71,F WITH IRON DEFICIENCY ANEMIA SECONDARY TO PER RECTAL BLOOD LOSS DUE TO SOLITORY RECTAL ULCER


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.


I have 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. 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


Case History and Clinical Findings A 70 YEAR OLD FEMALE C/O LOOSE STOOLS 2 YEARS PATIENT WAS COMPLAINING OF GENERAL WEAKNESS FROM 15 DAYS PAIN ABDOMEN SINCE 2 YEARS WEIGHT LOSS SINCE 2YEARS

 HOPI 
PATIENT WAS APPARENTLY ASSYMPTOMATIC 2 YEARS BACK SHE DEVELOPED LOOSE STOOLS ASSOSSIATED WITH BLOOD IN STOOLS NOT PAINFUL PAIN ABDOMEM RELIEVED AFTER PASSAGE OF STOOLS WEIGHT LOSS SINCE 2 YEARS SIGNIFICANT

 PAST HISTORY 
PATIENT WAS COMPLAINING OF SIMILAR COMPLAINS FROM 2016 FOR WHICH SHE WAS DIAGNOSED TO HAVE SOLITORY RECTAL ULCER ADVICED GASTRO ENTEROLOGIST ADVICED 2 PRBC FOR COLONOSCOPIC INTERVENTION IN V/O ANEMIA PATIENT IS NOT A K/NC/O HTN DM ASTHMA CAD EPILEPSY PERSONAL HISTORY APPETITE DECREASED
DIET MIXED SLEEP NORMAL ADDICTIONS NO BLADDER MOVEMENTS NORMAL BOWEL MOVEMENTS LOOAE STOOLS ASSOSIATED WITH BLOOD

 GENERAL EXAMINATION
 PT C/C/C PALLOR PRESENT NO CYANOSIS NO CLUBBING NO LYMPHEDENOPATHY NO KOILONYCHIA NO PEDAL EDEMA
 PR 87BPM BP-120/80 MM OF HG CVS S1S2 + RS BAE PRESENT P/A 
SOFT NON TENDER CNS NAD Investigation HEMOGRAM AT THE TIME OF ADDMISSION HB 6.4 GM /DL AFTER 1 PRBC TRANSFUSION HB IS 7.9 GM AFTER SECOND PRBC TRANSFUSION HB IS9.8 GMS BGT O POSITIVE Treatment Given(Enter only Generic Name) 
2 PRBC TRANSFUSIONS GIVEN COURSE IN THE HOSPITAL PATIENT WAS ADMITTED IN V/O PER RECTAL BLEEDING AND GASTROENTEROLOGIST ADVICE WAS TAKEN AND COLONOSCOPY WAS ADVICED AND 2 PRBC TRANSFUSION FOR HEMOGLOBIN ADVICED Advice at Discharge TAB OROFER XT 100MG PO OD HALF AN HOUR AFTER FOOD
On follow up: Morbidly ill
71,F
Diagnosis IRON DEFICIENCY ANEMIA SECONDARY TO PER RECTAL BLOOD LOSS DUE TO SOLITORY RECTAL ULCER 

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