CASE OF A 40 YEAR FEMALE WITH PEDAL EDEMA : SHORT CASE
1601006087
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A 40 year old female patient, works at a construction site came to the opd with
CHIEF COMPLAINTS OF :
1. Chest pain since 5 days
2. Shortness of breath since 5 days
HISTORY OF PRESENT ILLNESS :
The patient was apparently asymptomatic 5 days ago, the she developed chest pain, non radiating & increased on taking deep inspiration.
Shortness of breath on & off
No h/o orthopnea, PND, fever, Cough
PAST HISTORY : Not a k/c/o DM, HTN, CAD, Asthama, epilepsy and Tb
PERSONAL HISTORY :
Mixed diet
Appetite normal
Sleep is adequate
Bowel and bladder movements regular
No addictions
FAMILY HISTORY : Not significant
GENERAL EXAMINATION :
• She is conscious,coherent and cooperative
• Moderately built & moderately nourished
• No Pallor, icterus,clubbing,cyanosis,koilonychia and lymphedeopathy
BILATERAL PEDAL EDEMA present, pitting type
• JVP is raised - 5cm
VITALS :
•Afebrile
• PR : 102 bpm, regular rythm, normal volume, no radio radial & radio femoral delay, condition of the arterial wall is normal.
• RR : 18 cpm
• B.P : 110/80 mm hg
SYSTEMIC EXAMINATION :
• CVS : S1, S2 + , No added murmurs
• RS : NVBS, bilateral air entry present, no added sounds
• CNS :
All higher motor functions are normal
Cranial nerves intact
Sensory system normal
Motor system normal
Cerebellar signs normal
No meningeal signs
• P/A : Soft, non tender, no organomegaly, bowel sounds heard
INVESTIGATIONS :
Complete blood picture :
ECG :
COLOUR DOPPLER 2D ECHO
TREATMENT GIVEN :
Tab. Nexpro 40 mg OD
Syrup sucralfate 10 mg TID
Provisional Diagnosis: early signs of right heart failure
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