A 45 year old female patient residence of kattangur came to opd with 

A 45 year old female patient residence of kattangur came to opd with 

Cheif complaints :
-generalised body pains since 3 months   
  - generalised swelling of body since 1 month
 -shortness of breath  since yesterday morning 

History of presenting illness:

Patient was apparently asymptomatic 3 months back and then developed generalised body pains since 3 months which is pricking type and aggravated while doing daily routine work and walking and not relieved on medication  

C/o of generalised swelling all over the body 1 month back which is gradually progressive and swelling in legs is aggravated during walking and during nights and not relieved on medication

C/o Shortness of breath from yesterday Morning which is sudden in onset which is of grade 2  aggravated during walking and relieved by taking rest.


No H/o palpitations and chest pain 

No H/o burning micturition, decreased urine output.

No H/o fever and headache.

Past history: 

She is a known case of diabetes since 3 years and 

known case of hypertension since 1 year and is on medication.

Not a known case of tuberculosis,asthma, lymphedenopathy, epilepsy and thyroid disorders.

Personal history:

Mixed diet, 

adequate sleep,

Regular bowel and bladder movements 

Decreased appetite

No drug allergies are present

Occasionally toddy consumption.

Family history: Not significant

General examination:

Patient is conscious coherent and well oriented to place and time.

Moderately built and moderately nourished.

VITALS

Temperature: Afebrile on touch

Blood pressure: 150/100 mmHg

Pulse rate: 72bpm

Respiratory rate: 26 cpm

Pallor-present

iceterus:absent 

Cyanosis: absent

Clubbing:absent

Lymphedenopathy:absent 

Pedal edema: pitting type
Systemic examination.   

CVS EXAMINATION: 

INSPECTION.

Shape of chest wall- eliptical

No precordial bulge present 

No kyphoscoliosis present

Apical impulse- present 

No dialated veins and scars are present

Jugular venous pulse- normal

PALPATION.

Apical impulse- present in the 5th intercostal space

Pulsations are heard(aortic, pulmonary and mitral areas)

No thrills and murmers present 

PERCUSSION

All the borders of heart are felt

AUSCULTATION.

S1 S2 are heard (tricuspid,aortic and pulmonary areas)  

PER ABDOMEN:

INSPECTION:

Shape of abdomen: distended

Visible scars 

Umblicus is inverted

No engorged veins present

No visible pulsations

Abdominal wall movements are normal.

PALPATION:

Superficial- 

Temperature-afebrile 

Tenderness-absent

Liver - not palpable

Spleen - not palpable

PERCUSSION:

Liver span-

Dull note is heard because of fat 

ASCULTATION: bowel sounds are heard

PROVISIONAL DIAGNOSIS: Anasarca and anemia.




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