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? 

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