A 51 year old male with SOB since 1 month

 CHIEF COMPLAINTS :

A 51M farmer by occupation , resident of nalgonda came to opd with c/o shortness of breath since 2 months and bleeding per rectum since 2 months .


HOPI 

Patient was apparently asymptomatic 2 months ago then he developed SOB of insidious onset, gradually progressive increasing in intensity since 2 months (Glade II- III)

The patient had undergone surgery for Haemorrhoids 2 years ago , and then ,there was relapse of Haemorrhoids again 2 months ago and he was losing blood in an amount of 30ml/day during passing of stools

No h/o constipation , nausea , vomiting ,burning micturation .


PAST HISTORY :

N/KC/O DM , HTN , CAD , CVA , EPILEPSY , THYROID DISORDERS 


FAMILY HISTORY : 

not significant 


PERSONAL HISTORY : 

Decreased appetite 

Mixed diet 

Decreased bowel movements 

Normal micturition 

Addictions : consumes alcohol regularly from 2 years


GENERAL EXAMINATION :

I have examined the patient after taking prior consent and informing the patient in the presence of a attendant. The examination was done in both supine and sitting position in a well lit room. 


- patient was conscious, coherent and cooperative

- well oriented to time, place and person

- well built and adequately nourished

- pallor present 




- icterus present



- no cyanosis 

- no clubbing of fingers

- no lymphadenopathy 

- no pedal edema

- koilonychia present




VITALS :

Temperature :  afebrile

BP :  100/70 mmhg                       

Pulse rate : 100/min

Respiratory rate : 16/min

SPO2 : 98% RA


SYSTEMIC EXAMINATION :

CVS : 

S1S2 +

Cardiac murmurs heard

No thrills

RS : 

Position of Trachea - central

BAE +

NVBS +

P/A :

Soft , Non tender

CNS :

NFND


INVESTIGATIONS :

18/10/2023











PROVISIONAL DIAGNOSIS: 

Anemia secondary to blood loss due to haemorrhoids


TREATMENT :

1) TAB.OROFER - XT PO/OD

2)TAB.LIMCEE - PO/OD

3)TAB.MVT - PO/OD






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