35 year female with c/c SOB fever generalised weakness

April 17, 2023

35 year female with c/c SOB fever generalised weakness

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Case :

35 years old female,resident of choutuppal,occupation cleaning works in the hotel, came with chief complaints

SOB since 3 months ,

fever since 3 months ,

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.aggravated by prolonged walking

-C/o generalised weakness since 1month ,2 weeks 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,relieved on taking medication ( Dolo625mg )

-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