A 35yr old female came with complaints of fever

 Hi,I’m Rohith.N 5th semester medical student.This is an online e block to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio

A 35 year old female came to OP with fever and weakness 

Chief complaints:

The patient came to the general medicine op with chief complaints of fever, weakness, shortness of breath since 4days 

History of present illness

The patient was apparently asymptomatic 3 months back.Then she developed fever associated with chills for which she went to a local hospital where she was diagnosed with severe anemia(3gm/dl) then she used medication for 1 month. Then 1 month back the patient developed fever and weakness and shortness of breath which got aggravated on exertion and relieved on rest.4 days back she Kims hospital and she was administered 2units of blood and 1unit of iron.The haemoglobin level rise up to 8gm/SL

History of past illness:

The patient is not a known case of diabetes,asthma,epilepsy and hypertension 

Personal history:

Diet- mixed

Appetite- normal

Sleep- decreased 

Bowel Movement’s - regular

Addictions: none. 

burning micturition present 

Family history :

No significant family history

Surgical history:

2 caesarean sections done. 

PHYSICAL EXAMINATION 

GENERAL : 

Pallor present 

No icterus 

No cyanosis 

No clubbing of fingers 

No lymphadenopathy 

No pedal edema

Pulse rate : 86/min 

Respiration rate : 16/min 

BP : 140/80 mm/hg  

INVESTIGATIONS

SYSTEMIC EXAMINATION 

CARDIO VASCULAR SYSTEM 

No thrills 

S1 S2 cardiac sounds 

Cardiac murmurs - NO 

RESPIRATORY SYSTEM 

Position of trachea - central 

Breath sounds - vesicular 

ABDOMEN 

Tenderness - not 

Palpable mass - no 

CENTRAL NERVOUS SYSTEM 

Conscious 

Speech - normal 

Reflexes are present 

TREATMENT:

PROVISIONAL DIAGNOSIS 

SEVERE ANEMIA.