Medicine log book by kyasa Sai Brigisha admin no 1601006107

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May 01, 2021

This is an onlineE log book to discuss our patients de- identified health data shared after taking his / her guardian' s signed informed consent . Here we discuss our individual patients problems through series of inputs from available global online community of experts with with an aim to solve those patients clinical problems with collective current best evidence based inputs . This E log book also reflects my patient my patient- centered online learning portfolio and your inputs are welcome

May 2 2021

SHORT CASE

This is an online elogbook to discuss our patient's deidentified health data shared after taking her/guardian's informed consent.

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)

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Comments

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