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A 35 year old male patient come with cheif complaints of abdominal discomfort and difficulty in passing stools from 1 month.
Patient was apparently asymptomatic 15 years back then he had an episode of pain abdomen and constipation , went to hospital and was given medication and got relieved from his symptoms. Patient was normal till 5 years, later in 2010 he complained of stools which are watery in consistency , black coloured , 2-3 episodes per day lasted for 8-10 days. He had alterations in bowel movements.
He some times experiences loose stools and sometimes constipation. Whenever he had constipation,he passes streaks of blood in stools,no h/o painful defecaation.
Feeling of incomplete evacuation present.
Emotional exertion leads to increase frequency of stools.
He has lactulose intolerance and whenever he takes milk or curd he experiences increased frequency of stools.
Whenever he consumes food having masala or non vegetarian, he develops increased frequency of stools.
H/ burning micturition from 10 years , on and off associated with fever.
Not a k/c/o hypertension, diabetes , TB , asthma, epilepsy, CVA , CAD ,.
Personal history :
Decreased appetite
Mixed diet
Bowel irregular
Burning mint from 10 years
Occasionally consumes alcohol
Smokes beedi 5/ day from 20 years.
General examination:
Patient is conscious, coherent , cooperative.
No pallor,icterus,cyanosis,clubbing,lymphadenopathy,edema.
Vitals:
Temp : afebrile
Pulse rate : 84bpm , regular
BP : 120/80 mmHg
Resp rate : 20cpm
Systemic examination:
CVS : S1 S2 heard
Rs : BAE +
CNS : NAD
P/A : Soft , non tender.
Referred to psychiatry I/v/o emotional exertion.
Patient was married 20 years back after which his wife had 2 still births in a period of 1 years and 5 years. During this period patient was stressed in taking care of his wife health and his financial status was also not too good. Patient says that his financial worries came to end after birth of his 3rd child. He adds that he is very happy with his one child.
Patient was apparently asymptomatic 1 year back after which he experienced passing hard stools which was associated with blood. He consulted physician and took some Medication by which his symptoms were subsided then developed again later.
MSE : Normal
GC fair , patient is oriented to time place and person.
Impression : Deferred ( no psychiatric intervention needed )
Gastroenterology referral :
Adviced - Sitz bath
Syrup CREMAFFIN 15 ml po/Hs
High fibre diet
General surgery referral :
P/A : Grade 1 internal haemorrhoids present at 12,11’ O clock 3’ , 7’ O clock position.
Diagnosis: Internal haemorrhoids.
Rx:
High fibre diet
Syrup Cremaffin 15ml HS
Sitz bath
Smuth ointment for L/A
Ophthalmology referral taken for diminished vision
On examination
Vision
RE : -0.5
LE : -0.25
Eyelids , cornea , conjunctiva , anterior chamber , pupils , iris normal in right and left eye
Rx
Spectacles use
Eye drops LUBRE X
INVESTIGATIONS:
TREATMENT:
High fibre diet
Syrup Cremaffin 15ml Po/Hs
Sitz bath 1-1-1
Smuth ointment for L/A
T . PANTOP 40mg OD/BBF.
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