26year old male with chronic diarrhoea








DR.NAVYA(INTERN)

DR.CHETANA(INTERN)

DR.ABDUL RAHEEM (INTERN)

DR.ASHFAQ(INTERN)

DR.SRAVYA(INTERN)

DR.GNANADA(INTERN)

DR.CHARAN(PG1)

DR.VAMSI(PG1)

DR.SUSMITHA(PG2)

DR.ADITHYA (PG3)

DR.PRANEETH(PG3) 

DR.PRAVEEN NAIK (ASS.PROF)

DR.RAKESH BISWAS(HOD)


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Here we discuss our individual 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 on the comment box is welcome.

Here is a case i have seen:
 A 26 year old man from North East India presented with a 6 month history of anasarca. 

An avid footballer and a keen farmer, the patient was absolutely normal upto age 15, when he first recalls having altered bowel habits. On questioning further, he reports that he had been having large volume, bulky, incredibly foul smelling stools since that age. He reports that the consistency was similar to that of sputum and a thick nasal discharge, the stench was offensive, it was sticky and so difficult to water down that he had to use a few buckets of water. He also recalls that he occasionally had pain with this defecation abnormality, which was a poorly localising deep ache that instantaneously resolved with defecation. He cannot recall having seen frank or altered blood in stools. His bowel habits were erratic and these symptoms were initally only sporadic. He denies having undue fatigue, dyspnea, low back ache, painful joints, or facial puffiness or pedal edema at this point. 

Over the next 6 years, these symptoms started becoming even more troublesome and the patient recalled that he started losing weight, evident by his clothes becoming loose. However, significantly, he did not have any loss of appetite. In fact, he had a voracious appetite on occasions. He specifically cannot recall which foods aggravte these symptoms but he confided that although eating rotis was the norm in their household, he often felt a sense of bloating and uneasiness, followed by defecation of large volume, foul smelling stools with rotis. He has, since a decade, resorted to rice as his staple diet. 

His appetite still raging on and his symptoms equally raging on from the other end. The patient since age 21, had significant weight loss and started feeling 'less powerful' which eventually culminated in seeking retirement from football. Farming too proved elusive. He also worked as a light decorator for a few years but disinterest quickly consumed it. 

Importantly, he reports that his mother too had similar symptoms for 20 years, which quite emphatically relieved with herbal medicine. The patient opted to go down the same route, but alas, the outcomes were polarisingly contrasting. His symptoms worsened and he developed bloating and the same large bulky stools again. This was 2 years ago. He denies Jaundice, fatigue, loss of appetite, breathlessness or palpitations. Crucially, he reports that he had been having diarrhea at 2 or 3 am in the night. This was fortunately only occasional and not really troublesome. 

Several consultations with several doctors resulted in polypharmacy with little relief in symptoms. 

Since the last 6 months, the patient started developed facial edema, early in the morning, followed quickly by pedal edema and distention of abdomen. He reports having frothy urine for a week or so , a year ago. He is perplexed at the idea of hematuria and dysuria and strongly denies it. He also denies polyuria and oliguria. The edema has been constitently progressing since the last 6 months .

The patient is a jolly young fellow with an elder sister and younger brother who have no medical symptoms of note. He is quite enthusiastic about football and has a keen interest in farming. He previously enjoyed alcohol use and was an avid marijuana smoker for 2 hours, which interestingly did not relieve his symptoms. The patient is hoping to spring back to normalcy and to pursue farming.

No H/o Dm,HTN, Asthma, Epilepsy, Thyroid disorders,

On examination:

Patient conscious, coherent,cooperative,thin built and nourished.

Vitals:

Temperature:98.2F

Bp:110/80mm Hg

PR: 82 bpm, regular rhythm, normal volume

RR:20cpm

Grbs:132mg/dl

No signs of pallor,icterus,cyanosis, clubbing,koilonychia

B/L pedal edema of pitting type

Facial puffiness present





CVS:

S1,S2 Present

No added sounds.

RS:

B/L Air entry present

Normal vesicular breath sounds heard

No added sounds

CNS:

No focal neurological deficit

Per abdomen:

Soft, distended,

Tenderness present at umbilical region

Shifting dullness present

Bowel sounds present.












INVESTIGATIONS:

Heamogram:

Hb:12.3gm/dl

TLC:5,000cells/cu.mm

PCV:35.6

MCV:79.0fl

MCH:26.9pg

MCHC:34.5

PLATELETS:2.97Lakhs/cu.mm

RBC count: 4.56millions/cu.mm

Smear: Normocytic normochromic RBC,

WBC:within normal limits, adequate platelets .

