60 year old male came with bleeding per rectum, hemoptysis, hemetesmis
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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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan.
A 60year old male with bleeding per rectum,hematemsis,hemoptysis
Cheif complaints-
Patient came to the casualty with cheif complaints of:
-bleeding per rectum since 4days
-hemoptysis since 4days
-hematemsis since 2days
-dark stools since 2days
-bleeding from penis since 2days
History of presenting illness:
Patient was apparently asymptomatic 4days back later he developed bleeding per rectum, since 4days, hemoptysis since 4days, hemetesmis since 2days, dark stools since 2days, bleeding from penis since 2days.
Daily routine:
Patient wakes up at 5am and does his daily routines, takes breakfast at 7am and goes to work(watchman) at 8am and takes lunch at 1pm and again goes to work returns home at 8pm and takes dinner at 9pm and sleeps at 11pm
Past history:
6years ago Patient had h/o consumption of op poison for which he was admitted and found to be serology positive (HIV and HbsAg) but didn't use any medication.
1month ago he took Antiretroviral drugs for 10days and stopped taking medication from 20days
N/k/c/o DM,HTN,TB, Asthma Epilepsy
Personal history:
Diet- mixed
Appetite- normal
Sleep- Adequate
Bowl and bladder- regular
Habits-
Treatment history:
2 SDP Transfusion done on 20/9/22 outside
Family history
Not significant
General examination
Patient is conscious, coherent, cooperative well oriented to time, place and person
Thinly built and nourished
Pallor- absent
Icterus- absent
Cyanosis- absent
Clubbing- absent
Lymphadenopathy- absent
Edema- absent
Vitals on admission:
BP- 110/80
PR- 107bpm
RR- 20cpm
Temp- 97
SpO2- 100 @RA
GRBS- 103mg/dl
CVS- S1 S2+
RS- BAE+
CNS- intact
PA- soft, non tender
Investigations
24/9/22
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