I am Mridul Tak, a final year MBBS student, and this is an online elog documenting de-identified patient health data after taking his signed consent to enforce a greater patient centered learning.
DEIDENTIFICATION -
The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.
Case Scenario -
28 year old male patient presented to the OPD with chief complaints of bleeding per rectum and itching and rashes all over the body since last 2 months.
History of Presenting Illness -
- 28 year old male patient from Calcutta came to the OPD with chief complaint of bleeding and pain while passing stools since last two months associated with itching and Rash all over the body, more prominent in the groin region and inner thighs.
-Patient used to reside in Kerala and work in jewellery shop in night shift with improper dietary schedule and was asymptomatic 15 years back.
-In 2010 patient started having bleeding while passing stools once every 2 to 3 months which were hard in nature and foul smelling. He was constipated and used to pass stools minimum 3 to 4 times a day.
-Then in 2012 bleeding while passing stools became regular but the patient did not approach the doctor due to language and leave constraints.
-But as the problem increased, patient approached a local doctor in 2014 who prescribed him some medications which made passing of stools easy and his bleeding stopped.
-But after one year bleeding started again and he approached another doctor in 2016 who gave him some 4 to 5 injections around his anus after which bleeding stopped and the patient's life became normal.
-Then in 2017, he shifted to Dubai where he started eating excessive non-vegetarian and spicy food due to which bleeding started again and patient came back to Kolkata in 2019, where he visited a homeopathic doctor because his friend told him that allopathy will give him serious side effects due to which the patient got afraid of Allopathy.
-After taking homeopathic medicine, the bleeding stopped, frequency of defecation decreased and pain also decreased. For two years patient kept on taking it and was normal.
-But since last 2 months he developed Itching associated with rash which was papular in the hands, between fingers and trunk and purplish plaques predominant in the inner thighs and groin region and also bleeding started again associated with pain even after taking homeopathic medicine.
Therefore he approached a specialist doctor in Kolkata, who advised him 30 to 40 injections along with 3 months of rest as treatment. But as the patient cannot take 3 months of leave so he visited our hospital in hope of better and faster treatment.
History Of Past Illness -
No previous history of rashes. No previous history of Diabetes, Hypertension, Asthma, TB.
Treatment History -
2014 - Medication used to stop bleeding per rectum.
2016- 4-5 Injections around the anus to stop bleeding per rectum.
2019- Started homeopathic treatment for bleeding per rectum which is continuing till now.
Personal History -
Unmarried.
Occupation: Previously worked in Jewellery Shop at night shift. Currently working during day shift.
Appetite: Normal
Diet : Non vegeterian, Spicy
Bowels: Multiple times a day (3-5)
Micturition: Normal
No known allergies
Smoking - 15 to 20 cigarettes and bidis/day. Patient has a habit of smoking in washroom.
Alcohol - 1 to 2 times a month with friends.
Family History -
Insignificant
PHYSICAL EXAMINATION -
GENERAL EXAMINATION -
- Pallor: no
- Icterus: no
- Cyanosis:no
- Clubbingof fingers /toes:no
- Lymphedenopathy: no
- Edema of feet : no
- Malnutrition : no
- Dehydration :no
VITALS -
- Temperature: 103° F
- Pulse rate: 74 bpm
- RR : 24 cycles per minute
- BP : 126/82 mm hg
SYSTEMIC EXAMINATION -
CVS - Cardiac sounds S1 & S2 are present.
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