GENERAL MEDICINE
GM-CASE 6
Tuesday,March 13th ,2023
March 13th, 2023
CASE scenario....
Hi, I am G Sukanya, 3rd year bds 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 HISTORY
Patient details
A 27 years old male Resident of kodhada,occupation by chef presented with the
Chief complaint of
Generalized weakness/Giddiness all over the body and gradually progressive ,fatigability and Shortness of breathe since 1 month.
History of present illness
Patient was apparently asymptomatic 1 month back and then had Generalized weakness/Giddiness all over the body which is insidious in onset and gradually progressive in nature. Easy fatigability, and Shortness of breathe which is Grade 1 in onset and gradually progressed to Grade 2 that is ,Patient was having dyspnoea in rest position.
Weakness, fatigability, breathlessness are aggrievated by walking and while doing normal daily activities
No relieving factors
History of past illness
No known case of Diabetes
/Tuberculosis/Asthma/Hypertension/CVA.
Patient was daignosed with jaundice 1 year back, as he went to the hospital because of weakness
Personal history
Diet:Vegetarian
Sleep:Adequate
Apetite:loss of apetite
Bowl/bladder:Regular
Habits:Occasional Alcoholic 1 year back and then stopped drinking .
Family history
No Diabetes/Hypertension
General examination
Patient was Conscious and Co-operative
Thin Built
Moderately Nourished
Pallor:present
Cyanosis:No
Clubbing:No
Icterus:slight yellowish discoloration is present
Lymphadenopathy:No
Edema:No
-------PROVISIONAL DIAGNOSIS----- The patient is having yellowis discoloration of sclera and slight Pallor was observed.so,this is probably a case of
"ANAEMIA "
1) Is my anemia temporary or long lasting?
2)what type of Anaemia Do I exactly suffering with?
3) what diet should I take to get rid of these anemia?
4)Is these Anemia may leads to any other consequences ?
Comments
Post a Comment