GENERAL MEDICINE

GENERAL MEDICINE

GM CASE 3

Monday 6 March 2023
6 march 2023
CASE Scenario.....

Hi ,I am S.Aishwarya, 3rd bds student.This is an online elog book to discuss our patient health data after taking his consent. This also reflects my patient centered online learning portfolio
                  CASE HISTORY
Patient details
A 13 years old female resident of komattigudam presented with
chief complaint
Shortness of breath with exertion since 1 year easy fatiguability since 1 year

History of present illness
Patient was apparently Asymptomatic 1 year ago and then  she  started feeling difficulty in breathing on running for small distances and also while playing games.  and fatigue . shortness of breathe which is insiduous onset that is grade 2 and gradually progressed grade 3 and gets relieved while at rest.
History of past illness
No fever
No cough
No cold
No asthma
No epilepsy
No tuberculosis
No CAD
Personal history
Occupation:student
Diet:mixed
Appetite:Normal
Sleep:normal
Bowels: regular
Micturation:normal
Allergies:not allergic to any substances
Addictions:no any addictions
Menstrual history
Age of menarche not attained
Family history
No significant family history
General examination
Pallor:yes
Icterus:no
Cyanosis:no
Koilonchyia:no
Clubbing:no
Oral examination
Gingivitis:no
Angular stomatitis:no
Chelitis:no
Glossitis:no
Drug history
Provisional diagnosis
Anemia
Q/A
1)Is anemia temporary or long standing?
2)what kind of food should i take regularly?
3)Is it  curable by medication?


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