CUE:

Albumin:trace

Sugar:nil

Pus cells: 3_6 /HPF

Epithelial cells:2_3/HPF

RBC: nil

RBS:101mg/dl

LFT:

Total bilirubin:0.62mg/dl

Direct bilirubin:0.13mg/dl

AST:101IU/L

ALT:127IU/L

ALP:190IU/L

Total protein:2.3gm/dl

Albumin:1.7gm/dl

A/G ratio:3.11

RFT:

Urea:13mg/dl

Creatinine:0.6mg/dl

Uric acid:5.3mg/dl

Calcium:7.7 mg/dl

Sodium:137mEq/dl

Potassium:3.5mEq/dl

Chloride:106mEq/dl

Phosphorus 2.3mg/dl

Stool examination:


Stool for occult blood positive

No ova and parasites detected

Fecal leucocyte count:


Chest x-ray:


ECG:
CECT ABDOMEN





Diagnosis:
 
Chronic malabsorption with maldigestion
?IBD
?Celiac disease
? autoimmune enteropathy


Treatment:

Inj.Thiamine 1 ampoule in 100 ml NS IV OD

Inj.optineuron 1 ampoule in 100 ml NS IV OD

ORS Sachet in one litre water_after each episode of loose stools

Temperature,Bp,PR monitoring  4th hourly.

Discussion and learning points



On 26.01.2021
S- Patient complains of 
loose stools 6 tyms since night till morning, in small amounts ,non foul smellimg, no food particles, non blood stained ,with no food particles  with abdominal pain which subsided after defecation.
pedal edema extending upto knees
Also abdominal tightness.
O- 
BP: 110/80 mm hg
PR: 76 bpm
CVS: S1 S2 heard, no murmurs
RS: clear
Abdomen: soft, non tender
A-
?  IBD( CROHN'S/ CELIAC DISEASE) 
? AUTO IMMUNE ENTEROPATHY
P- 
Inj. THIAMINE- 1amp in 100 ml NS IV OD
Inj. OPTINEURON - 1 amp in 100 ml NS IV OD
ORS sachets in 1 lit water.

27.01.2021



S- H/0 loose stools 7 time since yesterday evening
O- 
BP: 100/60 mm hg
PR: 82 bpm
CVS: S1 S2 heard, no murmurs
RS: clear
Abdomen: soft, non tender
A-
?  IBD( CROHN'S/ CELIAC DISEASE) 
? AUTO IMMUNE ENTEROPATHY
P- 
Inj. THIAMINE- 1amp in 100 ml NS IV OD
Inj. OPTINEURON - 1 amp in 100 ml NS IV OD
ORS sachets in 1 lit water after each episode of stool 
Bp, PR, temperature monitoring 4th hrly
Planning for enteroscopy.

27/1/2021 evening SOAP update 

27 years old male patient

?  IBD( CROHN'S/ CELIAC DISEASE) 

? AUTO IMMUNE ENTEROPATHY

S-

 H/0 15 episodes of loose stools since morning


O- 

BP: 100/70 mm hg

PR: 84 bpm

CVS: S1 S2 heard, no murmurs

RS: clear

Abdomen: soft, non tender

A-

?  IBD( CROHN'S/ CELIAC DISEASE) 

? AUTO IMMUNE ENTEROPATHY

P- 

Inj. THIAMINE- 1amp in 100 ml NS IV OD

Inj. OPTINEURON - 1 amp in 100 ml NS IV OD

ORS sachets in 1 lit water after each episode of stool 

Bp, PR, temperature monitoring 4th hrly

*bowel preparation for enteroscopy tomorrow  with Peglec powder and soap water enema.



Male ward 


date -28/1/2021 morning SOAP update

27 years old male patient

?  IBD( CROHN'S/ CELIAC DISEASE) 

? AUTO IMMUNE ENTEROPATHY

S-

 H/0 2 Episodes of loose stools

O- 

BP: 100/60 mm hg

PR: 76 bpm, regular rhythm, normal in volume

GRBS: 85mg/dl

CVS: S1 S2 heard, no murmurs

RS: clear

Abdomen: soft, non tender

A-

?  IBD( CROHN'S/ CELIAC DISEASE) 

? AUTO IMMUNE ENTEROPATHY

P- 

Inj. THIAMINE- 1amp in 100 ml NS IV OD

Inj. OPTINEURON - 1 amp in 100 ml NS IV OD

ORS sachets in 1 lit water after each episode of stool 


BP, PR, temperature monitoring 4th hrly


Patient on NBM and bowel preparation for enteroscopy, and colonoscopy with peglec powder and soap enema is done

29/1/2021 morning  SOAP update 

 27 years old male patient ?  CELIAC DISEASE

S- pain during defecation and foul smelling stools - still present .No fresh complaints

O:BP: 100/60 mm hgPR: 74 bpm

CVS: S1 S2 heard, no murmurs

RS: clear

Abdomen: soft, non tender

A_?  CELIAC DISEASE

P- cap. alpha D3 0.25 mcgI

Inj OPTINEURON - 1 amp in 100 ml NS IV OD

ORS sachets in 1 lit water after each episode of loose  stool .
protein powder 2 scoops in a glass of milk / water  BD 
Bp, PR, temperature monitoring 4th hrly. 
colonoscopy , upper GI endoscopy done yesterday. 
samples taken for biopsy , reports awaited.






