36 M with Nausea,Loose stools,Tingling sensation in all 4 limbs

Medical case disscussion 

July 27,2022

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent

Here we discuss our patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

This E log book also reflects my patient - centered online learning  portfolio and your valuable inputs inthe comment box are welcome.

Name : Mounika 8th sem 

Roll no : 46

I have been given this case to solve an attempt to understand the topic of "patient clinical analysis data " to develop my competency in reading and comprehending clinical data including clinical history,clinical findings, investigations and come up with a diagnosis and treatment plan

   CASE DISCUSSION

A 36 year old male patient farmer by occupation came to general medicine OPD with chief compliants of 

Decreased appetite since 1 year.

Nausea and Vomiting since 6 months.

Loose stools since 6 months.

Tingling sensation in his both Upper Limbs and Lower Limbs since 10 days.

HOPI :

Patient was apparently alright 1 year back then initially he had decreased appatite associated with nausea which was gradually progresed to complete loss of appatite with in 5-6 months but able to still manage his daily routine activities. Then patient developed vomitings, 4-5 episodes per day , greenish , immediately after food intake. With food particles as contents. Not a/w blood in vomiting.

Since 6 months patients had loose stools now increased in frequency since 2 months. 5-6 episodes per day, Watery consistency, large quantity, associated with greenish mucous with No blood in stools. 

Then problem of passing loose stools has worsened in past 2 months.

There is a significant decrease in his body weight in past one year ( 70 kg  --> 50 kg ).

Last month with similar complaints patient went to one of the corporate centers in nearest city and evaluated further where he also had intra hospital hypoglycemic attacks.

PAST HISTORY :

Not a known case  of  HTN , DM and TB.

FAMILY HISTORY :

No similar complaints in family.

PERSONAL HISTORY : 

Appetite : decreased

Sleep : disturbed and inadequate

Diet : mixed 

Bowel and bladder : irregular

GENERAL EXAMINATION :

 •Patient is examined in a well lit room after obtaining consent

Patient is concious, coherent and co-operative

Built : weak and malnourished.

There are no signs of dehydration.

                        

Pallor : present

Icterus : absent

 

Clubbing : present

Cyanosis : absent

Lymphadenopathy : absent

Edema : bilateral pedal edema upto knees present(pitting edema)

Vitals : 

BP : 80 / 60 mm Hg

PR : 110 bpm

RR : 20 cpm

Temperature : afebrile

SpO2 : 98 % (@ room air )

GRBS : 98 gm/ dl

SYSTEMIC EXAMINATION :

CVS : S1 & S2 Heard and no abnormal murmurs heard.

RS : BAE+ and NVBS.

ABDOMEN :

INSPECTION

Shape : mild distended 

Umbilicus: normal 

Movements : normal

Visible pulsations : absent

Skin or surface of the abdomen : normal 

PERCUSSION- tympanic

AUSCULTATION : bowel sounds heard

CNS : no focal neurological deficits

INVESTIGATIONS

At his previous hospital 

Hb : 9.6, 

Albumin : 1 gm/dl, 

Cytology:showed mixed inflammatory cells with negative malignant cells and lymphocytes

Chest X-ray : normal

USG abdomen : thickening of terminal ileal loop, moderate ascites, bilateral pleural effusion.

CECT Abd : Diffuse long segment circumferential wall enhancement of small bowel loops

Colonoscopy:non specific segmental colitis

MRI Abd : subcentrimetric lymphadenopathy and tiny rt renal cortical cyst. 

H/o significant weight loss upto 20kgs with in 1 year. 

H/o blood in stools present once a while .

At our facility

Hb : 8.3

Albumin : 2 gm/dl

USG abdomen : Submucosal edema of multiple small and small bowel loops with moderate ascitis.

Short segment intussusception in large bowel at left hypochondrium.

ECG :

X- Ray Chest :

ABG :  

pH 7.57

pCO2 : 19.8

PO2 : 114

Hco3 : 18.5

St. Hco3 : 22.8

Spo2 : 98

*Stool microscopy reveals eggs of Capillaria Philippinesis.

                                                                                                     Provisional Diagnosis :                                                

 Chronic diarrhoea under evaluation.

D/D :                                                                              

 Inflammatory bowel disease                          

 Protien losing enteropathy                              

 Whipples disease                                             

 Malignancy                                                       

Treatment:                                                                      

*Iv fluids 1 unit NS @ 75ML/HR                 

*T.Albendazole 400mg                                 

*Inj. Zofer 4 mg sos                                      

*Inj. PAN 40 mg IV BD                                   

*Inj. Optineuron 1 amp in 100ml NS IV OD

*Inj. PCM 1 gm IV sos if Temp >102F         

*Tab. Loperamide 4mg po BD                      

*Tab. Sporolac DS po TID                             

*Ors sachets 1 packet in 1 ltr water.           

*HIGH Protein Deit.                                        

*GRBS 4th hourly.