A 35 year old female with fever and generalised 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.

CHIEF COMPLAINTS:

Breathlessness since 15 days

Generalised weakness since 15 days

Fever since 1month.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 1month back,then she got fever which was sudden in onset,low grade, intermittent,relieved on taking medication.She complained of body pains and headache during the episodes of fever.No h/o evening rise of temperature,night sweats.She complained of generalised weakness and SOB on walking and doing household chores since 15 days,which previously did not affect her day to day activities.She went to nearby government hospital and they advised her to come to our hospital and get treated here in the view of above complaints.

No h/o palpitations,chest pain, giddiness, orthopnea,pnd,pica,loss of appetite,pedal edema.No h/o of hematemesis, blood in stools,vomitings,nausea, diarrhoea, difficulty in swallowing, cough, hemoptysis.No h/o decreased urine output and burning micturition.

MENSTRUAL HISTORY:

Attained menarche at the age of 13.                         Cycle is irregular, frequency is 5days for every cycle,a/w pain on first 2days of cycle,spasmodic type of pain and not a/w clots.                                   Last month she had periods for two days with 10 days gap in between.

PAST HISTORY:

OBSTETRIC HISTORY:

Two children, delivered by C section,no anemia during pregnancy.Tubectomy done after the birth of second child.

No k/c/o DM,HTN,CKD,heart disease,epilepsy,TB.

FAMILY HISTORY:

No similar complaints.

PERSONAL HISTORY:

Diet: Mixed
Sleep: adequate
Appetite: Decreased
Bowel movements: regular
Bladder movements: Normal.                                     No addictions.

GENERAL EXAMINATION:

Patient is conscious, coherent, and comfortable
Pallor is present, No icterus, No clubbing, No lymphadenopathy, No pedal edema, No cyanosis.

Pallor:

Koilonychia:


VITALS:-
Temperature:97.8F
PR-84bpm
RR-20cpm
BP-108/70mm Hg
SpO2-100%
Fever charting
SYSTEMIC EXAMINATION:
CVS:-
S1,S2 heard and no murmurs
No elevated jvp

P/A :-
- shape of abdomen is scaphoid 
  No flank fullness is seen 
  Umbilicus is inverted and skin is normal 
  No engorged/dilated veins 
  Hernial surfaces are normal
-On palpation
 No tenderness
 No other organomegaly.
-No fluid thrill
 Liver span-15cm
-bowel sounds were reduced (7/min )

RS :- BAE+ , NVBS heard, tracheal position is 
central 

CNS :- HMF present and no focal  neurological deficits are noticed.

PROVISIONAL DIAGNOSIS:-
Anemia 2° to menorrhagia

INVESTIGATIONS:
12/01/24
13/01/24
ECG:
FINAL DIAGNOSIS:-
Iron deficiency anemia

TREATMENT:
Tab PCM 650mg PO,TID
Inj NEOMOL 1gm IV/SOS If temp > 101F
T.Orofer XT PO/OD.

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