28 years old man with blood in stool

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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 -

A 28 year old male came to the OPD with the chief complaint of blood in stools since 1.5 years and sob on exertion since 1 year. 

History of presenting illness-

The patient was apparently asymptomatic 18 months back then he noticed blood in his stools, about few drops of red blood, once every 1 to 2 months,which is not associated with any pain during defecation. 

There is no h/o abdominal pain, constipation, hemetemesis.

No mass per rectum. 

He has been experiencing difficulty in breathing on exertion (NYHA grade 2) since 12 months. 

He has h/o palpitations and tremors since 6 months.  

He developed fever 10 days which is of low grade, continuous and associated with chills. He was prescribed paracetamol by the local rmp but the fever did not subside. He was then sent to the local hospital in Miryalaguda where he was found to have decreased hemoglobin. 

Hb-2.1%

RBC-1.5 million /mm3

Platelets- 1lakh

He was then referred to our hospital for gastroenterologist.

Here he was transfused blood owing which his Hb increased as follows - 

He recieved another unit of blood (PRBC) on the afternoon of 21-8-22. 

Past history- 

He is suffering from poliomyelitis since the age of 5 yrs due to which his left lower limb is paralysed and wasted. 

He is not a k/c/o HTN, diabetes, TB, asthma, epilepsy, CAD. 

Treatment history -

He had undergone a surgery in his left thigh for releasing the contracture due to polio

Personal history -

He is a post graduate student whose daily activity includes studying at home. 

Appetite - low ( from childhood) 

Diet - mixed 

Bowel & bladder habits - regular 

Sleep - adequate 

Addictions - none 

 

Family history - 

No significant family history 

General physical examination -

The patient is conscious, coherent and cooperative and well oriented to time, place and person. 

He is lean built. 

Pallor - present

Icterus _ absent

Cynosis- absent

Clubbing_absent

Generalized Lymphadenopathy _absent

Bilateral pedal oedema _absent

Vitals -

Temp - 98 degree F

PR - 89bpm

RR- 20cpm

BP - 110/90mmof hg

Spo2 - 98% at room air

Systemic examination -

CVS - S1 , S2 heard , no murmurs 

CNS - Higher mental status- N

Cranial nerves- intact

Motor - 

Tone- normal (left lower limb- hypotonic)

Power- normal (left lower limb-no power)

Reflex-  B       S     T      K     A       P

       Rt-     ++     ++    ++     +     +      flexion

       Lt-     ++     ++    ++      -      -           -

Cerebellar functions- N

Gait- walks by supporting his left lower limb with left hand 

RESPIRATORY SYSTEM - BAE- present, trachea - central, NVBS heard 

ABDOMEN - soft, non tender, mild splenomegaly present 

Lab investigations -

On 18-8-22

On 19-8-22

On 20-8-22

Icterus - absent 

Cyanosis - absent 

Clubbing - absent 

Generalised lymphadenopathy - absent 

B/l pedal edema - absent 

Provisional diagnosis- 

Severe anemia 

??autoimmune  polyglandular syndrome

Treatment-

PRBC transfusion

Inj. LASIX 20mg I.V sos

Inj. VITLOFOL OD 

Tab. BANDYPLUS H/s

Adviced - 

High fibre diet 

ANOBLISS ointment

Syrup CREMAFFIN

SITS bath/ with betadine TID

Review SOS