Date:30.1.2021

S-10 episodes of loose stools yesterday night,small in quantity associated with mild abdominal pain
O- no dehydration
BP: 110/70 mm hg
PR: 88 bpm
CVS: S1 S2 heard, no murmurs
RS: clear
Abdomen: soft, mild diffuse tenderness present
A-protein loosing enteropathy
?  CELIAC DISEASE

P- 1.cap. alpha D3 0.25 mcg/po/OD
2.Inj. OPTINEURON - 1 amp in 100 ml NS IV OD
3.ORS sachets in 1 lit water after each episode of loose  stool .
4.Cap.Racecodotril 100mg TID
5.Tab.LOPERAMIDE 4mg/PO/BD

Stomodeal input:.                                                                   

Proctodeal output.     

                                                        

 31.01.2021 SOAP UPDATE
S- Decreased Urinary output(water intake approx 2 litres and output 250ml  approx )
O- BP 100/60 mmHg
     PR 85 bpm
     CVS S1 S2 heard
     RS BAE +
   P/A SOFT, distended,non tender
CNS - NFND.
A- ?celiac disease.
P- * Inj Optineuron 1amp in 100ml NS IV/OD
* Cap Bio -D3 0.25mg OD
Cap.Racecodotril  100 mg TID 
* ORS sachets in1 litre water after each episode of loose stool.
* BP/PR monitor 4 th hourly.
Stomodeal input.                                                                     


Proctodeal output:.                                                              

1.02.2021
27 years old male patient
?  CELIAC DISEASE
S- 3episodes of loose stools since night,
O- no dehydration
BP: 100/60mm hg
PR: 80 bpm
CVS: S1 S2 heard, no murmurs
RS: clear
Abdomen: soft, distended,diffuse tenderness present 
A-?CELIAC DISEASE

P- 1.cap. alpha D3 0.25 mcg/po/OD
2.Inj. OPTINEURON - 1 amp in 100 ml NS IV OD
3.ORS sachets in 1 lit water after each episode of loose  stool .
4.Cap.Racecadotril 100mg TID
5.Tab.LOPERAMIDE 4mg/PO/BD
Stomodeal input:.                                                                  

                        Proctodeal output:.                                                                        


2.2.2020.  SOAP UPDATE 
                               27 years old male patient

?  CELIAC DISEASE
Dr.Praneeth (PGY3)
S-  loose stools resolved

O- no dehydration
BP: 110/80mmhg
PR: 82bpm
CVS: S1 S2 heard, no murmurs
RS: clear
Abdomen: soft, distended,non tender
A-?CELIAC DISEASE

P-
1.cap. alpha D3 0.25 mcg/po/OD
2.Inj. OPTINEURON - 1 amp in 100 ml NS IV OD
3.ORS sachets in 1 lit water after each episode of loose  stool .
4.Cap.Racecadotril 100mg TID
5.Tab.LOPERAMIDE 4mg/PO/BD

3.02.2020 , SOAP UPDATE
27 years old male patient
?  CELIAC DISEASE 

S- loose stools resolved
    Normal consistency pale coloured stools 

O- no dehydration
BP: 110/80mmhg
PR: 82bpm
CVS: S1 S2 heard, no murmurs
RS: clear
Abdomen: soft, distended,non tender 

A-?CELIAC DISEASE
    ? Giardiasis 

P- 
1.cap. alpha D3 0.25 mcg/po/OD
2.Inj. OPTINEURON - 1 amp in 100 ml NS IV OD
3.ORS sachets in 1 lit water after each episode of loose  stool .
4.Cap.Racecadotril 100mg TID
5.Tab.LOPERAMIDE 4mg/PO/BD
6. Plan to add metronidazole or tinidazole after stool microscopy report. 
Stomodeal input                                                        


Proctodeal output


4.02.2021

27 years old male patient
?  CELIAC DISEASE 

S- loose stools resolved
    Normal consistency pale coloured stools 

O- no dehydration
BP: 110/80mmhg
PR: 82bpm
CVS: S1 S2 heard, no murmurs
RS: clear
Abdomen: soft, distended,non tender 

A-?CELIAC DISEASE
    ? Giardiasis 

P- 
1.cap. alpha D3 0.25 mcg/po/OD
2.Inj. OPTINEURON - 1 amp in 100 ml NS IV OD
3.ORS sachets in 1 lit water after each episode of loose  stool .
4.Cap.Racecadotril 100mg TID
5.Tab.LOPERAMIDE 4mg/PO/BD
6. Plan to add metronidazole or tinidazole after stool microscopy report. 



Giardiasis











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