Introduction :
The patient is a 65 year old retired man hailing from a small hilly village.
A note on Consent and De identification :
All identifiers have been adequately removed so as to protect the privacy of the concerned patient . Consent has been obtained after thorough counselling.
I thank Dr. Rishik who is in charge of this patient of ours , for providing me with all details about the patient .
Source of the image above :
(updated )
It has been taken from the e log of the General Medicine Monthly Assessment Scheme ( for the month of May made by me ; link to the same shall be mentioned here in )
https://drsaranyaroshni.blogspot.com/2021/05/assignment-patient-centred-learning.html?m=1
The gentleman complains of -
Loss of appetite
Unintentional Significant Weight Loss
Being extremely tired
Indigestion
Acidity issues.
A Past Background
A quick background of his past issues before elaborating his present problems:
About 6 years ago, he used to have hemorrhoids which had been successfully operated upon, and since then it has not disturbed him again. ( evaluation done in 2015 ; Surgery done in 2019 )
He used to be anaemic when he had the problem of hemorrhoids but it got corrected after the surgery
.
Presently the patient has ..
His gastrointestinal symptoms ( complaint of "indigestion" , flatulence ) began about a decade ago and have remained in him since then but have aggravated of late ( i.e. 6 months ago)
Other problems which began 6 months back
He began feeling very weak and tired , felt like staying in bed all day long , he noticed that his appetite had decreased.
And he complains of a 'dark discolouration of his skin'
About two months back, because these symptoms were not getting relieved ,he had taken a consultation with a local physician
Who suggested him to get a complete blood picture done.
In the reports , hemoglobin came out to be 7g / dl
The physician suggested a transfusion
He recieved 2 units of blood
And the test done after the transfusion showed Hb of 7 g/dl again.
Patient mentions having less tolerance to heavy,spicy food to a certain extent.
He also complains of burps and belches and a tendency to have flatulence and indigestion.
His bowel and bladder movements are normal except for some occasional bouts of constipation which get relieved on consumption of fibre rich food and natural fibre husk supplements.
Please Note : The gastrointestinal symptoms have been there in him ,on and off over the years (got aggravated of recent )
Patient cannot recall any particular reason which led to the precipitation of these problems.
He does not complain of
Nausea
Vomiting episodes
Fever
Cough
Blood in stools
Blood in vomitus
Abdominal pain
Some more details about the patient :
He is a chronic smoker since 40 years ,smokes about 12 cigarettes per day.
He used to be an alcoholic but got rid of the addiction 15 years back.
He admits of being around 70 kg ,6 months ago, but as of today he weighs 58 kg
Making it a loss of 17% of his total body weight within a span of 6 months which is quite significant.
He is not a known case of hypertension , diabetes mellitus, thyroid disorders.
He has truncal obesity , and had been diagnosed to have Fatty liver earlier.
He does not have any history of past tuberculosis .
A Few Reports:
A Clinical Look at the Patient :
The Need of the Hour :
Presently the patient is keen on getting rid of his fatigue,wants to get his appetite back as it used to be and maybe to find a reason of his significant unwanted weight loss so that he can regain his fit self once again.
Questions :
Why is he suffering from anemia ?
Why did his Hb levels not increase even right after 2 units of transfusion?
Any active bleeding going on?
If yes ,then what is the source of pathology?
What is causing his loss of appetite and the significant weight loss ?
What investigations can help us move towards the underlying cause?
All your valuable inputs and differentials are warmly welcomed such that the patient can be healed optimally.
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