35yrs old female with generalised weakness since 1month

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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. 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

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)

DAILY ROUTINE:

She wakes up at 6 am and does her morning routine and drinks tea at 9 :am,(she does not eats breakfast) and goes to work (works in hotel) ,lunch at 3 pm ,again continues work and comes back at 6 pm ,dinner at 8 pm (sometimes she eats, sometimes will sleep without eating dinner only) , goes to bed at 10pm.

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

Cyanosis - absent

Clubbing - absent

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 ++. ++

Knee. ++. ++

Ankle ++. ++

PROVISIONAL DIAGNOSIS:

Anemia secondary to menorrhagia

INVESTIGATIONS:

12/4/2023-.

AT THE TIME OF ADMISSION HEMOGLOBIN WAS 3.9, 2 PRBCS WERE TRANSFUSED AND HEMOGLOBIN IMPROVED TO 7. 1 DOSE OF IRON SUCROSE100MG IN 100 ML NS IV WAS GIVEN ON 16/4/23 AND 18/4/23. OBGYN REFERRAL WAS TAKEN I/V/O MENORRHAGIA AND ADVICE FOLLOWED PATIENT IS HEMODYNAMICALLY STABLE AND PLANNED FOR DISCHARGE REFERRAL: OBGYN OPINION: I/V/O MENORRHAGIA AND ADVICE IS FOLLOWED Investigation HEMOGRAM: 12/4/23 HB: 3.9 TLC: 9,300 PCV: 16.1 RBC:2.99 MILLIONS/CUMM PLATELETS: 8 LAKHS/CUMM 13/4/23 HB: 5.5 TLC: 11,000 PCV: 20.5 RBC: 3.48 MILLIONS/CUMM PLATELETS: 7.4 LAKHS/CUMM 15/4/23 HB: 5.7 TLC: 5000 PCV: 22.2 RBC: 3.72 MILLIONS/CUMM PLATELETS: 2.19 LAKHS/CUMM 17/4/23 HB: 7 TLC: 10500 PCV: 26 RBC: 4.15 MILLIONS/CUMM PLATELETS: 4.60 LAKHS/CUMM

BLOOD TRANSFUSION: ON 13/4/23 1UNIT OF PRBC TRANSFUSION WAS DONE. ON 15/4/23 1 UNIT OF PRBC TRANSFUSION WAS DONE. USG: NO SONOLOGICAL ABNORMALITY DETECTED. 2D ECHO: MILD LVH IS PRESENT EF: 66% TRIVIAL MR+/TR+/AR+ NO RWMA, NO AS/MS GOOD LV SYTOLIC FUNCTION NO DIASTOLIC DYSFUNCTION, NO PAH ECG: NORMAL SINUS RHYTHM USG: Treatment Given(Enter only Generic Name) INJ. IRON SUCROSE 100MG IN 100 ML NS IV/WEEKLY THRICE -- >DOSE GIVEN INJ. NEOMOL 1 GM IV/SOS IF TEMP >101F TAB. OROFER-XT PO/BD --> 5 DAYS TAB. DOLO 650 MG PO/SOS Advice at Discharge IRON RICH DIET TAB. OROFER-XT PO/BD --> 1 MONTH TAB.LIMCEE 500 MGPO/OD --> 1 MONTH TAB. DOLO 650 MG PO/SOS OINT. THROMBOPHOBE L/A B/D--> 3 DAYS

Follow up:No limitation in physical activity