M.B.B.S Final Practical Examination Long Case - 1701006038

D. Gaurav Singh
1701006038

DE-IDENTIFIED CONSENT FORM :
A 80 yr old female, dailywaged labourer by occupation was brought to the casuality with 

CHIEF COMPLAINS :
× Shortness of breath since 3 days 
× Dry cough since 3days

HISTORY OF PRESENTING ILLNESS :

C/O - Shortness of breath which was insidious in onset  progressed from exertion to rest . 
C/O - Dry cough since 6 days. 

PAST HISTORY : 
A known case of  
# Diabetes Mellitus( Tab metformin 500 mg)
# Hypertension ( Tab Atenalol 50 mg +Amlodepine 5 mg)
Not a known case of epilepsy, TB, Asthama. 

MENSTRUAL HISTORY :
# Age of menarchy 14 years. 
# Age of menopause 43 years. 

FAMILY HISTORY :
 No similar complains in the family

PERSONAL HISTORY :

# Diet- mixed
# Appetite- normal
# Total Calories = 1942 K Cal
 
# Sleep- 8-9 hours daily ( normal ) 
# Bowel and Bladder movement- normal
# Urine frequency - normal
× no history of addictions. 
× no history of allergies. 

GENERAL PHYSICAL EXAMINATION :
The patient is Concious Coherent and Cooperative well oriented to Time Place and Person
Moderately build and Moderately nurished

(Source of above image DR KULKARNI MD BLOGSPOT) 
Pallor - present
Icterus - absent
Clubbing - present
Schamroth window test - positive
Loss of lovibond angle
Kolonichya - absent
Lymphadenopathy - absent
Edema - present pitting type

VITALS : 
Temperature - afebrile
Blood pressure - 130/80 mn of Hg
Pulse rate - 53 bpm irregularly irregular
Respiratory rate - 15 cycles per minute
Apex beat 2cm lateral to mid clavicular 


EXAMINATION :
Palpation- no hepatimeghaly ans spleenomeghaly
Percussion- dull note heard
Auscultation- crepetus heard
Raised Jugular Venus Pulse (JVP) 
E-JVP grading - 2
Image source JVP Research Papers 

SYSTEMIC EXAMINATION :

CVS Examination -  s1 and s2 heard no murmurs

Respiratory system examination - Bilateral air entry present, trachea in midline, Bilateral lower zone crepetus present

CNS Examination - all reflexes are normal
Tone - 5/5 
Power - 3/5

ECG showing bradyarrythmia

Chest X-Ray showing
(1) Enlarged cardiac silhonette
(2) Bilateral pleural effusion
(3) Ground glass appearance

DIAGNOSIS :
Heart failure with spared ejection fraction

Treatment :
PREVENTION BETTER THAN CURE
(1)Bed rest
(2)Regular stamina building exercise
(3)Avoid excess salt intake
(4)Diuretics - Furesemide
(5)Vasodilators - Nitrates
(6)ACE inhebitor
(7)Angiotensin II receptor blockers
(8)Digoxin
(9)Beta blockers
Oxygen setup 
SpO2 - 91% with 4 litre oxygen given through venturi mask








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