SHRUTHI ARUKONDA 02

 GENERAL MEDICINE. 


28 July ,2021. 

Note: This is an online E Log book recorded to discuss and comprehend our patient's  de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.


             CASE REPORT 

A 37 year old male with chief complaints of passing hard stools since 8 months. 

CHIEF COMPLAINTS: 

Passing of hard stools since 8 months 


HISTORY OF PRESENT ILLNESS: 
  • Patient was apparently asymptomatic until 15 years back, then he had an episode of pain abdomen and constipation. 
  • The patient visited the local hospital and his symptoms were relieved and was normal until next 5 years 
  • In 2010, he suddenly developed stools with watery consistency and were black in colour, 2-3 episodes per day which lasted for 8-10 days 
  • He had alterations in bowel moments 
  • He had loose stools and constipation. Whenever he passes stools, there are streaks of blood in it (piles?) 
  • No tenesmus, feeling of incomplete evacuation. 
  • Consuming non veg food items and food with excess Masala causes loose stools. 
  • Lactose intolerance +(milk, curd) 
  • Burning micturition since 10 years. (On and off) 
,
HISTORY OF PAST ILLNESS: 
N/k/c/o HTN,DM,TB,CAD,CVBA, Epilepsy. 


TREATMENT HISTORY:
Nothing significant 


PERSONAL HISTORY: 
Appetite: normal 
Non vegetarian 
Sleep : decreased 
Alcohol: occasionally 
Smoke: 5 beedies everyday since last 20 years 


FAMILY HISTORY: 
Nothing significant 


PHYSICAL EXAMINATION: 

GENERAL EXAMINATION. 
No signs of pallor, icterus, cyanosis, clubbing of fingers, lymphadenopathy, oedema
Mild dehydration. 

VITALS:
Temperature: afebrile 
Pulse rate: 90bpm
Respiration rate: 12 cpm/min 
BP: 130/70mm 
SPO2:99% 

SYSTEMIC EXAMINATION: 
 
CVS: 
Thrills: no 
Cardiac sounds: s1,s2 + 
Cardiac murmurs : no 

RESPIRATORY SYSTEM: 
Dyspnoea: no 
Wheeze: no 
Position of trachea: central 
Breath sounds: vesicular 

ABDOMEN: 
Shape of abdomen : obese 
Tenderness: not 
Palpable mass: no 
Hernial orifice:Normal 
Free fluid: no 
Bruits: no 
Liver: not palpable 
Spleen: not palpable 
Bowel sounds: yes 

CENTRAL NERVOUS SYSTEM: 
1. Level conscience: conscious 
2. Speech: normal 
3.glassgow scale:15/15

INVESTIGATIONS: 

CBP:
Hb%- 13.6gm/dl 
Total count- 9,200 cells/cu mm
Neutrophils-69%
Lymphocytes-#19%
Eosinophils- 05%
Monocytes-07%
Basophils-00.0%
Platelet count- 2.72 lakhs/cu mm 
Smear- normocytic normochromic 

SERUM ELECTROLYTES: 
Sodium -136 MEq/L
Potassium -4.1 MEq/L
Chloride -103 MEq/L


TREATMENT: 
  • Sup. Cremaffin plus 10ml x—x—x 
  • Fibre rich diet 
  • BP/PR/temp/spo2 monitoring 
  • Tab. Pantop 40mg od 
  • Sup.liquid paraffin 15ml po/hs 





DETAILS OF HIS LAST ADMISSION : 

