| Provisional Diagnosis | - | Anemia (iron def)
Vit D def state
IgE mediated food allergy
IBD (Crohn's)
Neurasthenia | |
| Final Diagnosis | - | Crohn's disease
Iron & vit D def state
Neurasthenia
IgE mediated food allergy | |
| History and Findings | - | Chief Nursing Officer Incharge AIMS
H/o hypothyroidism 2006-2007 Off Rx after 2007
Anemia,Lack of energy,tiredness,plapitation-Chr
low grade fever x 2yrs
H/o Rx for enteric fever in 2008
Pain neck,brachialgia,eye strain,muscle spasm x 4yrs
Wt-61k BP-130/80
Features of Neurasthenia ++
| |
| Investigation | - | Inv earlier-MDCT abd/Thorax/Pelvis 24/08/07-N study
MRI Brain 24/08/07-N study,CT Neck 3/12/07-early spondylitis,multiple L.Nodes (Benign),MDCT Thorax 03/12/07-Small pleral tagging,postr basal segment Lt,USG abd-13/06/08-N study,MDCT abd 18/06/08-Bulky ovaru with follicular cyst,colonoscopy & rectal biopsy 12/07/08-Multiple aphthoid ulcers in rectum,biopsy unremarkable,BMFT study 18/07/08-N study,Echo-21/06/08-MVP with AML prolapse
Present Inv:Hb-9.76,ESR-62,MCV & MCH low,stool fat +ve,OB NegS Iron-19.9,fe-7.44,ALP-84.3,Stool chymotripsin-14.1,25(OH)vit D-4.96,S PTH-109.7,Corrected ca-8.6,P-2.3,IgE-406.2,food allergy pulmo done,Urine CCR-0.03,CK-47.4,ASCA IgA-38.5 normal <20,CRP-7.73,ECG-WNl,CXr-increased BVm Rt base C.Spine-C.Spondylosis | |
| Treatment | - | calcirol sachets,Citromacalvit,Dexorange,
Tab.Mesacol,Folvite,Rantac,Cap.Doxepin,Tab.allegra+
Ensure | |
| Follow Up | - | 08/09/10-CRP-6.04,ESR-40,Hb-10g
15/11/10-Hb-10.6
14/5/11-Hb-10.1,ESR-40
07/1/11-CA-125-22.5(N),CRP-5.65,ESR-46,hb-11 | |
Bri.Sai Bala M/35yrs/F 29/06/10
doctor bhaskaaran
wkfvcepdupscibtlbsbo, http://www.lmyhjkaety.com iaroburchp
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