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