Female with fever , SOB , and generalized weakness

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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-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 ++. ++8

Knee. ++. ++

Ankle ++. ++

PROVISIONAL DIAGNOSIS:

Anemia secondary to menorrhagia

INVESTIGATIONS:

12/4/2023-