case study-3
CASE STUDY - 03
S.Nikhil kumar
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 patient problem through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence input.
This E blog also reflect my patient centered online learning portfolia and your valuable inputs on the comment box is welcome.
I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis to develop my compentency in reading and comphrending clinical data including history , clinical finding , investigation and come up with diagnosis and treatment plan....
35years old male who is an electrician came to OPD on 21/7/21
with the cheif complaint of sudden weakness and giddiness which caused him to fall - but was aware of his surroundings - This lasted for around 15 minutes.
History of present illness:-
One year ago, he had a similiar episode of weakness and fall, and was administered i.v. Ferric Carboxymaltose.
Following the episode one year ago, He had the following complaints since then
1. Giddiness and fatigue ; effort intolerence
2. Shortness of breath at exertion
His mother gives a history of improper dietary habits.
Alcohol - twice/thrice weekly (beer)
Smoking - 10 cigarrettes/day since 5 years
Patient complains of Bleeding from stools on and off since the last 3 months along with pain during defecation.
Difficulty to sit post defecation
Last one month - Bleeding in stools daily and tightness in stools.
No h/o hemetemesis, melena, hematuria, bleeding problems
Family history:
No.
Dietary history:-
Diet - Mixed
Appetite - reduced since 3 months
Sleep - Adequate
Bladder - regular
Bowel - Bleeding in stools
On Examination:-
Pt is conscious coherent cooperative, oriented to time, place and person.
Pallor present
Icterus Absent
Clubbing Absent
Koilionychia Present on toes
Pedal Edema absent
Afebrile
BP - 120/50
PR - 108 bpm
RR - 24
ORAL CAVITY EXAMINATIION -
BALD TONGUE
Resp System -
BAE+ NVBS+
CVS -
S1 S2 heard, no murmurs
Per abdomen -
Soft non-tender, bowel sounds heard
CNS -
NFND
Grade 4 External Hemorrhoids on 2, 6 , 7, and 10 'o' clock position
Provisional Diagnosis -
Iron Deficiency Anemia with Grade 4 hemorrhoids
Clinical findings:-
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