33/F chronically anemia 2° to grade 1 hemorrhoids
This blog also reflects my patient centered online learning portfolio and valuable inputs on the comments box is welcome.
I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation
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A 33 year old woman a homemaker and a resident of Bangalore
belonging to upper middle class according to modified kuppuswamy scale presented
to the general medicine OPD with c/o
-loss of appetite since 20days
-passage of blood in stool 20 days ago
History of presenting illness
Patient was apparently asymptomatic 15 years ago , when she
had , loss of appetite , fatigue , SOB grade 3 according to NYHA scale , palpitations
, she was clinically diagnosed with anemia and her Hb level was 4gm/dl for which
she was given 3 units of packed cell transfusion after which her Hb level rose
to 8gm/dl , patient was asymptomatic until her first pregnancy 9 years ago ,
due to episodes of dizziness she was given iron injections in the second
trimester of pregnancy ,since then patient has hemorrhoids grade 1 and was
advised a high fibre diet and stool softeners , 20 days ago she had noticed blood
in her stool associated with difficulty in passing stool , she also reports headache
, blurring of vision and giddiness on waking up in the morning and came to the OPD , where on evaluation her Hb
was 7 gm/dl
She was given one iron injection 7 days ago
History of past illness
n/k/c/o DM ,HTN , TB , asthma , epilepsy
h/o blood transfusion
h/o episiotomy
menstrual history
attained menarch at 14 years
regular cycles 4/30
heavy cycles since 4 months
associated with clots sized 1cm * 1.5cm
not associated with pain
LMP : 27-04-2023
Not associated with pain and clots
Moderate flow
Obstretic history
Obstretic formula para 2 live 2
-first pregnancy ; iron injections @ 5th month and
episiotomy performed
-second pregnancy ; uneventful NVD
Treatment history
-stool softeners for grade 1 hemorrhoids
-iron injections
-progesterone pills (for heavy cycles)
Family history
Not significant
Personal history
Diet : VEGETARIAN
Appetite : loss of appetite
Bowel : intermittent passage of blood in stool since 7
years
Bladder : normal and regular
No known allergies
No known addictions
DIETARY HISTORY {according to 24 hour recall method}
|
Meal |
Calories |
protiens |
|
Breakfast : fruits Lunch : rice and curry 1 cup Dinner : chappati 3 , curry 1 cup |
|
4.6gm , 5.2gm 9gm . 5.2 gm |
Required calorie intaken : 1900 kcal
Required protein intake :
Protein deficit :
Calorie deficit : 536 kcal
GENERAL EXAMINATION
Patient was c/c/c and oriented to space ,time and person
Weight :
INVESTIGATIONS
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