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)
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:
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
31.01.2021 SOAP UPDATE
Proctodeal output:.
? 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
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