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55 year old female with anasarca and sob

A 55 year old female garden worker by occupation came with  complaints of Generalized oedema since 1 month,

sob since 1 month

HOPI:

Patient was apparently asymptomatic 3 years back went to local hospital for regular check up and diagnosed with DM( type 2) and HTN

Infected with covid-19 6 months back

One month back patient complained of  gradual onset of sob grade 2 (ordinary work), relieved with rest ,orthopnea -ve , paroxysmal nocturnal dyspnoea +ve

No c/o chest pain, palpitations,syncopal attacks.

H/o loss of consciousness, for around 4 to 5 hours taken to hospital responded to Non invasive ventilation and woke up,and admitted for 5 days diagnosed with Obstructive sleep apnea ,TYPE 2 RESPIRATORY FAILURE with cor pulmonale ,sepsis ,AKI 

Again presented to our casualty with similar complaints

No c/o fever, cold, cough


TREATMENT HISTORY

T.METFORMIN 500 MG PO/OD 

T.TELMA 40 MG OD 


T.DIGOXIN 0.25 MG 

T.SILDENAFIL 20 MG 

T.CARDIVAS 3.125

T.DYTOR 10 MG +SPIRONOLACTONE 

T.FUROSEMIDE +SPIRONOLACTONE 

SURGICAL HISTORY

HYSTERECTOMY 22 YRS BACK 

HERNIOPLASTY 1 year BACK 

2 LSCS 

PERSONAL HISTORY

She was married with 2 children 

Agriculture by occupation

Appetite - normal

Diet - mixed

Sleep- not adequate sleep in nights(but we'll in day time with snoring)

Bowl and bladder - regular

No known allergies

Occasionally takes alcohol ( last 25 days back)

Tobbaco -chewable form( stopped 3 years back)

GENERAL EXAMINATION

Done after obtaining consent , in a well lit room , in the presence of an attendant , with adequate exposure

NO PALLOR ,ICTERUE, CYANOSIS,CLUBBING ,LYMADENOPATHY 

ANASARCA + 

TEMPERATURE - AFEBRILE 

PULSE RATE - 64 BPM 

RR-20 CPM 

BP- 140/90 MM HG 

SPO2 -98PERCENTAGE 

GRBS - 119 MG/DL 

SYSTEMIC EXAMINATION 

CVS -

 S1 ,S2 HEARD ,

NO MURMUR 

RS- 

INSPECTION

Oral cavity- bald tongue, cracking of mouth

Nose- dns, polyps absent 

Pharynx- no post nasal drip

Trachea - central in position

Chest- symmetrical

Respiratory rate-20cpm

 In rhythm

PALPATION

Position of trachea - central

Chest expansion - symmetrical

No tenderness


Dyspnoea-grade  2

Wheezing- absent


Breath sounds - vesicular

Crepitations - no

BAE + 

Abdomen-

Shape- obese but not distended

Tenderness- not seen

Palpable mass- no

Hernial orifices - normal

Free fluid - no

Liver - not palpable

Spleen - not palpable

Bowel sounds- heard

CNS - 

level of consciousness-alert

Speech - normal 

Signs of meningeal irritation 

No neck stiffness 

Kernig's sign -ve

Cranial nerves

Motor nerves.             (NAD)

Sensory system 

Glass gow scale 













REPORTS:



27/01/2022






28/01/22:













PROVISIONAL DIAGNOSIS 

COR PULMONALE 

WITH Heart Failure Preserved Ejection Fraction 

WITH SEVERE Pulmonary Arterial Hypertension 

WITH HTN AND DM 2 

WITH OBSTRUCTIVE SLEEP APNEA

 WITH TYPE 2 RESPIRATORY FAILURE

 WITH PAST H/O COVID 6 MONTHS BACK 


TREATMENT 

HEAD END ELEVATION 

O2 INHALATION TO MAINTAIN SPO2 94 PERCENTAGE

INJ LASIX 60 MG - 40 MG -X

TAB CARDIVAS 3.125 PO/OD (2PM) 

TAB ATORVAS 20 MG PO/HS 

TAB SILDENAFIL 20 MG PO/OD (8AM) 

CPAP OVER NIGHT

STRICT I/O , WEIGHT MONITOR- DAILY 

MONITOR VITALS 4 TH HOURLY 

TAB TELMA 40 MG PO/OD (9 AM ) 

TAB METFORMIN 500 MG PO/OD (8AM) 

ZYTEE GEL L/A TID (30 MINS BEFORE FOOD )

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