A 35 yr old male laborer by occupation resident of gottupal came to our opd with chief complaints
Blood in stools since 1 month
Shivering of hands and feet since 1 month
Lightheaded ness since 1 month
Black spots all over his body with itching since 15 days
Fever with headache since 4 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 month back he then noticed epigastric pain followed by yellow colored vomitus( single episode) for which he used medication given by doctors ( no records of the medicine), no present complaints of epigastric pain.
Patient noticed blood after passing stools since a month, approximately 30 ml blood loss per day,bright red to maroon colored with out any mucus and non foul smelling,no evidence of clots
No spotting of underwear.
Complaints of lightheaded ness after walking for 100m associated with shivering and chills,without any loss of consciousness.
Also complaints of SOB started 6 months ago which now progressed to grade 3(MMRC).
Shivering of hands and feet while trying to grab things since 1 month.
Hyperpigmented papules and macules varying in size from 2 mm to 5 mm present all over the body except over his face and neck, associated with itching throughout the day, no evidence of bleeding on itching and reduce in itching on using aloe Vera gel.
Patient complaints of intermittent fever associated with sweating,chills and rigor at night time since 4 days.
Headache in the frontal region since 4 days.
Palpitations since 4 days.
No history of vomiting,loose stools,constipation,abdominal distension,steatorrhea,abdominal pain,weight loss.
PERSONAL HISTORY:
Alcoholic since 15 yrs
Daily 250 to 500 ml whiskey
No smoking
Bowel and bladder movements regular
Sleep adequate
No known allergies.
Diet is mixed.
PAST HISTORY:
No similar complaints in the past
No history of DM, HTN ASTHMA EPILEPSY.
General examination:
Pallor noted on lower palpebral conjunctiva.palms are relatively paler.
Icterus is present ,slight yellowish discoloration of bulbar conjunctiva.
Clubbing present with obliteration of lovibond angle.
No cyanosis and lymphadenopathy
Bilateral Pedal edema present,pitting type grade 1.
VITALS:
Radial pulse 110 beats per minute.
Blood pressure 135/80 mmhg
Respiratory rate 22 per minute
Temp 99.5F.
ABDOMINAL EXAMINATION:
INSPECTION
Small hyperpigmneted papules noted
Shape distended
Umbilicus inverted
No scars sinuses or engorged veins
Hernial orifices are free
PALPATION:
Epigastric tenderness noted
Liver and spleen are not palpable.
PERCUSSION:
liver span 10 cm.
No shifting dullness
No fluid thrill.
AUSCULTATION: 6 bowel sounds per minute.
CARDIOVASCULAR SYSTEM:
Inspection : Shape of chest- elliptical
No engorged veins, scars, visible pulsations
Visible jugular venous pulse on sitting.
Palpation :
Apex beat can be palpable in 5th inter costal space below the nipple around 2 cm.
No thrills and parasternal heaves can be felt
Auscultation :
S1,S2 are heard
no murmurs.
RESPIRATORY SYSTEM:
Inspection:
Shape- elliptical
B/L symmetrical ,
Both sides moving equally with respiration .
No scars, sinuses, engorged veins, pulsations
Palpation:
Trachea - central
Expansion of chest is symmetrical.
Vocal fremitus - normal
Percussion: resonant bilaterally
Auscultation:
bilateral air entry present. Normal vesicular
CENTRAL NERVOUS SYSTEM:
Conscious,coherent and cooperative
Speech- normal
No signs of meningeal irritation.
Cranial nerves- intact
Sensory system- normal
Motor system:
Tone- normal
Power- bilaterally 5/5
Reflexes: Right. Left.
Biceps. ++. ++
Triceps. ++. ++
Supinator ++. ++
Ankle ++.++.
PROVISIONAL DIAGNOSIS:Anemia secondary to blood loss in stools due to grade 1 hemorrhoids.
LAB REPORTS:
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