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A 35 year old female patient with shortness of breath,fever and generalised weakness



This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 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


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:
Abdomen is scaphoid
No tenderness
No palpable mass
Non palpable liver and spleen
Bowel sound are not heard.

CARDIOVASCULAR SYSTEM:
S1,S2 are heard
no cardiac murmurs
No thrills

RESPIRATORY SYSTEMS:
No dyspnea
No wheeze
Central location of trachea
Vesicular breath sound


CENTRAL NERVOUS SYSTEM:
Conscious,coherent and cooperative 
Speech- normal
No signs of meningeal irritation. 
Cranial nerves- intact
Sensory system- intact
Cerebellum function -
Finger nose test-normal
Knee heel test- normal 

PROVISIONAL DIAGNOSIS:
Anemia secondary to menorrhagia

INVESTIGATIONS:








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