Severe anemia





 This is an 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 patient's 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 the comment box

A.Nikhil 

1701006013

28 year old male patient came to opd with 

chief complaint of blood in the stools since 1 1/2 year &

Sob on exertion since 1 year

HOPI:-

Patient was apparently normal 1 1/2 year back then he noticed bleeding per rectum(once in every 1-2 months) , not associated with any pain during defecation , no mass per rectum and there is  fresh drop of blood per rectum. Aggravated whenever he is straining while passing stools  

Since 1 year he developed  sob on exertion not associated with chest pain , no palpitations, no giddiness he has fever since 1 week which is of low grade associated with chills and dry cough at first he went to local practitioner  but fever did not subsided then he was refered to local hospital in Miryalaguda where he had 

   Hemoglobin- 2.1%

     RBC     - 1.5 millions/ mm3

     Platelets- 1 lakh 

From there he was  referred here for gastroenterologist 

HISTORY OF PAST ILLNESS:- 

 H/o  polio at  the  age of  5 years

N/A/K/O DM, HTN,ASTHM, epilepsy 

TREATMENT HISTORY:-

He had under gone a surgery  in his left thight for releasing is contracture for polio

PERSONAL HISTORY:-

Diet - mixed 

Appetite- normal

Bowel - regular (a/w blood)

Bladder - regular

No addiction 

FAMILY HISTORY:- 

No signicant family history 

GENERAL EXAMINATION:-

Patient is c/c/c






pallor - present ,NO  icterus , cyanosis, clubbing , lymphadenopathy, pedal edema 

VITALS AT THE TIME OF EXAMINATION :-

Temperature - afebrile , BP:-110/70mmhg ,PR:- 94 bpm,

RR- 16 cpm, Spo2:- 98%@RA  

SYSTEMIC EXAMINATION:-

CVS :- S1,S2 +( Increase in jvp)

R/S :- BLAE +

P/A :- SOFT ,NON Tender with mild splenomegaly NT

CNS :NAD








INVESTIGATION:- 

HEMOGRAM:-

Date- 18-8-22


Date :- 19-8-22



Date - 20-8-22

DATE 22-08-22

DATE:- 23-08-22




ESR:-

LFT:-

BLOOD UREA:-


SERUM CREATININE:-

SERUM ELECTROLYTES:-

PROPTOSCOPY:-
Fissures in ano



PROVISIONAL DIAGNOSIS:- 

Severe anemia secondary to   Bleeding per rectum 

TREATMENT:-

INJ.VITCOFOL IM/OD

TAB.OROFER-XT. PO/OD        

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