1601006132 SHORT CASE

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A 46 year old female agriculturer by occupation hailing from miryalaguda presented with chief complaints of 

1. Shortness of breath since 5 days

2.Generalised swelling of the body since 5 days

HISTORY OF PRESENTING ILLNESS

The patient was apparently assymptomatic 5 days back and then she developed shortness of breath with was insidious in onset and gradually progressive grade 4. which aggravated by lying down and relieved by medication.

It was associated with wheeze and paroxysmal nocturnal dyspnea.

She also complains of generalised swelling of the body which started on the same day which was noted in the legs initially and later involving the whole body.

She has cough with mucoid expectoration since 5 days.

No history of fever,jaundice,palpitations.

PAST HISTORY

She is a known case of COPD since 8 years and is using inhalers

Similar complaints were present in the past.

Known case of hypertension since 2 years and is on telmisartan 80 mg OD.

GENERAL EXAMINATION

Patient is conscious ,coperative ,moderately bulit 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

Raised JVP

SYSTEMIC EXAMINATION

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

CARDIOVASCULAR EXAMINATION

Inspection - precordium appears to be normal.

Palpation - 

  Left parasternal heave

  Palpable P2

  Apex beat in the 5th intercostal space lateral to midclavicular line.

Auscultation

S1, S2 heard

Loud P2 

No murmurs 

PROVISIONAL DIAGNOSIS

A 46 year old female complaining of shortness of breath and generalised edema from 5 days is provisionally diagnosed to be a case of Right heart failure secondary to COPD (cor pulmonale).