1601006091 SHORT CASE

 

1601006091 SHORT CASE



HALL TICKET NO.1601006091
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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. 

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 A 46 yr old female, labourer by occupation resident of Nakirekal came to the hospital with

chief complaints of -

Shortness of Breath since 5 days and 

Generalized swelling of body since 5 days. 



History of Present illness : 

      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(orthopnea) and wakes up in the middle of the night(PND) 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 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 , moderately built and moderately nourished.

Pallor present

Icterus absent,

clubbing absent, 

cyanosis absent ,

koilonychia absent,

lymphadenopathy absent,

Bilateral pitting type of pedal edema is present upto the level of knee.

Vitals:
Temperature:-Afebrile.
Pulse rate :- 91 bpm, regular rhythm ,voluminous.

Blood pressure:- 110/70 mmHg, right upper arm in sitting position.

Respiratory rate: - 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.



CXR :
Lower lung consolidation
Perihilar hazziness
Enlarged central pulmonary artery

ECG:
     Right axis deviation
     Dominant S wave in V5
     P pulmonale
PROVISIONAL DIAGNOSIS:-
 Right heart failure secondary to COPD(Cor pulmonale)


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