1801006080 - SHORT CASE

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I have been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency and to comprehend clinical data including history, clinical finding investigations and come up with a diagnosis and treatment plan.

CHIEF COMPLAINTS 

• Pain abdomen since 2 months 
• Abdominal bloating since 2 months 
• Blood in stools 2 months ago 
• Shortness of breath on exertion since 1 month 
• Palpitations since 1 month

HISTORY OF PRESENTING ILLNESS

The patient was apparently alright 2 months ago and then he developed pain in the right lumbar region which then became diffuse in nature. The pain was intermittent and had no aggravating or relieving factors. It was a dull aching type of pain. He also complained of bloating and belching with no H/O of any loose stools or vomitings. He then got himself checked in a local hospital where during the routine investigations it was found that he has low haemoglobin and he then underwent 2 blood transfusions and also used other syrups for it. Around that time after the blood transfusions he found out he had passed blood in his stools. He then developed shortness of breath on exertion since 1 month and palpitations since 1 month. He also gives a history of easy fatiguability and dizziness. 

PAST HISTORY

H/O haemorrhoids 1 year ago.  

No H/O DM, HTN, asthma, epilepsy, CAD

FAMILY HISTORY 

No similar complaints in the family 

PERSONAL HISTORY 

DIET: Mixed 

APPETITE: decreased 

SLEEP: adequate 

B&B: regular

He is a chronic alcoholic since 25 years (the last binge of alcohol was 2 months ago) He used to drink a type of Local alcohol and then changed to whisky.  

No allergies 

GENERAL EXAMINATION 

The patient was conscious, coherent, cooperative, well oriented to time, place, person. He was moderately built and moderately nourished. 

Pallor: Present

No icterus, cyanosis, clubbing, lymphadenopathy, pedal edema

VITALS: 

Temperature: Afebrile

BP: 120/80 mm Hg

PR: 94 bpm

RR: 30 cpm

PER RECTAL EXAMINATION

No Skin tag at 6 o clock position and grade 1 haemorrhoids at 7 o clock position. 

SYSTEMIC EXAMINATION

CVS - S1, S2 heard 

RS: BAE + 

P/A: soft, non tender

CNS: NAD

PROVISIONAL DIAGNOSIS: 

Iron deficiency anemia secondary to Nutritional anemia/ chronic blood loss/ Haemorrhoids.  

INVESTIGATIONS: 

ULTRASOUND: 

 

Test	Result
HAEMOGLOBIN	# 3.1 gm/dl
TOTAL COUNT	# 10,800 cells/cumm
NEUTROPHILS	72%
LYMPHOCYTES	# 18 %
EOSINOPHILS	1%
MONOCYTES	9%
BASOPHILS	0%
PCV	# 13.5 vol%
M C V	# 54.9 fl
M C H	# 12.6 pg
MCHC	# 23.0 %
RDW-CV	# 24.5 %
RDW-SD	46.9  fl
RBC COUNT	# 2.46 millions/cumm
Platelet count	6.6 lakhs/cu.mm

Peripheral smear: 

RBC: microcytic hypochromic with few pencil forms 

Platelet count increased on smear 

Blood group: O positive

Serum creatinine: 0.7 mg/dl

LFT: 

Test	Result
Total Bilurubin	0.58 mg/dl
Direct Bilurubin	# 0.24 mg/dl
SGOT(AST)	15 IU/L
SGPT(ALT)	10 IU/L
ALKALINE PHOSPHATE	# 208 IU/L
TOTAL PROTEINS	6.8 gm/dl
ALBUMIN	3.7 gm/dl
A/G RATIO	1.24

TREATMENT:

1. 2 PRBC Transfusions done on 19th and 21st of November.

2. TAB. OROFER - XT

3. TAB. RANTAC

4. INJ. Ferric carboxymaltose 500 mg/ iv

TIMELINE: