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

Comments

Post a Comment

Popular posts from this blog

45 year old male with history of Pedal oedema and Shortness of breath

Image
CASE :  45 year old male , lorry driver by profession , resident of Nalgonda came with chief complaints of Shortness of breath since 4 months HOPI : Patient daily routine includes , he used to drive lorry across the states - work for 5-6 days a week from the age of 20 yrs. Until 4 months back he was living happily with his family but 4 months back everything started to go wrong when he was not able to do his work of earning. He was apparently asymptomatic 4 months ago then he developed shortness of breath grade - 3 insidious in onset , progressive ,relieved on taking medication and rest . associated with orthopnea. He was taken to a local hospital and dialysis was initiated. History of Pedal oedema after a week , pitting type upto knees was seen . Dialysis was done since 4 months , twice weekly History of Dry cough since 15 days , sudden in onset 7-10 episodes in a day and each episode consisting of 8-10 bouts of cough . Oliguria since 1 week No history of fever, burning micturition
Read more

34 year old male with vomiting, hiccups and cough

Image
A 34 year old male patient lorry driver by occupation resident of chitiyala came to opd with chief complaints of Vomiting, Hiccups and Cough since 3 days HOPI-  Patient was apparently asymptomatic 3 days back then he had vomiting 10 episodes per day which is sudden in onset,non bilious,non projectile,food and water as the contents.  Vomiting is present immediately after food,water and alcohol intake.After vomiting he was associated with generalized weakness for which he went to local hospital and was under normal saline 3 days back. There is history of dark stools 3 days back lasted for 1 day, which is non blood stained. Hiccups Since 3 days continuously and associated with mild difficulty in swallowing  Cough- dry since 3 days not associated with fever sore throat cold. Similar complaints --3 months back he had vomiting and was diagnosed with jaundice  ---10 years ago he met with an accident and was in coma for 2 days. Past History- Not a known case of Dm,Tb, epilepsy, asthma,HTN No h
Read more

A 51 year old male with SOB since 1 month

Image
  CHIEF COMPLAINTS : A 51M farmer by occupation , resident of nalgonda came to opd with c/o shortness of breath since 2 months and bleeding per rectum since 2 months . HOPI  Patient was apparently asymptomatic 2 months ago then he developed SOB of insidious onset, gradually progressive increasing in intensity since 2 months (Glade II- III) The patient had undergone surgery for Haemorrhoids 2 years ago , and then ,there was relapse of Haemorrhoids again 2 months ago and he was losing blood in an amount of 30ml/day during passing of stools No h/o constipation , nausea , vomiting ,burning micturation . PAST HISTORY : N/KC/O DM , HTN , CAD , CVA , EPILEPSY , THYROID DISORDERS  FAMILY HISTORY :  not significant  PERSONAL HISTORY :  Decreased appetite  Mixed diet  Decreased bowel movements  Normal micturition  Addictions : consumes alcohol regularly from 2 years GENERAL EXAMINATION : I have examined the patient after taking prior consent and informing the patient in the presence of a attenda
Read more