This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
I have 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.
CASE:
A 28 year old man, resident of miryalaguda, and post graduate came to the old with chief complaints of blood in stools since 1 and half year and dyspnea on excertion since 6 months
History of presenting illness:
Patient was apparently asymptomatic 18 months back then he noticed blood in his stools from 1 and half months , intermittently (once in every 1-2months) , few drops of blood while passing the stools, fresh blood ,not associated with pain and without any straining.
No history of constipation and hemetemesis, abdominal pain .
He has been having Dyspnea on working for some distance and also has palpitations and tremors since 6months .
He has fever since 1week which is of low grade, continuous , associated with chills and dry cough .He went to a local practitioner who prescribed him with DOLO but the fever did not subside and found to have decreased hemoglobin and was sent to local hospital in miryalaguda where he had hb-2.1%, RBC-1.5 million /mm3, platelets- 1lakh and he referred the patient here (for gastroenterologist). Here on 18-8-2022 he was transfused with one unit of blood and increased from 2.5 to 3.5 and on 19-8-2022 evening he was again transfused with one unit of blood.
Past history:
He has history of polio at the age of 5 for which his left lower limb is paralysed.
Patient is not a known case of hypertension, diabetes, asthma, tuberculosis, epilepsy, cad.
No history of blood transfusion.
Family history:
Not significant.
Personal history:
Diet-mixed
Appetite-normal
Sleep-adequate
Bowel and bladder movements- regular
Addictions-none.
General examination:
Patient is concious coherent and cooperative
Poorly built and moderately nourished
Pallor-present
Icterus-absent
Cyanosis- absent
Clubbing-absent
Generalized lymphadenopathy-absent
Pedal edema-absent
Fine tremors-present.
Vitals:
Temperature-98 degree F
Pulse rate-89bpm
Respiratory rate-20cpm
Blood pressure-110/90mmof hg
Spo2-98% at room air
Systemic examination:
Cardiovascular system:
S1 and S2 heard and no murmurs heard.
Apex beat- 5th intercostal space in the mid clavicular line.
Per Abdomen:
Soft and non tender and mild spleenomegaly present and no hepatomegaly.
Respiratory system:
Bilateral air entry-present, Normal vesicular breath sounds heard.
Central nervous system:
Patient is concious coherent.
Higher mental status-
Cranial nerves- intact
Motor
Tone- normal (left lower limb- Hypotonic d/t LMN Lesion -polio)
Power- normal (except for left lower limb-no power)
Reflex- B S T K A P
Rt- ++ ++ ++ + + flexion
Lt- ++ ++ ++ - - -
Cerebellar functions-normal
Gait- he supports his left lower limb with left hand while walking.
Investigations:
On 18-8-2022
On 19-8-2022
Treatment:
PRBC transfusion
Inj. LASIX 20mg I.v sos
Inj. VITLOFOL OD
Tab. BANDYPLUS H/s
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