PATIENT WAS APPARENTLY ASYMPTOMATIC 15 YEARS BACK.THEN HE HAD EPISODE OF PAIN ABDOMEN AND CONSTIPATION.PAT WENT TO LOACL HOSPITAL HE GOT HIS SYMPTOMS RELIEVED AND WAS NORMAL TILL 5 YEARS. IN 2010 HE SUDDENLY DEVELOPED STOOLS WITH WATERY CONSISTENCY BLACK COLORED STOOLS,2-3 EPISODES/DAY LASTED FOR 8-10 DAYS HE HAD ALTERATIONS IN BOWEL MOVEMENTS.HE HAD LOOSE STOOLS AND CONSTIPATION.DURING CONSTIPATION HE PASSES STOOLS AND STREAKS OF BLOOD IN IT (? PILES)NO TENISMUS.FELLING OF INCOMPLETE EVACUATION+.EMOTIO0NAL EXERTION LEADS TO INCREASE FREAQUENCY OF STOOLS.MASALA AND NON-VEG ITEMS ALSO-HE EXPERIENCES LOOSE STOOLS.LACTULOSE INTOLERENCE+(MILK,CURD).BURNING MICTURITION SINCE 10 YEARS.ON AND OFF FEVER
N/K/C/O HTN,DM,TB,EPILEPSY,CVBA,CAD.
DECREASED APPETITE,DISTURBED SLEEP.
DRINKS ALCOHOL NOCCASSIONALLY,AND SMOKES BEEDIS 5/DAY SINCE 20 YEARS GENERAL EXAMINATION : PT C/C/C MODERATELY BUILT AND NOURISHED.
NO PALLOR,CYANOSIS,CLUBBING,ICTERUS,LYMPHADENOPATHY,PEDAL EDEMA. VITALS : AFEBRILE,BP 120/80MMHG.PR 84BPM,RR 20CPM.
CVS : S1 S2 HEARD,NO MURMURS.
RS : NVBS+
PER ABDOMEN : SOFT NON-TENDER,BOWEL SOUNDS+
CNS:INTACT
REVIEWERD BY GENERAL SURGEON : DIAGNOSED AS INTERNAL HEMORRHOIDS(GRADE 1 - 12 O'CLOCK,11 O'CLOCK,3 O'CLOCK,7 O'CLOCK POSITIONS).ADVISE:1)High fibre diet,2)Syrup Cremaffin 15ml Po/Hs 3)Sitz bath 1-1-1, 4)Smuth ointment for L/AT . 5)PANTOP 40mg OD/BBF
REVIEWED BY GASTROENTEROLOGIST : ? IRRITABLE BOWEL SYNDROME,ADVICED SIGMOIDOSCOPY,CECT,CRP.
REVIWED BY PSYCHIATRY

PATIENT WAS MARRIED 20 YEARS BACK AFTER WHICH HIS WIFE DELIVRED STILL BIRTH BABIES FOR TWO TIMES IN A PERIOD OF 1 YEAR AND 5 YEARS DURING THIS PERIOD PT WASVERY BSTRESSED IN TAKING CARE OF HIS WIFE AND HER HEALTH AS HIS FINANCIAL STATUS WAS ALSO NOT GOOD.PATIENT DENIES ANY SYMPTOMS OF PALPITATIONS SWEATING TREMORS LIGHTHEADEDNES,DIZZINESS,EPIGASTRIC DISCOMFORT NERVOUSNESS DURING THAT PERIOD.PATIENT CONSULTED MANY DOCTORS FOR HIS WIFE AND HER HEALTH AND WAS WORRIED ABOUT HERTILL MHIOS NTHIRD CHILDBIRTH PATIENT SAYS THAT HIS FINANCIAL WORRIRS PERSONAL WORRIES CAME TO END AFTER BIRTH OF HIS THIRD CHILD HE IS VERY HAPPY WITH HIS ONE CHILD OHNJ ASKING HE SAYS THAT HE NEVER THOUGHT OF ANOTHER CHILD AS DOCTORS SAID THAT ANOTHER CONCEPTION WOULD MAKE HIS WIFE LIFE RISKY SINCE TTHGEN THEY ARE LEADING A VERY HAPPY LIFE GOING TO HIS CONSTUCTION WORK REGULARLY AND TAKING CARE OF HIS FAMILY.
PATIENT WAS APPPARENTLT ASYMPTOMATIC 10 YEAR BACK AFTER WHICH HE EXPERIENCED PASSING HARD STOOLS WHICH WAS ASSOCIATED WITH BLOOD. HE THEN CONSULTED A DOCTOR AND HAS TAKEN SOME MEDICATIONS BY WHICH HIS SYMPTOMS SUBSIDED PATIENT SAYS HE EXPERIENCES LOOSE STOOLS ONCE IN A MONTH BAND HARD STOOLS ONCE IN A MONTH. BOTH OF THESE SYMPTOMS WOULD SUBSIDE ON TAKING MEDICATIONS.THESE SYMPTOMS WERE NOT PRECEEDED BY ANY ANGER OUTBURSTS,STRESSORS.PATIENT SMOKES 4-5 BEEDIS PER DAY SINCE 20 YEARS.HE DENIES REDUCED CONCENTRATION AND ATTENTION ,REDUCED SELF ESTEEM AND SELF CONFIDENCE.
PATIENT DENIES IDEAS OF GUILT,UNWORTHYNES,SUICIDE.NO H/O SEVERE ANXIETY SYMPTOMS,HTN,DM,HEAD INJURY,SEIZURES.OTHER SUBSTANCE ABUSE,SELF TAKING AND SELF SMILING,SUSPICIOUSNESS,REPTITIVE THOUGHTS AND ACTIONS.
MSEI GAB -PATIENT SITING COMFORTABLY ON CHAIR,LOOKING APPROPRITE TO AGE,MODERATELY BUILT.
ETEC+ SUSTAINED.PMA -N,RAPPORT ESTABLISHED,SPEECH NORMAL.PATIENT ORIENTED TO TIME,PLACE,PERSON.
OPHTHALMOLOGY REFERRAL FOR DIMINISHED VISION: DIMINISHED VISION IN BOTH EYES FROM 2 MONTHS
RE : -0.50
LE : -0.25
ON EXAMINATION :
LIDS , CONJUNCTIVA , CORNEA , ANTERIOR CHAMBER , IRIS , PUPIL , LENS NOEMAL IN RIGHT AND LEFT EYE.
Rx : SPECTACLES US

E/D LUBRE QID x 5DAYS
Investigation
HEMOGRAM :
HB : 13.3 GM/DL
RBC 5.42 MILLIONS/CU.MM
TLC : 8,300CELLS/CU.MM
PLATELET : 1.64 LAKHS/CU.MM
PREDOMINANTLY NORMOCYTIC NORMOCHROMIC WITH FEW MICROCYTEWS SEEN NO HEMOPARASITES.
CUE :
PALE YELLOW COLOR,CLEAR,ACIDIC.
NO ALBUMIN,SUGARS,BILE SALTS,BILE PIGMENTS
NO RBC,CASTS,CRYSTALS.
COLONOSCOPY :TERMINAL ILEUM ,CAECUM,ASCENDING COLON ,HEPATIC FLEXURE,TRANSVERSE COLON,SPLENIC FLEXURE,DESCENDING COLON,SIGMOID COLON,RECTUM,ANAL CANAL,PER RECTUM ALL ARE NORMAL.BIOPSIES TAKEN HPE TO RULE OUT IBD.
NOPRMAL MUCOSAL STUDY

09:24:AM
Treatment Given(Enter only Generic Name)
DAT 1:
SITZ BATH
SYP.CREMAFFIN 15ML PO/HS
SMUTH CREAM FOR LOCAL APPLICATION HIGH FIBRE DIET
PLENTY OF FLUID INTAKE.
DAY 2:
SITZ BATH
SYP.CREMAFFIN 15ML PO/HS
SMUTH CREAM FOR LOCAL APPLICATION

HIGH FIBRE DIET
PLENTY OF FLUID INTAKE.
DAY 3:
SITZ BATH
SYP.CREMAFFIN 15ML PO/HS
SMUTH CREAM FOR LOCAL APPLICATION
HIGH FIBRE DIET
PLENTY OF FLUID INTAKE.
Advice at Discharge
LIQUIUD PARAFFIN
SITZ BATH
SYP.CREMAFFIN 15ML PO/HS
SMUTH CREAM FOR LOCAL APPLICATION
HIGH FIBRE DIET
PLENTY OF FLUID INTAKE.



DISCHARGE SUMMARY OF PRESENT ADMISSION: 

Diagnosis
CHRONIC ACTIVE DUODENAL ULCER
?IBS
Case History and Clinical Findings
37Y/M CAME WITH THE CHIEF COMPLAINTS OF PASSING HARD STOOLS SINCE 8 MONTHS

PATIENT WAS APPARENTLY ASYMPTOMATIC UNTIL 15YEARS BACK THEN HE HAD AN EPISODE OF PAIN ABDOMEN AND CONSTIPATION . THE PATIENT VISITED A LOCAL HOSPITAL AND HIS SYMPTOMS WERE RELIEVED AND WAS NORMAAL UNTIL NEXT 5 YEARS .IN 2010 HE SUDDENLY DEVELOPED STOOLS WITH WATERY CONSISTENCY AND WERE BLACK IN COLOUR 2 TO 3 EPISODES PER DAY WHICH LASTED FOR 8 TO 10 DAYS . HE HAD ALTERATIONS IN BOWEL MOVEMENTS .HE HAD LOOSE STOOLS AND CONSTIPATION. WHENEVER HE PASSES STOOLS , THERE ARE STREAKS OF BLOOD IN IT(?PILES). NO TENESMUS, FEELING OF INCOMPLETE EVACUATION
CONSUMING NONVEG FOOD ITEMS AND FOOD WITH EXCESS MASALA CAUSES LOOSE STOOLS
LACTOSE INTOLERANCE PRESENT(MILK,CURD)
BURNING MICTURITION SINCE 10 YEARS ON AND OFF
NOT A K/C/O HTN, DIABETES, TB, CVD,CAD, EPILEPSY
PERSONAL HISTORY-
APPETITE- NORMAL
DIET- MIXED
SLEEP-DECREASED
ALCOHOL- OCCASIONALLY
SMOKES 5 BEEDIES EVERYDAY SINCE 20 YEARS
VITALS-
TEMPERATURE- AFEBRILE
PULSE- 90BPM
RR-12CPM
BP-130/70 MM HG
SPO2- 99%
SYSTEMIC EXAMINATION-
CVS- S1S2+
RS-BAE+, NVBS HEARD
PER ABDOMEN-OBESE, NON TENDER, NO ORGANOMEGALY, BOWEL SOUNDS+ CNS- NFND
Investigation
UPPER GI ENDOSCOPY- CHRONIC ACTIVE DUODENAL ULCER
Investigations
** 


Treatment Given(Enter only Generic Name)
COURSE IN HOSPITAL-
SURGERY OPINION WAS TAKEN IN VIEW OF HEMORRHOIDS
DRE AND PROCTOSCOPY WAS DONE. NO HEMORRHOIDS WERE SEEN
1. SYP. CREMAFFIN PLUS 10 ML HS
2. FIBRE RICH DIET WAS ADVICED
3. TAB. PAN 40 MG OD
4. SYP. LIQUID PARAFFIN 15 ML PO HS
IN VIEW OF UPPER GI SYMPTOMS, GASTROLOGY REFERRAL WAS DONE ENDOSCOPY WAS DONE AND GIVEN AS CHRONCI ACTIVE DUODENAL ULCER. H.PYLORI KIT WAS GIVEN
Advice at Discharge
1. SYP. CREMAFFIN PLUS 10 ML HS
2. H. PYLORI KIT FOR 14 DAYS
Follow Up
REVIEW IN MEDICINE OPD SOS











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