35 yr old male with blood in the stools ,SOB,east fatigability, itching all over the body

 This is an 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.

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.

INVESTIGATIONS

HEMOGRAM

RBC: 3.6gm/dl

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

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