119 roopesh

S.roopesh

Roll no :119

3rd sem

 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.

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;