This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients’ clinical problems with collective current best evidence-based inputs.
This e-log book also reflects my patient centred online learning and your valuable inputs on comment box is welcome.
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
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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:
Date:18-8-22
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Provisional diagnosis:
Severe anemia secondary to Bleeding per rectum
Treatment:
INJ.VITCOFOL IM/OD
TAB.OROFER-XT. PO/OD
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