General medicine

28 yr old male with blood in stools and shortness of breath 

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.

28 year old male came to the OPD with the chief complaint of blood in stools since 1.5 years

History of presenting illness-
patient was apparently asymptomatic 18 months back then he noticed blood in his stools
He has no abdominal pain or constipation 
He has been experiencing difficulty in breathing since 12 months. 
He has h/o palpitations and tremors
He developed fever 10 days which is of low grade, continuous and associated with chills. 
He used paracetamol tablets given by local doctor then his fever subsided
Then later he went to another hospital where he got to know that he had less amount of hemoglobin
 He came to our hospital for gastroenterologist
As he has less amount of hemoglobin blood transfusions are done
Past history- 
He is suffering from poliomyelitis since he was 5 yrs if age due to which his left lower limb is paralysed
He has no history of hypertension 
No diabetes 
No asthama
No tuberculosis 
He had undergone a surgery to his left thigh for releasing the contracture due to polio

Personal history -

Appetite - decreased
Diet - mixed 
Bowel & bladder habits - regular 
Sleep - adequate 
Addictions - none
Normal micturation 

Family history - 
No significant family history

General examination -
The patient is conscious,
 coherent
cooperative 
well oriented to time, place and person. 
He is lean built. 
Pallor - present
Icterus - absent 
Cyanosis - absent 
Clubbing - absent 
Generalised lymphadenopathy - absent 
B/l pedal edema - absent


Vitals -
Temp - 98 degree F
Pulse rate - 89bpm
Respiratory rate 20cpm
Blood pressure - 110/90mmof hg
Spo2 - 98% at room air


Systemic examination -

CVS - S1 , S2 heard , no murmurs 
RESPIRATORY SYSTEM - BAE- present, trachea - central, 
ABDOMEN - non tender
mild splenomegaly 
CNS 
He walks by supporting his left lower limb with his left hand


Investigations

Diagnosis
Severe anemia secondary bleeding 


Treatment 
Blood transfusions 
Inj. LASIX 20mg I.V sos
Inj. VITLOFOL OD 
Tab. BANDYPLUS h/s 
High fibre diet 
ANOBLISS ointment
Syrup CREMAFFIN
SITS bath/ with betadine TID




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