Cpc (2) (1)

10
CPC GM VI

Transcript of Cpc (2) (1)

Page 1: Cpc (2) (1)

CPCGM VI

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HISTORY• 50 Year old lady

• C/O Palpitation x 2 weeks. Increased since last 2 days

• C/O Breathlessness on exertion (NYHA II) for 2 weeks

• C/O abdominal distension for 5 days

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• No h/o chest pain/ cough/ syncope/orthopnoea/ PND

• No h/o decreased urine output

• No h/o fever

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• K/C/O TYPE II DM for 5 years on Tab Metformin 500 BD

• Not a k/c/o Sys HTN, Bronchial Asthma, TB, Epilepsy, CAD, RHD , Thyroid disorder

• POSTMENOPAUSAL

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ECG

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On Examination• Conscious ,oriented ,Afebrile

• BP- 120/80 mm of Hg

• SpO2 96%

• No Pallor/Icterus/cyanosis/clubbing/lymphadenopathy

• B/L PITTING PEDAL EDEMA +

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SYSTEMIC EXAMINATION• CVS – Variable S1, TACHYCARDIA +

• RS- B/L AE+, NVBS+

• P/A – Soft, no organomegaly

• CNS - NFND

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INVESTIGATIONSBIOCHEMISTRY PATHOLOGY OTHERS

TOTAL PROTEIN 7.6 FBS 86 TC 7100 CPKMB 14

ALB -4.1 PPBS 133 N72 L21 E1 M6 CPK TOTAL 106

T. BIL 2.3DIRECT 1.2

UREA 20CREATININE 0.68

HB 11.4

SGOT 29SGPT 19

PLATELET 2.49 LAKHS

ALP 108 URINE RE- WNL

Na 134 K 3.3 Cl 101

INR 1.61

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2D ECHO• RA RV DILATED

• MILD PAH

• ADEQUATE LV FUNCTION

• SEVERE TACHYCARDIA DURING STUDY

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CASE IS OPEN FOR DISCUSSION


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