25 yr old male cane to opd with blood in stools and shortness of breath

This is 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 patients clinical problems with collective current best evidence based inputs .This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. 

A 25 yr old male patient from narketpally runs a wine shop came to opd

CHEIF COMPLAINTS: 
 Blood in stools since 12 days  ,
Shortness of Breath since 7 days , Headache since 9 days.




HISTORY OF PRESENTING ILLNESS: 
Patient was apparently asyptomatic 5 months back then he noticed blood before and after passing stools for which he took medication( unknown) .
From 12days he again complains of hard blood in stools associated with an episode of vomiting,not associated with pain in the abdomen,fever.
He had Headache since 4 days which is continuos with no aggravating and relieving factors .

He had Shortness of Breath Grade 2 since 4 days which is sudden in onset not associated with chest pain which aggrates on walking and relieves on sitting.
He went to a hospital in Nalgonda and he was found to have Hb -3.6 gm% came to Kims Narketpally for further management.

 Past History : 
He had similar complaints 5 months back.
No History of Diabetes mellitus,hypertension, Tuberculosis,Asthma, Coronary artery Disease , Epilepsy.
No surgeries underwent in the past.

Family History:
No member of the family has similar complaints.

PERSONAL HISTORY
 Diet : Mixed 
Appetite is normal 
Bowel and Bladder movements : regular sleep :adequate
He consumes Alcohol ( 1 beer),Toddy occasionally since 3 years .
No history of smoking.
No known Drug,Food Allergies.

Daily routine:
 He wakes up at 6 am  ,
he goes to fish market and returns at 9 am he'll have his breakfast and goes to shop by 10 am.
He'll take his lunch 2 pm and goes back home by 10:30
Dinner  and sleep at 11 pm.

General Examination:
Patient was conscious, coherent, cooperative 
ILL BUILT and poorly nourished.
  Pallor: present.


Icterus: Absent
Cyanosis: Absent
Clubbing: Absent
Generalised lymphadenopathy: Absent
Bilateral pedal Edema: Absent.

Vitals:
Temperature: 98.6 F
Pulse rate: 121 beats/ min
Bp: 110/60 mmHg
Respiratory rate: 20 cycle/ min.

Systemic Examination:

Abdomen: Soft and non tender. Bowel sounds heard 

Cardiovascular system: S1,S2 heard 
Central nervous system: No focal neurological deficits.
Respiratory system: Bilateral Air entry present. NVBS 
   Breath sounds heard all over the chest. Trachea is Central .

Provisional Diagnosis:
Anaemia secondary to Iron deficiency 


Investigations:
 1.Complete blood picture:

2. Ecg

Treatment:



Comments

Post a Comment

Popular posts from this blog

MY EXPERIENCE IN MEDICINE DEPARTMENT

 This in D.Naga Sai Rohith Naidu  a medical student from India. Welcome to my blog .I came to postings when I am in my 3rd semester i don't know how to take a case, what are the things to ask ,how to examine a patient ,how to present myself  towards a patient how to present a case, slowly with my pgs and with  my hod  help i learned how to take a proper history of a patient . As it is very clear that Case taking and history taking are fundamental aspects of the medical  practice. They play a crucial role in gathering relevant information about a patient's condition, which helps in making an accurate diagnosis and developing an appropriate treatment plan. With the help of this Case taking and history taking provided me an opportunity  to establish a rapport with the patients.  I established a patient and doctor relationship which feels so excited  to me. This blog system helps us to keep every information together in a place which is very useful. NOTE: THIS IS AN ONLINE E LOGBOO
Read more

A 27 YR OLD MALE CAME WITH LOWER BACK PAIN

Image
 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. 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. A 27 OLD MALE PATIENT CAME TO OPD WITH  CHEIF COMPLAINTS :  Lower back pain since -10 Days  HOPI -  Patient was apparently asymptomatic 3 months back and then he developed fever which is sudden in onset ,no di
Read more