38 year old male patient
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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.
CHIEF COMPLAINTS :
A 38 year old male patient farmer by occupation came to general medicine OPD with chief compliants of
a) decreased appetite since 1 year.
b) nausea and vomiting since 6 months.
c) loose stools since 6 months.
d) tingling sensation in his both Upper Limbs and Lower Limbs since 10 days.
HOPI :
Patient was apparently asymptomatic 1 year ago.
Then his appetite has come down which gradually proggressed over time and was associated with nausea.
After 6 months he developed vomitings a/w nausea with 5 to 6 episodes per day and occured immediately after consumption of food.
Contents : food particles
Colour : green
Due to which he developed fear of food.
He also had loose stools since 6 months.
Consistancy : watery.
Frequency : 5 - 6 times / day.
Colour : green
Nature : mucoid
Quantity : large
Tenesmus +
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 ).
They visited a private hospital in nearest city.
Where they gave him medications for his problems for a week.
The problem returned so they consulted our facility.
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 but in the recent past he hasnt been consuming much food.
Bowel and bladder : irregular
GENERAL EXAMINATION :
Patient is concious, coherent and co-operative
Built : weak and malnourished.
There are no signs of dehydration.
Pallor : present
Clubbing : present
Cyanosis : absent
Lymphadenopathy : absent
Edema : bilateral pedal edema upto knees present.
X- Ray Chest :
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,
USG abdomen : thickening of terminal ileal loop, moderate ascites.
CECT Abd : Diffuse long segment circumferential wall enhancement of small bowel loops
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 :
ABG :
pH 7.57
pCO2 : 19.8
PO2 : 114
Hco3 : 18.5
St. Hco3 : 22.8
Spo2 : 98
Stool for occult blood : positive.
Provisional Diagnosis : Chronic diarrhoea under evaluation.
D/D :
? Inflammatory bowel disease
? Protien losing enteropathy
? Whipples disease
? Malignancy
