GM case-2

August 19,2022
Case scenario.......

Hi, I am P.kathyayani , 3rd sem medical student.This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.

CASE SHEET:A 28 year old male resident of miryalaguda with blood in stool

Chief complaints:
Blood in stool in drops which is intermetient (1/2 months) from one and half year and fever since 1 week




HISTORY OF PRESENT ILLNESS:
Bleeding per rectum not associated with pain during defecation,fresh drops of blood per rectum since one and half year and he is also anaemic,blood transfusion was done on 18/08/2022
He was suffering from shortness of breath since 1 year while walking, working.




ASSOCIATED DISEASES: nil





PAST HISTORY: 
He was effected with polio at the age of 5 wasting of muscle seen in left leg and thigh.
No hypertension and no diabetes mellitus 


PERSONAL HISTORY:
Diet:mixed
No stomach pain
Bowel: regular
Due to blood loss their is dizziness




FAMILY HISTORY:nil



DRUG HISTORY:nil



GENERAL EXAMINATION:
hyperpigmentation seen on fingers
Clubbing of fingers:yes

VITALS:
Temperature:Afebrile 

Pulse:80 beats per minute

Respiratory rate: 20 cycles per minute

Blood pressure: 100/70 mm of Hg

SPO2: 97%

SYSTEMIC EXAMINATION:

Cardiovascular system:

___ thrills
___murumurs
Cardiac sounds: S1, S2 ____
Respiratory system:

____ dyspnea
____ wheezing
Breath sounds heard: vesicular

Abdomen:

Shape: scaphoid
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:
   



PROVISIONAL DIAGNOSIS:
severe anemia and Hook worm infection.
_____________

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