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CASE
35 yrs old Male resident came to opd with chief complaints of blood in the stools ,SOB ,itching all over the body since 1month.
HOPI:
Patient was apparently asymptomatic 1month back then he observed blood in the stools not associated with pain during defecation, bright red in colour and the quantity was around 30ml .
No H/o loose stools, no H/o constipation, no H/o abdominal pain.
He complaints of SOB while doing work and lifting little weights because of which he had to stop going to work since 1 month. The sob was sudden in onset and gradually progressed to an extent that he is not able to walk distances that he previously used to.(nyha class 2). The sob relieved on sitting. Not associated with cough.
No H/o chest pain.
History of itching all over the body ,due to itching there are small hyperpigmented patches on both upper and lower limbs since 1month . It was sudden in onset and was first observed on the lower limb which later involved upper limb and abdomen.
PAST HISTORY:
Similar complaints 1 yr back (blood in stools for 15 days)
N/k/c/o Hypertension, diabetes,asthma, epilepsy,CAD
DAILY ROUTINE:
He wakes up at 5 am and does his daily routine ,eats breakfast at 8:30 and goes to work at 9am , afternoon he takes alcohol and comes home and eats lunch and sleeps until 5 or 6pm ,then again he goes out , drinks alcohol and comes home and does his dinner and goes to bed at 10 pm.
PAST HISTORY:
Similar complaints in the past 1 yr back
Not a k/c/o Diabetes,asthma, coronary artery diseases,epilepsy,thyroid disorders.
FAMILY HISTORY :
Not signigicant
PERSONAL HISTORY:
Diet- mixed
Appetite - normal
Sleep -normal
Bowel and bladder -regular (blood in the stools)
Addictions-
-He has a habit of drinking alcohol since 15 years,
He drinks up to 180ml of whiskey everyday.
GENERAL EXAMINATION:-
-Patient is conscious, cooperative, with slurred speech
Well oriented to time, place and person
-Moderately built and moderately nourished.
Pallor - present
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy - absent
Oedema - absent
VITALS:
B.P:110/70 mmhg
P.R:76bpm
R.R: 22cpm
Temp:99.5 F
SYSTEMIC EXAMINATION:
ABDOMINAL EXAMINATION:
All quadrants moving equally with respiration
No scars, sinuses and engorged veins , visible pulsations.
Anemia due to blood loss by haemorraoids and fissure.
INVESTIGATION:
FINAL DIAGNOSIS:
Anemia secondary to blood loss by haemorraoids (grade 1) and active fissure (11'0 clock)
?IRON DEFICIENCY ANEMIA
Right renal cortical cyst .
TREATMENT
1)T.MONOCEF 200 mg po/BD
2)T.PAN 40mg po/bd
3)SYRUP. LACTULOSE 10ml po/BD
4)OINT.SMUTH
5)SITZ BATH WITH BETADINE -QID
6)HIGH FIBER DIET
7)INJ. VITCOFOL 1.5ml I.M/OD
8)INJ.THIAMINE 100mg in 100 ml NS IV/OD
6/4/2023:
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