55 year old with abdominal pain.

Date: November 20th 2022

This is an E log book to discuss our patients de-identified health data shared after guardians informed consent.

Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve this patients clinical problems with collective current best evidence based inputs.

This E-book also reflects my patients centered online learning portfolio and your valuable comments in comment box are most welcome.

    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 comprehending clinical data including history,clinical finding investigations and come up with a diagnosis and treatment plan.


November 20th 2022

Anurag K Vaddadi

Roll no: 189


 Case 

A 55 year old patient came with chief complaints of:

1) Abdominal pain since 4 months

2) Abdominal bloating since 4 months

3) Belching since 4 months

4) Shortness of breath on exertion since 1 month

5) Palpitations since 1 month 


History of presenting illness:

Patient was apparently asymptomatic 4 to 5 months ago, then he complained of pain in right lumbar region which later becomes diffuse, along with abdominal bloating and belching for which he sought medical help and was found to have low levels of hemoglobin and underwent two blood transfusions.



History of past illness

   No history of Hypertension/Diabetes Mellitus/ Asthma/CAD/ epilepsy 
 


Personal History


    Appetite :                      adequate
    Diet :                              mixed
    Sleep :                            adequate
    Bowel &
    bladder movements :    Normal, regular
    Addictions :                   history of alcohol intake everyday since 20 years, last binge 4                                                 months ago.


Family History
   
        No similar complaints in the family.



General examination

Patient is conscious, coherent and cooperative, well oriented to time, place, person. Thin built and moderately nourished.

    VITALS

          Temperature      97.8 F
           BP                       110/60 mmHg
           PR                       86/ min
           RR                       20/min
           SpO2                   97 %


       Pallor present










   SYSTEMIC EXAMINATION  

       

 CVS

     S1,S2 sounds heard



 RESPIRATORY SYSTEM

     BAE +
     Normal Vesicular Breath Sounds

P/A: soft, non tender 


CNS: NAD

PER RECTAL EXAMINATION

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



    


    
   PROVISIONAL DIAGNOSIS  : Chronic Iron Deficiency Anemia secondary to Nutritional Anemia/ Chronic blood loss/ Malignancy


 
 INVESTIGATIONS:






  •       LFT





  •        peripheral smear







  •           blood grouping and typing





  •          blood urea







  •        serum creatinine






  •       usg







      
          MANAGEMENT 
                
        
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










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