A 54year old woman with c/o Shortness of breath and generalised weakness
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A 54 year old female patient, housewife from Munugodu came with complaints of Shortness of breath and generalised weakness from 2days
History of presenting illness
Patient was apparently asymptomatic 3yrs back then she had joint pains and went to a local hospital and was found to have hyperthyroidism and was kept on medication(Carbimazole). In December 2021, she had fever, generalised weakness and shortness of breath and she went to a local hospital and was found to have Hb 3gm% and was transfused 1unit of blood and then Hb increased to 8gm%. On July 5,2022 she has complaints of Shortness of breath and went to a hospital, then her Hb was 3gm% and was again transfused 2units of blood and Hb raised to 7gm%
She has recurrent episodes of low grade fever since Dec,2021 and reduces with medication(Dolo)
She also has dry cough from 12days
Past history
She has history of surgery for correction of cleft lip at the of 3yrs
She had underwent hysterectomy 26yrs back
She had history of Tuberculosis 6years back and was under ATT for 6months
N/k/c of Diabetes, Hypertension, asthma, epilepsy, CAD
Personal history
Appetite: normal
Diet: mixed
Bowel and bladder movements: regular
Sleep:adequate
Family history: not significant
General examination
Patient is conscious, coherent and cooperative
She is ill built and poorly nourished
Pallor is present
No icterus, cyanosis, clubbing, lymphadenopathy and edema
Fine tremors
Temperature:98.6F
Pulse rate: 70bpm
Blood pressure:120/70mmHg
Respiratory rate:20cpm
GRBS:106gm%
Systemic examination
Respiratory examination
Inspection: shape of chest is normal
Chest movements are bilaterally symmetrical on breathing
Palpation:
Inspectory findings are confirmed
No palpable sounds are felt
Percussion:Resonant in all areas
Auscultation:normal vesicular breath sounds
Cardiovascular system examination
S1 S2 heart sounds heard, no murmurs
Raised JVP
https://youtube.com/shorts/Z92CV3ZV3YM?feature=share
Central nervous system examination
HMF intact
Cranial nerves intact
No focal neurological defecits
Per abdomen
Inspection: scaphoid, no distension
Palpation: soft, nontender
No hepatomegaly
No splenomegaly
Auscultation:bowel sounds heard
Provisional diagnosis: Anemia due to chronic inflammation with Renal failure
Investigations
On 1/08/2022
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