45yr male with anemia
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Case:
A 45 year ol male resident of Nalgonda, TSRTC busdriver by occupation came with chief complaints of black colour loose stools since 10 days, C/O loss of appetite since 10 days, C/O SOB while walking since 10 days, C/O easy fatigubility since 10 days
HOPI:
Patient was apparently asymptomatic 10 days back then he had loose stools daily 4-5 episodes, first episode of stool is semi solid, subsequent stool episodes are of black color and watery in consistency, non mucoid, non foul smelling, not associated with tenesmus.
H/o loss of appetite since 10 days associated with nausea
H/o dyspnea while walking and doing his daily activities associated with easy fatigubility and he also complains of epigastric discomfort which is of burning and pricking sensation present throughout the day not associated with food intake.
No h/o chest pain, palpitations, syncopal attack, abdominal pain, giddiness
No h/o fever, night sweats, burning micturition
Past history:
Low back ache since 5 years.
And usage of NSAIDS for pain almost daily.
K/c/o TB 25years back , used ATT
Not k/c/o HTN, DM, CAD, asthma
Personal history:
Bus driver
Decreased appetite
Black colored stools
Chronic alcoholic since 10 years daily upto 250ml of whiskey
Tobacco chewing since 10 years
General examination:
Conscious,thin built, moderately nourished.
Pallor is present
No icterus,cyanosis,clubbing,koilonychia, lymphadenopathy,edema
Afebrile
BP 110/70mm hg
PR-78bpm
RR-18cpm
Weight- 41.5 kgs
BMI- 18.5
CVS examination:
S1,S2 heard ,no murmurs heard
Respiratorysystem:
Bilateral air entry,normal vesicular breath sounds
P/A:
Soft,non tender
CNS examination:
Cranial nerves: intact
Investigations:
Hemogram,CECT,MRI,Stool for ova and cysts,UGIE,
Ultrasound,serumiron,serumferritin,LFT,RFT,LDH,ESR, Reticulocyte count,CUE
Diagnosis:
Anemia secondary to chronic blood loss due to Gastric ulcer disease
Past H/o TB
Treatment:
3 transfusions of PRBC done
Tab.pantocid HP kit PO BD
Tan.zofer 4mg PO BD
Tab Orofer xt 100mg oral BD
Syrup sucralfate 10ml PO BD
Tab PCM 650mg SOS
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