Female with fever , SOB , and generalized weakness
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome
I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
A female patient , age of 35 years , working as helper in restaurant , resident of Choutappal.
She came to hospital with cheif complaints of generalised weakness since 3 months , shortness of breath since 1 month and fever since 1 month.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 3 months back , then she developed generalised weakness and fatigability , which was gradually progressive while working .
There is history of shortness of breath , since 1 month , it was insidious in onset, gradually progressive from grade 1 to grade 3 according to MMRC classification. There is no history of diurnal variation . It usually aggravated on working and relieved
on taking rest. No history of orthopnea and PND , chest pain .
Fever since 1 month , insidious in onset , Intermittent and high grade in nature .
Fever is associated with chills & rigors, productive COUGH- sputum was green in colour, scanty in quantity, non foul smelling and non Blood tinged, no diurnal variation . It reduced with simultaneous reduction of fever , HEADACHE diffuse type with dragging type of pain , DIZZINESS, all these had no aggravating factors but relieved on medications and rest.
There is history of menorrhagia , she changes 6-7 pads/ day , regular cycles ever 28 days , her last menstrual cycle lasted for 13 days.
No history of nausea and vomitings , chest pain , palpitations, abdominal pain , abdominal distention, melena , loose stools .
PAST HISTORY
no similar complaints before
N/K/C/O diabetes, hypertension , epilepsy, tuberculosis, asthma and thyroid related disorders .
FAMILY HISTORY
No similar complaints
DRUG & TREATMENT HISTORY
not done anything
PERSONAL HISTORY
Diet- mixed
Appetite - normal
Sleep -normal
Bowel and bladder -regular
Addictions- none
GENERAL EXAMINATION:-
-Patient is conscious, cooprative, with slurred speech
Well oriented to time, place and person
-thinly built and malnourished.
Pallor - present.
Icterus - absent
Cyanosis - absent
Clubbing - absent
Koilonychia-presen
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 ++. ++8
Knee. ++. ++
Ankle ++. ++
PROVISIONAL DIAGNOSIS:
Anemia secondary to menorrhagia
INVESTIGATIONS:
12/4/2023-
Treatment
Iron sucrose 100mg infusion
Ferrous ascorbate 100mg oral,twice daily(orofer xt)
Paracetamol tablet 650mg
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