28 M with blood in stools

A 28 year old male patient came to opd with chief complaint of blood in the stools since 1 1/2 year & shortness of breath on exertion since 1 year.


HOPI:-


Patient was apparently normal 1 1/2 year back then he noticed bleeding per rectum and it was once in every 1-2 months .

It was not associated with any pain during defecation , no mass per rectum and there is  fresh drop of blood per rectum. Aggravated on straining while passing stools  

1 year back he developed  sob on exertion which was  not associated with chest pain , no palpitations, no giddiness.

He c/o fever since 1 week which is of low grade,associated with chills and dry cough

 First he went to local practitioner,  but fever did not subsided then he was refereed to local hospital in Miryalaguda where he underwent for cbp examination:

  Hemoglobin- 2.1%

  RBC     - 1.5 millions/ mm3

  Platelets- 1 lakh 

Then he was  referred here for gastroenterologist 


HISTORY OF PAST ILLNESS:- 

He had  h/o  polio at  the  age of  5 years

N/K/O DM, HTN,ASTHM, epilepsy,cad


TREATMENT HISTORY:-

Surgical history-

He had under gone a surgery  in his left thight for releasing  contracture for polio


PERSONAL HISTORY:-

Diet - mixed 

Appetite- normal

Bowel - regular (a/w blood)

Bladder - regular

Sleep - adequate

No addiction 


FAMILY HISTORY:- 

No signicant family history 


GENERAL EXAMINATION:-

Patient is c/c/c




pallor - present 
NO  icterus , cyanosis, clubbing , lymphadenopathy, pedal edema 

VITALS AT THE TIME OF EXAMINATION :-

Temperature - afebrile , 
BP:-110/70mmhg ,
PR:- 94 bpm,
RR- 16 cpm,
 Spo2:- 98%@RA  

SYSTEMIC EXAMINATION:-

CVS :- S1,S2 +( Increase in jvp)

R/S :- BLAE +

P/A :- SOFT ,NON Tender with mild splenomegaly 

CNS :NAD






INVESTIGATION:- 

HEMOGRAM:-

Date - 20-8-22 


ESR:-


LFT:-


BLOOD UREA:-


SERUM CREATININE:-




SERUM ELECTROLYTES:-




PROPTOSCOPY:-

Fissures in ano




PROVISIONAL DIAGNOSIS:- 

Severe anemia secondary to   Bleeding per rectum 

TREATMENT:-

INJ.VITCOFOL IM/OD

TAB.OROFER-XT. PO/OD        


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