GM case 03
August 17,2022
Case scenario.......
Hi, I am Pranavi V, 3rd sem medical student.This is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.
CASE SHEET:
Chief complaints: Stools with blood not associated with pain intermittent since one and half year.
HISTORY OF PRESENT ILLNESS:
The patient noticed stools with blood intially one and half year ago. Blood with stool appeared intermittently ( once in 2-3 months) . The patient sometimes had constipation and something had watery stools. He also experienced SOB on exertion during physical activities like climbing stairs.
The patient had fever since a week due to which he visited a local hospital and got some investigations including a colonoscopy . Blood investigations revealed that he has a low Hb levels due to blood loss. He also had dizziness .
He visited KIMS , Narketpalle for a blood transfusion on 18/8/2022.
ASSOCIATED DISEASES: Anemia due to excess blood loss.
PAST HISTORY: Polio at age of 5.
PERSONAL HISTORY:
Occupation: Student
Diet : Mixed
No known allergies
FAMILY HISTORY: Nil.
DRUG HISTORY:
GENERAL EXAMINATION:
Icterus: absent
Pallor : present
(Pic upload)
Mild spooning
Hyperpigmentation due to anemia
VITALS:
Temperature: Afebrile
Pulse:_20__ beats per minute
Respiratory rate: ___cycles per minute
Blood pressure: 100/70 mm of Hg
SPO2: 97%
SYSTEMIC EXAMINATION:
Cardiovascular system:
__no_ thrills
_no__murumurs
Cardiac sounds: S1, S2 ____
Respiratory system:
_No___ dyspnea
__No_ wheezing
Breath sounds heard: vesicular??
Abdomen:
Shape: distended
No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard
Central Nervous System:
Conscious
Speech: ___normal___
INVESTIGATIONS:
Blood Investigations:
ECG:
Pics upload...
PROVISIONAL DIAGNOSIS: Severe Anemia , Hookworm infection? Ulcerative colitis?
_____________
