IRON DEFICIENCY ANEMIA WITH GRADE 4 HEMORRHOIDS

GENERAL MEDCINE CASE REPORT;

22 JULY,2021;

SAI PRANEETH BATHINEEDI;
ROLL NO 116;
3 SEMESTER STUDENT;

HELLO GUYS, 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 evidence based input

I've 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.

CHIEF COMPLAINT;

35 YEARS OLD MALE WHO IS AN ELECTRICIAN BY OCCUPATION FROM CHOUTUPPAL CAME TO THE OPD WITH CHIEF COMPLAINTS OF SUDDEN WEAKNESS AND GIDDINESS WHICH CAUSED HIM TO FALL DOWN;

HISTORY OF PRESENTING ILLNESS;

The patient says he was aware of his surroundings even after the fall(caused by sudden weakness and giddiness) which lasted for about 15 minutes;

He had a similar kind of episode a year back for which he was administered with i.v. Ferric carboxymaltose;

Following that episode a year ago he started experiencing;

1)Giddiness and Fatigue;Effort intolerance;

2)Shortness of breath at exertion;

He complaints of bleeding from stools on and off since the last 3 months along with pin during defecation;Difficulty to sit post defecation;

Last month- Bleeding in stools daily and tightness in stools;

PAST HISTORY;

NO H/O Hemetemesis , melena , hematuria , bleeding problems;

PERSONAL HISTORY;

Diet- mixed (Improper dietary habits as described by his mother);

Appetite- Reduced since 3 months;

Sleep- Adequate;

Bladder- Regular;

Bowel- Bleeding in stools;

Alcoholic(2-3 times in a week ,beer);

Smoker-10 cigarrettes/ day since 5 years;

GENERAL EXAMINATION;

Patient is conscious, coherent and cooperative;oriented to time, place and person;

Pallor-present; Koilionychia- present on toes;

Absence of Icterus, clubbing, pedal edema;

VITALS;

AFEBRILE

BP-120/50 mm of Hg;

PR- 108 beats per minute;

RR- 24 times per minute;

SYSTEMIC EXAMINATION;

ORAL CAVITY EXAMINATION- Bald Tongue;

RESPIRATORY SYSTEM- BAE +,NVBS +;

CVS- S1,S2 Heard, No murmurs;

PER ABDOMEN-Soft, non tender, bowel sounds heard;

CNS- NFND;

ANAL- Grade 4 External Hemorrhoids on 2, 6, 7, and 10'o' clock position;

PROVISIONAL DIAGNOSIS;

IRON DEFICIENCY ANEMIA WITH GRADE 4 HEMORRHOIDS;

CLINNICAL IMAGES AND INVESTIGATIONS;








I WOULD LIKE TO THANK CHITRA MAAM(INTERN) FOR HELPING ME TO SUCCESFULLY COMPLETE THIS BLOG.









Comments

Post a Comment

Popular posts from this blog

A 40 YEAR MALE WITH COMPLAINTS OF BOUTS OF VOMITINGS

Image
 01/12/23; 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. Ihave 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 40 years male, resident of chityala, field assistant by occupation came to the opd with chief complaints of vomitings Since 6:00pm yesterday; History of presenting illness: Patient was apparently as
Read more

OSCE AND LEARNING POINTS

OSCE QUESTION AND ANSWERS: 1) What is the mechanism of action of insulin at cellular level? Insulin acts on a glycoprotein- tyrosine kinase receptors on the cell membrane and it binds to the alpha subunit which leads to phosphorylation of beta subunit. This leads to transport of GLUT RECEPTORS on to the cell membrane which in-turn transports glucose into the target cell( adipocyte and muscle cell); Gluconeogenesis is inhibited and glycogenesis is stimulated in the liver cell with the action of insulin on it; All these leads to decrease in the blood sugar hence it usage in hyperglycaemic state; 2)How do you differentiate a patient clinically on the bedside whether the patient is type1 or type 2 diabetic? In type 1 diabetics the beta cells are 100% destroyed and hence supplemenation with secretagogues(hypoglycaemic drugs) would not benefit the patient clinically whereas in type 2 diabetics almost 10-30% of beta cells are functional hence we can boost them up with secretagogues and increa
Read more

CHRONIC KIDEY DISEASE(CKD) IN HYPERTENSIVE WOMEN;

Image
 GENERAL MEDICINE CASE REPORT; 2 AUGUST,2021; SAI PRANEETH BATHINEEDI; ROLL NO 116; 3 SEMESTER STUDENT; HELLO GUYS, 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 evidence based input I've 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. CHIEF COMPLAINT; A 62 year old female presented to the OPD with chief complaints of; 1. lower back pain  2. Swelling of the leg  3. shortness of breath from the past 2 months HISTORY OF PRESENTING ILLNESS; The patient was app
Read more