1601006069 short case




I'm a final year medical undergraduate bearing the hall ticket number-1601006069. I've been allotted with this following de-identified case to present on the day of the final practical exam, so I've contacted the patient and took the verbal consent to take the history and to examine the patient. 


This E log also reflects my patient center’s online learning portfolio and valuable inputs on the comment box are welcome.


A 46yr old female, housewife resident of Nalgonda came to the hospital with chief complaints of shortness of breath since 5days 


History of present illness:

  She was apparently asymptomatic 5days back then she developed shortness of breath which was insidious in onset, gradually progressive, aggravated on lying down, and relieved on medication.


Associated with wheeze , paroxysmal nocturnal dyspnea


Anasarca since 5days and cough with expectoration since 5days which is insidious in onset.


Past History:


K/c/o COPD since 12yrs.


General examination:


Raised JVP.


Respiratory examination 


Inspection-normal


Palpation- normal


Auscultation - bilateral decreased breath sounds and bilateral rhonchi and crepitations and present at infrascapular, infra axillary areas.



Cvs examination 


Inspection -normal


Palpation


*left parasternal heave


*Palpable p2


*apex beat 5th ICS lateral to the midclavicular line


Auscultation


S1, S2 present


Loud p2


pansystolic murmur along left lower sternal border



Chest X ray:

  

Findings

The right atrium and right ventricle dilated


RVSP 85mmHg


Severe TR with PAH



Provisional diagnosis: RIGHT HEART FAILURE SECONDARY TO COPD( COR PULMONALE)


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