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 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)