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28 year old with blood in stools and sob

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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