33/F chronically anemia 2° to grade 1 hemorrhoids



This is an online e log book to discuss our patient identified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient problems through a series of inputs from available global online community of experts with a aim to solve those patients clinical problem with collective current best evidence based inputs.

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

 90kcal

194kcal , 156kcal

1080kcal ,156kcal

1.6gm 

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

DIET 
















Project PLAR : Nutritional iron deficiency anemia inferential gaps 




[5/17, 10:22 PM] Rakesh Biswas: https://www.hsph.harvard.edu/nutritionsource/healthy-eating-plate/



[5/17, 10:37 PM] Pt Adv 33F Chronic Anemia Karnataka: Thanq


[5/20, 7:29 AM] Pt Adv 33F Chronic Anemia Karnataka: Dry fruits


[5/20, 8:20 AM] Pt Adv 33F Chronic Anemia Karnataka: Mixed veg juice


[5/20, 8:28 AM] Pt Adv 33F Chronic Anemia Karnataka: Zeera water


[5/20, 10:06 AM] Pt Adv 33F Chronic Anemia Karnataka: Onion dosa



[5/20, 2:36 PM] Pt Adv 33F Chronic Anemia Karnataka: Spinach juice



[5/20, 6:47 PM] Pt Adv 33F Chronic Anemia Karnataka: Spinach juice


[5/21, 9:44 AM] Pt Adv 33F Chronic Anemia Karnataka: Zeera water



[5/21, 9:47 AM] Pt Adv 33F Chronic Anemia Karnataka: Veg juice


[5/21, 9:50 AM] Rakesh Biswas: Your patient's plate needs to hold every component in the proportion mentioned here 

From your daily images of what you are sharing as to what your patient is consuming, we are unable to figure out if she's consuming in the above balanced manner!



[5/21, 9:52 AM] Rakesh Biswas: @⁨Anahita Behara⁩ Can you upload the images of her daily food images shared above into her case report along with the conversations above as this is valuable data providing insights into her anemia that could be nutritional!



[5/21, 9:52 AM] Anahita 2019 KIMS: Yes sir , will do so


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