35 years Female with Generalised weakness,Shortness of breath and Fever

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

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

35 years Female working as helper in restaurant , resident of Choutuppal came to opd with chief complaints of 

 1.Generalised weakness since 3 months  2.Shortness of breath since 1 month 

3. Fever since 1 month.

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 3 months back , then she developed generalised weakness 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 which is insidious in onset , Intermittent and high grade in nature . Fever is associated with chills & rigors.

It is also associated with productive cough.The sputum was green in colour, scanty in quantity, non foul smelling and non blood tinged, no diurnal variation . It is reduced with simultaneous reduction of fever.

It is also associated with headache which is diffuse type with dragging type of pain.Also associated with dizziness which is relieved on taking medications and rest.

There is history of menorrhagia last month in which her menstrual cycle lasted for 13 days , she changes 6-7 pads/ day , before last month regular cycles of 28 days with normal flow of 4 days.

No history of nausea and vomitings 

No history of chest pain , palpitations

No history of abdominal pain , abdominal distention, melena , loose stools 

PAST HISTORY:

No similar complaints before 

Not a K/C/O diabetes, hypertension , epilepsy, tuberculosis, asthma and thyroid related disorders . 

FAMILY HISTORY :

No similar complaints

DRUG & TREATMENT HISTORY:None

PERSONAL HISTORY : 

Diet- mixed

Appetite - normal

Sleep - Adequate 

Bowel and bladder movements -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:

Per Abdomen:

Inspection:

Shape - Scaphoid 

Flanks - free

Umbilicus - inverted

All quadrants moves equally with respiration 

No engorged veins, visible pulsations

Hernial orifice are free

Palpation:

No local rise of temperature

Abdomen is soft and non tender

No palpable spleen and liver

No other palpable masses

Percussion:

Resonant.

Auscultation:

Normal bowel sounds heard

CVS:

Jvp not raised 

Inspection:

Shape of chest - elliptical

No visible pulsations

No engorged veins and scars 

Apical impulse not visible

Palpation:

Apex beat present over the left 5th intercostal space 1cm medial to midclavicular line

No parasternal heave

No precordial thrill

No dilated veins

Auscultation:

S1 S2 heard ,No murmurs 

Respiratory system:

Upper respiratory tarct - normal

Lower respiratory tract:

Inspection:

Chest bilaterally symmetrical,

Shape- elliptical

Trachea- Midline

Palpation:

Trachea is central

Normal chest movements

Vocal fremitus is normal in all areas 

Percussion: in sitting postion

                                                 Rt.            Lt

Supraclavicular. N(resonant).             N

Infraclavicular. N.                                  N

Mammary region. N.                              N

Inframammary region. N.                      N

Axillary region. N.                                  N

Infra axillary region. N.                            N

Supra scapular region. N.                         N

Interscapular region. N.                            N.  

Infrascapular region. N.                             N

Auscultation:

Normal vesicular breath sounds

No added sounds

Vocal resonance is normal in all areas

CNS :

Higher motor functions - intact

Cranial nerves - intact

Motor system:

             Rt- UL. LL.                  Lt- UL. LL

Bulk - normal N.                          N. N 

Tone - N. N.                                   N. N

Power - 5/5. 5/5.                           5/5. 5/5

Reflexes:        

                             UL.                             LL

Biceps. 2+.                                              2+

Triceps. 2+.                                            2+

Supinator. 2+.                                       2+

Knee 2+.                                                 2+

Ankle. 2+.                                               2+

 Sensory system: intact

Co ordination is present 

Gait is normal

No Cerebellar signs 

No signs of meningeal irritation 

Investigations:

Provisional diagnosis:

Anemia secondary to menorrhagia