28 yr old male with severe anaemia

28 yr old male with severe anaemia

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I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan.

 A 28 year old male patient came to opd with chief complaint of blood in the stools since 1 1/2 year &Sob on exertion since 1 year.

History of presenting illness:

Patient was apparently normal 1 1/2 year back then he noticed bleeding per rectum(once in every 1-2 months) , not associated with any pain during defecation , no mass per rectum and there is  fresh drop of blood per rectum. Aggravated whenever he straining while passing stools .

Since 1 year he developed  sob on exertion not associated with chest pain , no palpitations, no giddiness.

 He has fever since 1 week which is of low grade associated with chills and dry cough at first he went to RMP but fever did not subsided.Then he was refered to local hospital in Miryalaguda where he had  

  Hemoglobin- 2.1% 

   RBC     - 1.5 millions/ mm3

    Platelets- 1 lakh 

From there he was  referred here for gastroenterologist 

History of past illness:

 H/o  polio at  the  age of  5 years

Not a known case of diabetes, hypertension,asthma, epilepsy 

Treatment history:

He had under gone a surgery  in his left thigh 

Personal history:

Diet - mixed 

Appetite- normal

Bowel - regular ( with blood)

Bladder - regular

No addictions

Family history:

No signicant family history 

General examination:

Patient is conscious, coherent, cooperative.

pallor - present 

NO  icterus , cyanosis, clubbing , lymphadenopathy, pedal edema 

Vitals:

Temperature - afebrile , 

BP:-110/70mmhg ,

PR:- 94 bpm,

RR- 16 cpm, 

Spo2:- 98%

Systemic examination:

CVS :- S1,S2 +( Increase in jvp)

R/S :- BAE +(bronchial artery embolisation)

P/A :- SOFT ,NON Tender with mild splenomegaly 

CNS : no functional deficits 

INVESTIGATIONS

Provisional diagnosis:

Severe anemia secondary to Bleeding per rectum 

Treatment:

INJ.VITCOFOL IM/OD

TAB.OROFER-XT. PO/OD