60 year old male came with bleeding per rectum, hemoptysis, hemetesmis

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This is an online E-log book to discuss our patient de-identified health data shared after taking his/ her guardians sign informed consent

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve those patient clinical problem with collective current best evidence based inputs.

This E-log also reflects my patient centered online learning portfolio.

Your valuable inputs on comment box is welcome

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


Systemic examination:

CVS- S1 S2+

RS- BAE+

CNS- intact

PA- soft, non tender

Investigations 

24/9/22




        











Day 2 Hemogram


Day 3 Hemogram



Provisional diagnosis
?Idiopathic thrombocytopenic purpura

Treatment Day 1
1. 1U SDP Transfusion done
2. IV fluids 1U NS, 1RL @75ml/hr
3. INJ Ethylsmlyate 250mg IM (only if active bleeding)

Day 2
1. IU SDP Transfusion done
2. INJ Ethylsmlyate 250mg IM (only if active bleeding)



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