1801006014-short case

 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 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.

CASE:

A 28 year old female,housewife,from miryalguda came with chief complaints of loose stools and generalised weakness from 3 month

History of present illness:

Patient was apparently asymptomatic  3 months back ,on dec 5  at night 12am ,after having dinner at 9PM ,she started having loose stools which is sudden in onset, watery in consistency,non foul smelling,20 times per day, associated with pain after passing stools pain is relieved, then she went to government hospital ,there she has been treated for diarrhea but not cured there then  they went to the private practitioners,she stayed in hospital for 2days and treated with  medications such as metrogyl,cefixime,normal saline,ringerlactate,pantop,the loose stools have become soft stools but frequency is 10 times per day .

-From then onwards Recurrent abdominal pain and passage of loose stools . So she came to our hospital.

-H/o travel 3 days back before the onset of diarrhea to the khammam to visit his brother in law who got electric shock and she stayed in hotel and 2nd day they fought and she fasted that day Next day she has eaten chilli pickle as their family members did.That two days she has passed stools normal in consistency.Theres no similar complaints  in the family.

-H/o hallucinations( like some one is beating her) from 3mn ,when she tries to sleep .

PAST HISTORY:

Not a known case of hypertension, diabeties mellitus,asthma, epilepsy,TB

*PERSONAL HISTORY:

Diet-mixed 

Appetite-normal

Sleep - inadequate

Bowel and bladder movements- bowel is 10 times daily.bladder movements normal.

Habits- no addictions

*FAMILY HISTORY:

No similar complaints in the family members.

*GENERAL EXAMINATION:

Patient is conscious coherent and cooperative.

Well oriented to time place and person.

Moderately build and moderately nourished.

Pallor -absent 

Icterus -absent

Cyanosis- absent

Clubbing- absent

Lymphadenopathy- absent

Edema- absent 

VITALS:

Temp- 98°F

RR- 16cycles per min

Bp- 100/60mmHg

PR- 83bpm

*SYSTEM EXAMINATION:

Abdominal examination- tenderness in Right iliac fossa ,right lumbar and at umbilicus.

Respiratory system-inspection- trachea central,normal respiratory movements,normal vesicular breath sounds.

Cardio vascular system- S1 ,S2 heard ,no murmurs

CNS Examination- no focal neurological deficits.

*INVESTIGATIONS:

•Stool for occult blood - negative

•Stool examination:- normal 

•ESR-25mm/1st hr

•HIV 1&2 ELISA - Negative 

•USG: Normal,no significant findings

*PROVISIONAL DIAGNOSIS:

IRRITABLE BOWEL SYNDROME.

 Treatment:

-Patient counselling 

-dietary alteration-(avoid legumes and high fiber diet)

-Loperamide 

-antispasmodics for the pain 

Antidepressants