A 26 yr old male with ANAEMIA SECONDARY TO IRON DEFECIENCY ANAEMIA WITH FISSURE IN ANO

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

 Case History and Clinical Findings 
PATIENT CAME WITH C/O SOB SINCE 2DAYS ,HEADACHE SINCE 2 DAYS ,C/O FRANK BLOOD BEFORE AND AFTER PASSING STOOLS SINCE 10DAYS .
 HISTORY OF PRESENT ILLNESS::-
: PT WAS APPARENTLY ASYMPTOMATIC 1 YEAR BACK AND DEVELOPED BLOOD IN STOOLS FOR WHICH HE USED MEDICATION .NOW SINCE 10DAYS PT IS HAVING C/O PASSING OF FRANK BLOOD AFTER AND BEFORE PASSING STOOLS .(APPROX . 150ML BLOOD /EACH STOOL ) SOB SINCE 2 DAYS GRADE II NOT ASS WITH FEVER COLD .SOB AGGREVATING ON WALKING RELIEVES ON SITTING . 
PAST HISTORY  -NOT A K/C/O HTN /DM/ASTHMA /CAD /EPILEPSY . 
FAMILY HISTORY : NOT SIGNIFICANT PERSONAL HISTORY 
 DIET -MIXED 
APPETITE- NORMAL 
MICTURITION -NORMAL
 BOWEL -NORMAL
SLEEP -ADEQUATE 
ADDICTIONS -OCCASIONAL ALCOHOL 
. GENERAL EXAMINATION : 
PALLOR PRESNT 
NO ICTERUS NO CYANOSIS NO CLUBBING NO LYMPHADENOPATHY NO EDEMA 

VITALS ON ADMISSION
 BP 110/60 MMHG 
PR 121 BPM RR 20/ MIN 
GRBS 228 MG% SPO2 99 % WITH 
RA COURSE IN HOSPITAL : PT WAS ADMITTED AND INVESTIGATIONS WERE SENT ,SURGEERY REFERAL WAS TAKEN FOR BLOOD IN STOOLS ,AND FISSURE IN ANO WAS

DIAGNOSIS:-ANAEMIA SECONDARY TO IRON DEFECIENCY ANAEMIA WITH FISSURE IN ANO

 DIAGNOSED AND TREATMENT STARTED . I/V/O LOW HB 3 PRBS BLOOD TRANSFUSION WAS DONE .GASTROENTEROLOGIST OPINION WAS TAKEN AND COLONOSCOPY WAS ADVISED . 
Treatment Given(Enter only Generic Name)
 TAB .OROFER XT PO/OD 
SYP .CREMAFFIN PLUS 30ML PO/HS 
INJ VIT K 1 AMP IN 100ML NS IV /OD.
 INJ .PANTOP 40MG IV /OD
 INJ .TRANEXA 500MG IV /SOS 
INJ. ZOFER 4 MG IV /SOS 
Advice at Discharge 
TAB .OROFER XT PO/OD 
SYP .CREMAFFIN PLUS 30ML PO/HS
 TAB .PANTOP 4OMG PO/OD 
OINT .ANOBLISS L/A
Follow up:No limitation in physical activity

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