21 year old female

 CASE SCENARIO:

A 32 year old female presented to the OPD with dysphagia, significant weight loss, pedal oedema, SOB on exertion, blood in stool and pain during defecation.

COMPLAINTS AND DURATION

• Dysphagia to solids since 4 months (grade-3)

• Weight loss of 15 kgs in 6 months 

• Pedal edema - relieved on medication outside hospital

• Shortness of breath on exertion

• Blood in stool , no malena 

• Pain during defecation 

HISTORY OF PRESENT ILLNESS

Patient apparently asymptomatic , developed dysphagia which gradually progressed and the patient is now reluctant to take food.

HISTORY OF PAST ILLNESS

• Not a K/C/O HTN, DM, asthma, epilepsy

• Denovo detected hypothyroidism (started on 12.5 mg of thyronorm last month)

• H/o hearing loss since childhood (not evaluated)

TREATMENT HISTORY

No significant treatment history

PERSONAL HISTORY

• Single

• Appetite - lost

• Bowels- regular

• Micturition -normal

• No known allergies

• No addictions

FAMILY HISTORY

• No significant family history

MENSTRUAL HISTORY

• Age of menarche - 14 years 

• Menstrual cycle = 28 days/ 3 days. Oligomenorrhea since 6 months.

PHYSICAL EXAMINATION

1. GENERAL

• Weight - 34kgs

• Pallor - Yes (severe)

• Icterus - No 

• Cyanosis - No

• Clubbing of finger/toes - No

• Lymphadenopathy - No

• Oedema - yes 

• Malnutrition - yes 

• Dehydration - yes

• Koilonychia - present 

• Grade 1 goitre 

• Temperature - afebrile 

• Pulse rate 54 b/min

• Respiration rate - 17/min

• BP 80/60 mmHg 

SYSTEMIC EXAMINATION 

2. CARDIOVASCULAR SYSTEM

• Thrills - No 

• Cardiac sounds - S1 , S2 positive

3. RESPIRATORY SYSTEM 

• Dysponea - No 

• Wheeze - No

• Position of trachea - Central 

• Breath sounds - Vesicular 

• Adventitious - Rhonchi 

4. ABDOMEN

• Shape of abdomen - Scaphoid

5. CENTRAL NERVOUS SYSTEM 

• Level of consciousness 

1. Alert

2. Stuporous 

• Signs of meningeal irritation

1. Neck stiffness - no

2. Kerning’s sign - no

• Cranial nerves - normal 

• Motor system - normal

• Sensory system - normal 

• Glasgow system - normal 

• Cerebral signs

1. Finger nose coordination - Yes

2. Knee Heel In-coordination - Yes

   
   

F.MUSCULO SKELETAL SYSTEM - normal 

G. SKIN - normal

 

H. EXAMINATION OF BREAST - normal

I. EXAMINATION OF ENT - normal

J.EXAMINATION OF TEETH AND ORAL CAVITY - normal

K. EXAMINATION OF HEAD AND NECK  - normal

PROVISIONAL DIAGNOSIS/ DIAGNOSIS 

• Severe anaemia (? Iron deficiency anemia) 2 nd degree to

1. Blood loss ( H/o Haemorrhoids)

2. Nutritional cause

   
   

   HAEMOGRAM
   
   
   
   
   
   
   
   
   SERUM IRON
   

   

   
   
   BLOOD UREA
   
   
   
   BLOOD GROUPING AND RH TYPING
   
   
   
   ECG
   
   
   
   
   
   SERUM CREATININE
   
   
   
   LFT
   
   
   
   SERUM ELECTROLYTES
   
   
   
   HIV TEST
   
   
   
   HEPATITIS C TEST
   
   
   
   HEPATITIS B TEST
   
   
   

   
   
   

   

   
   

   LDH
   
   
   
   
   
   RETICULOCYTE COUNT
   
   
   
   
   
   COVID-19 TEST

   
   

   
   
   
   THYROID FUNCTION TESTS

   
   

   
   
   
   COMPLETE URINE EXAMINATION (CUE)

   
   

   
   
   
   REPEAT HAEMOGRAM

   
   

   
   
   
   ESR TEST

   
   

   
   
   
   28/7/21
   DEPARTMENT: GENRAL MEDICINE

   PROVISIONAL DIAGNOSIS/ DIAGNOSIS 

   • Severe anaemia (? Iron deficiency anemia) 2 nd degree to

   1. Blood loss ( H/o Haemorrhoids)

   2. Nutritional cause

   3. Hypothyroidism

   
   

   TREATMENT
   • Inj. OPTINEURON 1 amp 100 ml IV QD
   • TAB. OROFOR-XT BD
   • BP/PR/TEMP/SPO2 monitoring

   BLOOD TRANSFUSION ordered
   
   
   
   
   
   28/7/21
   REFERRAL BY GENERAL MEDICINE TO GENERAL SURGERY
   
   

   
   

   Severe IDA secondary to blood loss ( hemorrhoids?) (anal fissure?) c/0 blood in stool
   
   

   CROSS REFERRAL NOTES

   
   
   
   
   EXTERNAL HEMORRHOIDS FOUND - in 11 o clock, 7 o clock and 3 o clock positions.
   Patient not co-operative for proctoscopy
   
   
   PROVISIONAL DIAGNOSIS: EXTERNAL HEMORRHOIDS
   
   
   TREATMENT
   • Sitz bath with betadine TID
   • High fibre diet
   • Plenty of oral fluids
   • Oint. Smuth
   • Syp. Cremaffin 20ml TID
   INSTRUCTION:
   Review to surgical OPD after 2 weeks correction of anemia .
   No immediate surgical intervention intervention required as of now.