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Bri.Sai Bala M/35yrs/F 29/06/10

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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
doctor bhaskaaran

doctor bhaskaaran

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