28 year old with blood in stools progressed to severe anemia
M Vineela
2k 18 MBBS
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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.
Chief complaints-
blood in stools since 1.5 years and sob on exertion since 1 year.
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- Petient is conscious, coherent, co operative well oriented to day, time ,place and person.
Palior-
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.( Equine gait)
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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