A 35 year old female patient with shortness of breath,fever and generalised weakness

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Case :
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.
-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).

MENSTRUAL HISTORY:
-Regular cycle ,with normal flow until last Feb.
-Last month (March)heavy bleeding occurred which lasted for 11 days (1st 6 days heavy bleeding then next 2 days bleeding is stopped then again 5 days bleeding occured).

PAST HISTORY:
Ho H/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 and coherent.
Well oriented to time, place and person.
-thinly built and malnourished.
Pallor - present


Icterus - absent

Cyanosis - absent
Clubbing of fingers- 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-
CVS-
Cardiac sound S1 and S2
No thrills
No cardiac murmur.

RESPIRATORY -
No dyspnea
No wheeze
Central location of trachea
Vesicular breath sound .

ABDOMEN-
Abdomen is scaphoid
No tenderness
No palpable mass
Non palpable liver and spleen 
Bowel sound are not heard .

CNS-
Conscious 
Speech normal
Signs of meningeal irritation -
       No neck stiffness
       Kernig sign absent
Cranial system- intact
Motor system -intact
Sensory system -intact 
Cerebellum function -
      Finger nose test- normal
      Knee heel test- normal 

PROVISIONAL DIAGNOSIS:
Anemia secondary to menorrhagia

INVESTIGATION-
INVESTIGATIONS:
12/4/2023-






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