



ON EXAMINATION : 
Patient was conscious , coherent  and cooperative , well built and well nourished.
Pallor - present
Icterus - absent
Cyanosis- absent 
Clubbing - absent
Koilonychia - absent
Lymphadenopathy - absent
Edema of feet - bilateral pitting edema upto the level of knee







Vitals : 
 
 Temp -Afebrile
 PR- 91 bpm, regular rythm ,voluminous
BP- 110/70 mmHg, right upper arm in     sitting position
RR- 28 /min, thoraco abdominal
JVP - raised 
Hepatomegaly
Ascites present



 CARDIOVASCULAR EXAMINATION:
Inspection -
   precordium appears to be normal.
Palpation - 
  Left parasternal heave
  Palpable P2
  Apex beat in the left 5th intercostal space    lateral to midclavicular line.
 Auscultation -
  S1, S2 heard
  Loud P2 
  No murmurs 


RESPIRATORY SYSTEM :
Inspection - shape and symmetry of chest is normal
Trachea appears to be central 
Respiratory movements - rate is increased

Palpation - no tenderness or local rise of temperature
Trachea is central
Apical impulse in the left 5 th intercostal space lateral to midclavicular line.
Increased vocal fremitus is noted in the inframammary areas.

Percussion - dull notes were felt in the infraaxillary and infrascapular areas

Auscultation - bilateral decreased breath sounds and bilateral rhonchi and crepitations present in the infraaxillary and infrascapular areas


ECG :
 Right axis deviation
 Dominant S wave in V5


CXR :
Lower lung consolidation
Perihilar hazziness
Enlarged central pulmonary artery



PROVISIONAL DIAGNOSIS :
Right heart failure secondary to COPD (corpulmonale)




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