35 yr old with Severe Iron deficiency anemia

 NAME : M. NAGA VARSHA 

BATCH : 2017

ADMISSION NO. 176015


This is an 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 patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient centered online learning portfolio and your valuable comments 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 a diagnosis and treatment plan.

FOLLOWING IS THE VIEW OF MY CASE


35 yrs old Male resident of LB nagar, occupation serap dealer came to opd with chief complaints of blood in the stools ,SOB ,easy fatigability ,itching all over the body since 1mn.  

HOPI:

Patient was apparently asymptomatic 1mn back then he observed blood in the stools not associated with pain during defecation .

He complaints of easy fatigability,SOB while doing work and lifting little weights also.

History of itching all over the body ,due to itching there are small hyperpigmented patches on both upper and lower limbs since 1mn.

PAST HISTORY:

Similar complaints 1 yr back (blood in stools for 15 days)

N/k/c/o Hypertension, diabetes,asthma, epilepsy,CAD

DAILY ROUTINE:

He wakes up at 5 am and does his daily routine ,eats breakfast at 8:30 and goes to work at 9am , afternoon he takes alcohol and comes home and eats lunch and sleeps until 5 or 6pm ,then again he goes out , drinks alcohol and comes home and does his dinner and goes to bed at 10 pm.

PAST HISTORY:

Similar complaints in the past 1 yr back

Not a k/c/o Diabetes,asthma, coronary artery diseases,epilepsy,thyroid disorders.

FAMILY HISTORY :

Not signigicant

PERSONAL HISTORY:

Diet- mixed

Appetite - normal

Sleep -normal

Bowel and bladder -regular (blood in the stools)

Addictions-

-He is chronic alcoholic since 15 years,

GENERAL EXAMINATION:- 

-Patient is conscious, cooperative, with slurred speech 

Well oriented to time, place and person

-Moderately built and moderately nourished.

Pallor - present



Icterus - absent


Cyanosis - absent

Clubbing - absent


Lymphadenopathy - absent

Oedema - absent


VITALS: 

B.P:110/70 mmhg

P.R:76bpm

R.R: 22cpm

Temp:99.5 F

SYSTEMIC EXAMINATION:

ABDOMINAL EXAMINATION:

Inspection -
Small Hyperpigmented patches on the abdomen

          Umbilicus - inverted
          All quadrants moving equally with respiration
          No scars, sinuses and engorged veins , visible pulsations. 
          Hernial orifices- free.


Palpation -  
soft, non-tender

no palpable spleen and liver

CARDIOVASCULAR SYSTEM:

Inspection : 
Shape of chest- elliptical 
No engorged veins, scars, visible pulsations
JVP - raised
Palpation :
 Apex beat can be palpable in 5th inter costal space
No thrills and parasternal heaves can be felt
Auscultation : 
S1,S2 are heard
no murmurs


RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:

 bilateral air entry present. Normal vesicular breath sounds heard.



CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes: Right. Left. 

Biceps. ++. ++

Triceps. ++. ++

Supinator ++. ++

Knee. ++. ++

Ankle ++. ++



PROVISIONAL DIAGNOSIS:

 Anemia due to blood loss by haemorraoids and fissure.

INVESTIGATION:


USG


 

FINAL DIAGNOSIS:

Anemia secondary to blood loss by haemorraoids (grade 1) and active fissure (11'0 clock)

?IRON DEFICIENCY ANEMIA

Right renal cortical cyst .

TREATMENT

1)T.MONOCEF 200 mg po/BD

2)T.PAN 40mg po/bd

3)SYRUP. LACTULOSE 10ml po/BD

4)OINT.SMUTH 

5)SITZ BATH WITH BETADINE -QID

6)HIGH FIBER DIET

7)INJ. VITCOFOL 1.5ml I.M/OD

8)INJ.THIAMINE 100mg in 100 ml NS IV/OD

6/4/2023:




7/4/2023:


1PRBC Transfusion done on 7/3/2023 at 3:10 started and ended at 6:10


8/4/2023:
Post Transfusion heamogram 

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