November 24 2020

This is an online E log book to discuss our patients deidentified health data shared after taking his/her/guardians signed informed consent.

Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients 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.


CASE PRESENTATION:

A 70 year old women who is a housewife came with chief complaints of loose stools with blood since 6 days .

Patient was apparently asymptotic 1 year back then she developed loose stools associated with blood ( small volume , with increased frequency of stools ) 3 times in a day for last 3 days ( 4 times in a week, feeling of incomplete defecation present and intermittent constipation present,loose stools associated with smell and not associated with pain abdomen. Frequency of stools increased from one year when patient takes egg whites and associated on taking chicken and milk products and on emotional exertion.

No history of haemorrhoids or fissures.

No history of fever,vomitings,loss of appetite.

No complaints of Malena , weight loss.

Lost her husband 4 months back since then she developed emotional exertion.

Had similar episodes in the past one year , took medications from RMP when ever she had similar complaints. 

Not a known case of diabetes mellitus , hypertension,CAD,asthma,tuberculosis.

No history of blood transfusion.

No past surgical history.

Personal history:

Appetite : Normal

Diet : Mixed diet

Bowel : irregular 

Micturition: Normal

No known allergies.

No addictions.

No significant family history.

General examination:

Pt is conscious, coherent and cooperative.

Pallor present.

No icterus,cyanosis,clubbing,lymphadenopathy,edema.

Vitals:

PR:82 bpm regular rhythm and volume.

BP: 120/80 mmHg

RR: 18 cpm

Temperature: 98.6F

Systemic examination:

CVS: S1 S2 heard

RS: BAE + 

P/A : Soft non tender.

CNS: NAD

INVESTIGATIONS:










Diagnosis: 

? IBD ( Ulcerative colitis )

Treatment:

Inj Buscopan IM/ stat

Inj PAN 40mg IV / OD

IVF NS , DNS , RL ( with one amp optineuron @ 50ml / hour )








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