Medicine log book by kyasa Sai Brigisha admin no 1601006107
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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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