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1601006175 SHORT CASE

 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. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box are welcomed. 

1601006175 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 inframammary, 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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