35 year old female with sob,fever, generalized weakness
Medical case discussion
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CASE DISCUSSION
35 years old female,resident of choutuppal,works in the hotel, came with chief complains of
•SOB since 3 months
•fever and generalised weakness since 1 month.
HOPI:
Patient was apparently asymptomatic 3 months back then she had shortness of breath which relieved on taking rest ,No orthopnea, no PND.
-C/o generalised weakness since 1month ,13 days back she went to the Suryapet hospital ,there they did haemogram and diagnosed as anemia, at that time her hb was 3 gm/dl.
-C/o fever since 1 month, intermittent in nature.10 days back she had high grade fever, associated with chills and rigors,relieved on taking medication.
-C/o cough since 2 days ,which is productive, yellowish in colour and non foul smelling.
-H/o heavy bleeding last month (lasted for 11 days(1st 6 days heavy bleeding then next 2 days bleeding is stopped then again 5 days bleeding occured)
-No H/o blood in the stools, hematemesis , Malena,hemoptysis.
MENSTRUAL HISTORY:
-Regular cycle ,with normal flow until last Feb.
-Last month (March)heavy bleeding without clots ,lasted for 11 days (1st 6 days heavy bleeding then next 2 days bleeding is stopped then again 5 days bleeding occured)
DAILY ROUTINE:
She wakes up at 6 am and does her morning routine and drinks tea at 9 :am,(she does not eats breakfast) and goes to work (works in hotel) ,lunch at 3 pm ,again continues work and comes back at 6 pm ,dinner at 8 pm (sometimes she eats, sometimes will sleep without eating dinner only) , goes to bed at 10pm.
PAST HISTORY:
Not a k/c/o Diabetes,asthma, coronary artery diseases,epilepsy,thyroid disorders.
FAMILY HISTORY :
Not significant
PERSONAL HISTORY:
Diet- mixed
Appetite - normal
Sleep -normal
Bowel and bladder -regular
Addictions- none
GENERAL EXAMINATION:-
-Patient is conscious, cooperative, with slurred speech
Well oriented to time, place and person
-thinly built and malnourished.
Pallor - present
Icterus - absent
Cyanosis - absent
Clubbing - absent
Koilonychia-present
Lymphadenopathy - absent
Oedema - absent
VITALS:
Temp:97.8°F
B.P:110/70 mmhg
P.R:82 bpm
R.R: 20 cpm
SYSTEMIC EXAMINATION:
ABDOMINAL EXAMINATION:
Inspection -
Umbilicus - inverted
All quadrants moving equally with respiration. No scars, sinuses and engorged veins , visible pulsations.
Hernial orifices- free.
Palpation -
soft, non-tender
no palpable spleen and liver
CARDIOVASCULAR SYSTEM:
Inspection :
Shape of chest- elliptical
No engorged veins, scars, visible pulsations
JVP - raised
Palpation :
Apex beat can be palpable in 5th inter costal space
No thrills and parasternal heaves can be felt
Auscultation :
S1,S2 are heard
no murmurs
RESPIRATORY SYSTEM:
Inspection:
Shape- elliptical
B/L symmetrical ,
Both sides moving equally with respiration .
No scars, sinuses, engorged veins, pulsations
Palpation:
Trachea - central
Expansion of chest is symmetrical.
Vocal fremitus - normal
Percussion: resonant bilaterally
Auscultation:
bilateral air entry present. Normal vesicular breath sounds heard.
CENTRAL NERVOUS SYSTEM:
Conscious,coherent and cooperative
Speech- normal
No signs of meningeal irritation.
Cranial nerves- intact
Sensory system- normal
Motor system:
Tone- normal
Power- bilaterally 5/5
Reflexes: Right. Left.
Biceps. ++. ++
Triceps. ++. ++
Supinator ++. ++
Knee. ++. ++
Ankle ++. ++
PROVISIONAL DIAGNOSIS:
Anemia secondary to menorrhagia
INVESTIGATIONS:
12/4/2023-
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