A 28 year old young man with blood in stools, SOB, fever and cough
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19/8/22-
22/8/22
Chief complaint-
A 28 year old young man, a post graduate and resident of miryalaguda came to OPD with chief complaint of-
Blood in stools since 1½ yrs
Fever and cough since a week,
Shortness of breath on exertion since 6 months
History of present illness-
Patient was asymptomatic 1½yr ago and then he noticed blood in stools monthly once or twice.
He had fever associated with dry cough since a week.
Fever subsided on medication and recurred later.
He went to a local hospital and was found to have low hemoglobin concentration and they suggested him colonscopy.
He came here for colonoscopy( gastroenterologist)
He was admitted here on 18/8/22 and transfused with a unit of blood and another unit on 19/8/22.
History of past illness-
He had polio since he was 5 years old.
And had a surgery done on his left upper thigh region in 2009 at tirupathi hospital.
No history of HTN, Diabetes, Asthma
Family history-
Not significant
Personal History-
Diet: mixed
Appetite: normal
Bowel and bladder: regular
Sleep: adequate
Addictions: none
General Examination-
Patient is concious, coherent and cooperative
Poorly built and moderately nourished
Pallor-present
No icterus
No cyanosis
No Clubbing of fingers
No Generalised lymphadenopathy
Virals-
Temperature- 98⁰ F
Pulse rate- 89 bpm
Respiratory rate- 20 cpm
Blood pressure- 110/90 mmof Hg
SpO2- 98% at room air
Systemic examination-
Cardiovascular system-
S1 and S2 heard
no murmurs heard
Investigation-
18/8/22
20/8/22
22/8/22
I'd like to acknowledge the help of
Dr.Nikhil, 2017 for investigations on 20/8/22 and 22/8/22
https://avulanikhil09.blogspot.com/2022/08/gm.html?m=1
Dr. Sravani, 2018 for Investigations on 18/8/22 and 19/8/22
https://gaddesravani45.blogspot.com/2022/08/28-year-old-with-blood-in-stools-and-sob.html?m=1
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