1601006091 SHORT CASE
HALL TICKET NO.1601006091
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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.
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
Right heart failure secondary to COPD(Cor pulmonale)
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