35 year old female SOB,fever, generalized weakness





 Case :

35 years old female,resident of choutuppal,works in the hotel, came with chief complains 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  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 , 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 signigicant

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:

Iron deficiency anemia secondary to menorrhagia

Investigations:

15/04/23-




16/04/23-











Treatment: T.Paracetamol 650 mg PO/sos
                   T.orofer PO

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