GM case -3

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

Hi, I am P.sravani , 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: 

Chief complaints: stool with blood, intermittently from 1and half year and fever since 1 week 



HISTORY OF PRESENT ILLNESS:previously he admitted at miryalaguda clinic.there he came to know his haemoglobin level is 3 .there doctor suggested to do colonoscopy  but for doing colonoscopy his haemoglobin should be 7gm/dl.so there by he came to kamineni for blood transfusion.












ASSOCIATED DISEASES: nill



PAST HISTORY: polio at age 5

PERSONAL HISTORY: students


FAMILY HISTORY: nill



DRUG HISTORY:


GENERAL EXAMINATION:

(Pic upload)

VITALS:
Temperature: 97° f

Pulse:__97_ beats per minute

Respiratory rate: _20__cycles per minute

Blood pressure: __100/70__ mm of Hg

SPO2: ___97%

SYSTEMIC EXAMINATION:

Cardiovascular system:

_no__ thrills
__no_murumurs
Cardiac sounds: S1, S2 __increased Jvp__

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:normal 
Speech: _normal_____

INVESTIGATIONS:
Biochemical investigations:
   

Pics upload...

PROVISIONAL DIAGNOSIS:
_severe anaemia due to blood loss________

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