A 33yr old With Chronic anemia 2° to grade 1 hemorrhoids

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 
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 present 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

Investigation 
Hb: 7.9 (7/3/2023)

Diagnosis::-
Chronic anemia 2° to grade 1 hemorrhoids


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