A 28 year old man presented with fever and stool with blood

August 21,2022
August 19,2022
Case scenario.......

Hi, I am s princy rose , 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.
 
A 28 year old man presented with fever and stool with blood 

CASE SHEET: 

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



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


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:

___ thrills
___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_____
Tremors present 

INVESTIGATIONS:
Biochemical investigations:

Hemogram :



PROVISIONAL DIAGNOSIS:
_severe anaemia due to blood loss________
Hook worm?






Comments

Post a Comment

Popular posts from this blog

A 48 yr old man presented with weakness in lower limbs and burning sensation of feet

Image
Hi, I am princy rose , 5 th 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. June 7,2023 Case scenario...... CASE SHEET: A 48 year old male farmer by occupation,resident of chintapalli came to the opd with chief complaints of  WEAKNESS OF BOTH LOWER LIMBS SINCE 6MONTHS BURNING SENSATION OF FEET SINCE 1 MONTH HOPI:: Pateint was asymptomatic 6 months back then he developed weakness of both lower limbs which is insidious in onset and gradually progressive. Associated with burning sensation of feet and pain in the calf muscle Patient also complaint of losing footwear while walking Patient also complaints of tingling sensation in both feet but can't appreciate it became burning sensation is more Patient was able to walk on his own till I month back but since 1 month patient needs supply to walk Visited local hospital 6 months back and using treatment since then P
Read more

A 65 year old woman presented with shortness of breath and pedal edema.

Image
August 16 , 2022 Hi ,  Iam Princy rose ,3rd semester 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 portfolios. A 65 year old woman farmer by occupation came to causality with complaints of shortness of breath and pedal edema. CHEIF COMPLAINTS : > SOB for last 4 days  > Cough for last 4 days > Pedal edema for last 4 days > Pain in lower limb for last 4 days  HISTORY OF PRESENTING ILLNESS :  Patient was apparently asymptomatic 4 months back. In April , She had SOB on exertion with tingling sensation in both upper and lower limbs, pedal edema and decrease in urine output ( creatinine : 3.1mg/dl ) for which she got treated in local hospital and her symptoms got relieved.   She had nausea , vomiting ,weakness ,burning micturition and pain in lower limb (creatinine : 3.8mg/dl uric acid:5.6mg/dl) again by end of June for which she was treated and all her complains got re
Read more

A 67 year old man presented with SOB and Fever

Image
 Hi, I am princy rose , 5 th 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. June 5,2023 Case scenario....... CASE SHEET: A 67 year old male barber by occupation,resident of miryalaguda came to the opd with chief complaints of  Shortness of breath since 1 week  Fever since 4-5 days HOPI : Pateint was asymptomatic 1 week back then he developed shortness of breath grade 2-4 aggrevating on doing work, walking and temporarily relived on medication and fever for which he went to local hospital and they gave medication but symptoms are not relieved and then they went to miryalaguda hospital for checkup and they referred to our hospital. He also had fever since 4days high grade evening raise temperature associated with chills and rigors relieved by medication and increases again. H/O decreased urine output since 6 months C/o pain abdomen on &off left lumbar regio
Read more