A 70 yr OLD MALE WITH IRON DEFICIENCY ANEMIA SECONDARY TO PER RECTAL BLOOD LOSS DUE TO SOLITORY RECTAL ULCER

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 70 YEAR OLD FEMALE C/O LOOSE STOOLS 2 YEARS PATIENT WAS COMPLAINING 
OF GENERAL WEAKNESS FROM 15 DAYS PAIN ABDOMEN SINCE 2 YEARS
 WEIGHT LOSS SINCE 2YEARS 
HISTORY OF PRESENT ILLNESS::-
PATIENT WAS APPARENTLY ASSYMPTOMATIC 2 YEARS BACK SHE DEVELOPED LOOSE STOOLS ASSOSSIATED WITH BLOOD IN STOOLS NOT PAINFUL PAIN ABDOMEM RELIEVED AFTER PASSAGE OF STOOLS
 WEIGHT LOSS SINCE 2 YEARS SIGNIFICANT 
PAST HISTORY ::-
PATIENT WAS COMPLAINING OF SIMILAR COMPLAINS FROM 2016 FOR WHICH SHE WAS DIAGNOSED TO HAVE SOLITORY RECTAL ULCER ADVICED GASTRO ENTEROLOGIST ADVICED 2 PRBC FOR COLONOSCOPIC INTERVENTION IN V/O ANEMIA 
PATIENT IS NOT A K/NC/O HTN DM ASTHMA CAD EPILEPSY 
PERSONAL HISTORY::-
 APPETITE -DECREASED
DIET- MIXED 
SLEEP- NORMAL 
ADDICTIONS NO
BLADDER MOVEMENTS- NORMAL 
BOWEL MOVEMENTS LOOSE STOOLS ASSOSIATED WITH BLOOD 
GENERAL EXAMINATION 
PT C/C/C
 PALLOR PRESENT 
NO CYANOSIS, NO CLUBBING, NOLYMPHEDENOPATHY, NO KOILONYCHIA, NO PEDAL EDEMA
  VITALS:-
PR 87BPM 
BP-120/80 MM OF HG 
SYSTEMIC EXAMINATION::-
CVS : S1S2 + 
RS :BAE PRESENT 
P/A :SOFT NON TENDER 
CNS: NAD 
Investigation ::-
 HEMO GRAM AT THE TIME OF ADDMISSION HB 6.4 GM /DL  AFTER 1 PRBC TRANSFUSION HB IS 7.9 GM  AFTER SECOND PRBC TRANSFUSION HB IS9.8 GMS
 BGT O POSITIVE

DIAGNOSIS ::- IRON DEFICIENCY ANEMIA SECONDARY TO PER RECTAL BLOOD LOSS DUE TO SOLITORY RECTAL ULCER 

 Treatment Given ::-
 2 PRBC TRANSFUSIONS 

GIVEN COURSE IN THE HOSPITAL PATIENT WAS ADMITTED IN V/O PER RECTAL BLEEDING AND 
GASTROENTEROLOGIST ADVICE WAS TAKEN AND COLONOSCOPY WAS
 ADVICED AND 2 PRBC TRANSFUSION FOR HEMOGLOBIN ADVICED 
Advice at Discharge  TAB OROFER XT 100MG PO OD HALF AN HOUR AFTER FOOD
On follow up: Morbidly ill 

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