25/M with blood in stools

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A 25 yr old male patient resident of Narketpally ,runs a wine shop ,presented with chief complaints of Blood in stools since 9 days ,

Shortness of Breath since 4 days , Headache since 9 days.

HISTORY OF PRESENTING ILLNESS: 

Patient was apparently asyptomatic 5 months back, then he noticed blood before and after passing stools for which he took medication (unknown).

Since 9 days, he has been complaining of blood in stools  associated with an episode of vomiting, not associated with any pain and fever.

He had Headache since 4 days which is continuos with no aggravating and relieving factors .

He had Shortness of Breath (Grade 2) since 4 days which is sudden in onset not associated with chest pain which aggravates on walking and relieves on sitting.

He went to a hospital in Nalgonda and he was found to have Hb -3.6 gm%. He then came to Kims Narketpally for further management.

 Past History : 

No History of Diabetes mellitus,hypertension, Tuberculosis,Asthma, Coronary artery Disease , Epilepsy.

No surgeries underwent in the past.

Family History:

No member of the family has similar complaints.

PERSONAL HISTORY

 

He takes mixed diet,appetite is normal ,bowel and bladder movements regular ,sleep is adequate,He consumes Alcohol  ( 1 beer),Toddy occasionally since 3 years .No history of smoking.

No known Drug,Food Allergies.

Daily routine:

 He wakes up at 6 am and does his chores ,he goes to fish market and returns at 9 am , he'll have his breakfast and goes to shop by 10 am.

He'll take his lunch 2 pm and goes  back home at 

10:30 ,goes for dinner and sleeps by 11 pm.

General Examination:

Patient was conscious, coherent, cooperative 

ill builtand poorly nourished.

  Pallor: present.

Icterus: Absent

Cyanosis: Absent

Clubbing: Absent

Generalised lymphadenopathy: Absent

Bilateral pedal Edema: Absent.

Vitals:

Temperature: 98.6 C

Pulse rate: 121 beats/ min

Bp: 110/60 mmHg

Respiratory rate: 20 cycle/ min.

Systemic Examination:

Abdomen: Soft and non tender. Bowel sounds heard 

Cardiovascular system: S1,S2 heard.Ejection systolic murmur heard.

 

Central nervous system: No focal neurological deficits.

Respiratory system: Bilateral Air entry present.

   Breath sounds heard all over the chest. Trachea is Central .

Provisional Diagnosis:

Anaemia secondary to Iron deficiency 

Fissure in Ano

Investigations:

 1.Complete blood picture:

2. Ecg

Treatment: