38 years male pain abdomen under evaluation
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
Afeefa farzana
Roll no:03
Intern
This is a case of 38 year old male resident of narketpally came to gm OPD with chief complaints of pain abdomen and retrosternal burning sensation since 7 years
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 15 years ago then he developed abdominal pain which is diffuse,squeezing type of pain,insidious in onset,intermittent associated with alternating constipation and loose stools and generalised weakness since 15 years
History of blood passed in stools occasionally since 15 years
Patient also gives complaints of retrosternal burning sensation associated with nausea since 15 years
History of belching present
History of fever on and off
History of significant weight loss
No history of vomitings
DAILY ROUTINE
Patient wakes up at 7 AM performs his daily routine and eats rice in the breakfast and goes to work .He works in grocery shop eats rice in lunch and come back home at 8 PM eats rice in dinner and sleeps by 10 PM
SEQUENCE OF EVENTS
2009
Pain abdomen in left hypochondriac and lumbar region insidious in onset ,squeezing type of pain in 2009
2009 in view of pain abdomen he went to local RMP and used medications which were prescribed which gave him temporary relief.
prior to pain abdomen he had constipation for about 5 to 8 days followed by severe pain abdomen which is followed by passage of stools which were sometimes loose stools and sometimes hard stools
This continued till 2015,he used to go to pharmacy and get same medicines and used them whenever he gets pain abdomen. He used to have pain abdomen once weekly or once biweekly
In 2015 he had fever ,cough ,cold for which he used medications which were given by RMP but his symptoms didnot subside even after using for 7 days so he came to our hospital where He was diagnosed with tuberculosis and was started on ATT after using medications for 2 months he got tested again and test was negative for AFB he continued medications for 4 months and was tested again as it was negative for AFB he stopped medications after using for 6 months on doctors advice
From 2015 to 2019
His pain abdomen ,prior to pain abdomen constipation and followed by loose stools sometimes and hard stools sometimes continued so he used to get medications prescribed by RMP and used them
2019
Again he had cough ,fever for which he got tested again and was told he has TB again and was given medications for 6 months
2019 to 2021
His pain abdomen ,prior to pain abdomen constipation and followed by loose stools sometimes and hard stools sometimes continued so he used to get medications prescribed by RMP and used them
2021
He went to hospital in armoor ,Nizamabad where Endoscopy and colonoscopy were done and was diagnosed ulcerative colitis
He used medications which were prescribed by them for 3 months
He stopped medications for 2 months ge developed pain abdomen again then he went to RMP and used medications prescribed by him ,he used them whenever he got pain abdomen till 2023 March
MARCH 2023
As he was loosing weight [his clothes became loose]and was having fatigue he went to health centre at narketpally
Where He was given Tab.Pantop for 10 days,Tab buscopan for 3 days
Tab ofloxacin 200 mg for 3 days
In view of his pain abdomen not subsiding he came to our hospital
He had occasional blood and pus passing in stools and fever on and off since 2009
PAST HISTORY
Patient is a known case of pulmonary TB in 2015 and 2019
For which he used ATT
Not a known case of diabetes, Hypertension, epilepsy, thyroid abnormalities
No H/O blood transfusions
No H/O surgeries
PERSONAL HISTORY
Diet :mixed
Appetite : decreased
Bowel movements : constipation, goat pellets like stools alternating with loose motions occasionally blood in stools
Bladder movements:regular
Addictions:alcoholic stopped since 1 month
FAMILY HISTORY :Not significant
TREATMENT HISTORY:
Tab.Pantop for 10 days
Tab buscopan for 3 days
Tab ofloxacin 200 mg for 3 days
GENERAL EXAMINATION
Patient was conscious,coherent cooperative
Moderately build and moderately nourished
well oriented to time ,place and person
Pallor : pallor present
Icterus: absent
SYSTEM EXAMINATION:
Abdominal examination-
INSPECTION
On Inspection Abdomen is flat, no abdominal distension, umbilicus is central and inverted ,no engorged veins,no scars,sinuses,hernial ornifices are clear
PALPATION
All inspectory findings are confirmed
Tenderness present in left lumbar region and left hypochondrium region
PERCUSSION : No significant findings
AUSCULTATION: bowel sounds heard
RESPIRATORY EXAMINATION
trachea central,
normal respiratory movements,
normal vesicular breath sounds.
CARDIOVASCULAR SYSTEM
S1 ,S2 heard ,no murmurs
CNS EXAMINATION
CNS examination
No focal neurological deficits
PROVISIONAL DIAGNOSIS
?Irritable bowel syndrome
?ulcerative colitis
?malabsorption syndrome
?rule out autoimmune causes
INVESTIGATIONS
On 2 may 2023
Serology: negative
Hemogram
Hb:15 g/dl
TLC: 7,200 cells/cumm
Neutrophils:54
Lymphocytes:37
Eosinophil: 01
Monocyte: 08
Platelet: 3.77
CUE:
Albumin:+
Sugar:nil
Pus cells :2-3
Epithelial cells :2-3
Renal function tests
Urea:28
Creatinine:1.1
Sodium :144
Potassium:4.0
Chloride: 103
Calcium:1.2
USG: no sonological abnormality
ECG
Treatment given on 2 may 2023
IVF NS @75 ml/hr
Treatment given on 3 may 2023
IVF NS @75 ml/hr
Tab .Rifagut 550mg PO/BD
Tab.sporolac DS PO/BD
Tab.buscopan po sos
Comments
Post a Comment