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A 32 yr old female with dysphagia , weight loss , pedal edema

 Pravallika Gade , MBBS 3rd semester

Roll no: 41 

Under the guidance of Dr. Preeti (Intern)


This is an online E-log book to discuss our patient's identified health data shared after taking his/ her guardians signed informed consent.

 

Here we discuss our individual patient problems through a series of inputs from available Global online community of experts with an aim to solve the patients  clinical problem with current best evidence based input.

 

This E-log also reflects my patient centered online learning portfolio.

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 a diagnosis and treatment plan.


CASE SCENARIO:

A 32 year old female presented to the OPD with dysphagia, significant weight loss, pedal oedema, SOB on exertion, blood in stool and pain during defecation. Patient was apparently asymptomatic 1 months ago then she developed bleeding from rectum on and off since 1 month.


COMPLAINTS AND DURATION

  • Dysphagia to solids since 4 months (grade-3)

  • Weight loss of 15 kgs in 6 months 

  • Pedal edema - relieved on medication outside hospital

  • Shortness of breath on exertion

  • Blood in stool , no malena 

  • Pain during defecation 


HISTORY OF PRESENT ILLNESS

Patient apparently asymptomatic , developed dysphagia which gradually progressed and the patient is now reluctant to take food.


HISTORY OF PAST ILLNESS

  • Not a K/C/O HTN, DM, asthma, epilepsy

  • Denovo detected hypothyroidism (started on 12.5 mg of thyronorm last month)

  • H/o hearing loss since childhood (not evaluated)


TREATMENT HISTORY

No significant treatment history


PERSONAL HISTORY

  • Single

  • Appetite - lost

  • Bowels- regular

  • Micturition -normal

  • No known allergies

  • No addictions


FAMILY HISTORY

  • No significant family history


MENSTRUAL HISTORY

  • Age of menarche - 14 years 

  • Menstrual cycle = 28 days/ 3 days. Oligomenorrhea since 6 months.


PHYSICAL EXAMINATION

  1. GENERAL

  • Weight - 34kgs

  • Pallor - Yes (severe)

  • Icterus - No 

  • Cyanosis - No

  • Clubbing of finger/toes - No

  • Lymphadenopathy - No

  • Oedema - yes 

  • Malnutrition - yes 

  • Dehydration - yes

  • Koilonychia - present 

  • Grade 1 goitre 

  • Temperature - afebrile 

  • Pulse rate 54 b/min

  • Respiration rate - 17/min

  • BP 80/60 mmHg 


SYSTEMIC EXAMINATION 

  1. CARDIOVASCULAR SYSTEM

  • Thrills - No 

  • Cardiac sounds - S1 , S2 positive


  1. RESPIRATORY SYSTEM 

  • Dysponea - No 

  • Wheeze - No

  • Position of trachea - Central 

  • Breath sounds - Vesicular 

  • Adventitious - Rhonchi 


  1. ABDOMEN

  • Shape of abdomen - Scaphoid


  1. CENTRAL NERVOUS SYSTEM 

  • Level of consciousness 

  1. Alert

  2. Stuporous 

  • Signs of meningeal irritation

  1. Neck stiffness - no

  2. Kerning’s sign - no

  • Cranial nerves - normal 

  • Motor system - normal

  • Sensory system - normal 

  • Glasgow system - normal 

  • Cerebral signs

  1. Finger nose coordination - Yes

  2. Knee Heel In-coordination - Yes


F.MUSCULO SKELETAL SYSTEM - normal 


G. SKIN - normal

 

H. EXAMINATION OF BREAST - normal


I. EXAMINATION OF ENT - normal


J.EXAMINATION OF TEETH AND ORAL CAVITY - normal


K. EXAMINATION OF HEAD AND NECK  - normal



INVESTIGATIONS

HAEMOGRAM



SERUM IRON

BLOOD UREA

BLOOD GROUPING AND RH TYPING

ECG


SERUM CREATININE

LFT

SERUM ELECTROLYTES

HIV TEST

HEPATITIS C TEST

HEPATITIS B TEST

ULTRASOUND






SERUM LDH




RETICULOCYTE COUNT


COVID-19 TEST


THYROID FUNCTION TESTS


COMPLETE URINE EXAMINATION (CUE)


REPEAT HAEMOGRAM


ESR TEST


28/7/21
DEPARTMENT: GENRAL MEDICINE

PROVISIONAL DIAGNOSIS/ DIAGNOSIS 

  • Severe anaemia (? Iron deficiency anemia) 2 nd degree to

  1. Blood loss ( H/o Haemorrhoids)

  2. Nutritional cause

  3. Hypothyroidism


TREATMENT
  • Inj. OPTINEURON 1 amp 100 ml IV QD
  • TAB. OROFOR-XT BD
  • BP/PR/TEMP/SPO2 monitoring
BLOOD TRANSFUSION ordered


28/7/21
REFERRAL BY GENERAL MEDICINE TO GENERAL SURGERY


Severe IDA secondary to blood loss ( hemorrhoids?) (anal fissure?) c/0 blood in stool

CROSS REFERRAL NOTES


EXTERNAL HEMORRHOIDS FOUND - in 11 o clock, 7 o clock and 3 o clock positions.
Patient not co-operative for proctoscopy

PROVISIONAL DIAGNOSIS: EXTERNAL HEMORRHOIDS

TREATMENT
  • Sitz bath with betadine TID
  • High fibre diet
  • Plenty of oral fluids
  • Oint. Smuth
  • Syp. Cremaffin 20ml TID
INSTRUCTION:
Review to surgical OPD after 2 weeks correction of anemia .
No immediate surgical intervention intervention required as of now.








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