75 year old female

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Name : Thota Vaishnavi
Roll no : 133

Chief complaints 

75 year old female came with chief complaints of 
-Shortness of breath since 3days (grade 4) MMRC
-Orthopnoea since 3 days

HISTORY OF PRESENT ILLNESS

70 year old female, resident of chandanapally.
Patient was apparently asymptomatic 10days back.Then developped Shortness of breath(grade2)-which progresses to (grade4)-3days back.
Patient also have orthopnoea since 3days
She is developping fever(low grade) on and off since 1 year and subsides on taking medication.

Poor stream of urine since morning

Nausea since morning

No paroxysmal nocturnal dyspnea 

No h/o weight loss

No h/o lower abdominal pain,bleeding pervaginum


PAST HISTORY

15 years back she developped psoriasis in nails (UL) later which had spread to overall body within 5years. For 3 years she used Allopathy medicines, but she was not satisfied. Then she went to homeocare hospital and started on medication.After using medication, it subsided in few areas and even now she is on medication.

Aggravated during winter,recent(in January,2022)-spread to overall body

N/K/C/O-HTN,DM,Asthma,TB,Thyroid disorders,CVA,CAD or any other chronic illness.


FAMILY HISTORY

Not significant 

PERSONAL HISTORY

Appetite-decreased since jan2022(no h/o weightloss)
Sleep-adequate
Bladder movements-poor stream of urine since morning
Bowel movements-regular(normal in colour)
Diet-mixed

GENERAL EXAMINATION 

Pallor-present
Icterus-absenyt
Cyanosis-absent
Clubbing- present 
Lymphadenopathy-absent
Edema-absent

VITALS ON ADMISSION

BP-80/50mmhg
PR-104bpm
TEMP-98.2°F
SPO2-90% at RA and 100% on 5 lit O2
GRBS-162mg/dl

SYSTEMIC EXAMINATION

Cardiovascular system

            S1S2-+

            No thrills

            No murmurs

            Right Parasternal heave-present

             Raised JVP


Respiratory system 

           BAE-+

           NVBS-heard

           Dyspnoea-present

           Position of trachea-central

           No wheeze

           No adventitious sounds heard
P/A
            Soft and nontender
   
            Shape-scaphoid

            No palpable mass

            No free fluid

            No organomegaly

            Bowel sounds-heard

Central nervous system 

            -Patient is conscious, coherent and                cooperative.

            Speech-normal

            No signs of meningeal irritation

            NFND

PROVISIONAL DIAGNOSIS

HEART FAILURE WITH PRESERVED EF(EF-62.1)

WITH MODERATE TO SEVERE TR WITH PULMO ARTERY HYPERTENSION

WITH MODERATE MR

WITH BICYTOPENIA UNDER EVALUATION

WITH? PALMOPLANTAR PSORIASIS

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