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 29 year old male who is a lecturer by occupation came with c/o burniing sensation in the upper quadrants of abdomen since 10 months.
History of present illness:
Patient was apparently asymptomatic 10 months back,then developed burning sensation in the upper quadrant of the abdomen associated with nausea with heartburn. c\o burning micturation in the month of june which resolved on medication [complains of having intermittent burning micturition since then]not associated with fever.c\o increased frequency of stools{3-4 times a week,not associated with blood,mucus,foul smelling stools,pain abdomen. c\o small volume and feeling of incomplete defecation present and intermittent constipation present ,no tenesmus.frequency of stools increased when patinet taked egg white and chicken; had h\o streak blood.
Stool in the month of june for which he took homeopathy medication for 5 days and got subsided; no emotional exertion present. normal appetite ,no h\o haemorrhoids and fissures. in the month of july he took "probiotics" for a month. used tab.metrogyl and tab.pantop in the past. c\o weakness and tingling sensation of all 4 limbs. nct studies were done and came out to be normal. h\o jaundice in the year 2006.
k\c\o lactose intolerance since birth. h\o colonoscopy and endoscopy done in the past came out to be normal. h\o disturbed sleep for which he intermittently took escitalopram [10mg] and clonazepam [0.5mg]. h\o weight loss present since june . in 2017, his stool examination showed giardia cyst for which medication was taken.
Personal history;
Tutor by occupation,normal appetite,mixed diet,irreguar bowel movements,burning Micturition present,no known allergies,no addictions.
General examination;
Patient is concious,coherent,cooperative
moderately build and nourished
no pallor,icterus,cynosis,clubbing,lymphadenopathy,oedema.
temperature:99c
pr:84bpm
rr:20cpm
bp:100\80mmhg
spo2:100%
grbs:96mg\dl
systemic examination:
cvs:s1s2 sounds heard,no murmurs present.
rs:bae+,no added sounds
p\a: soft,non tender
cns: intact
reffered to gastroenterology:
advised:anti-gliardin ab,ltg ab[ tissue transglutamine],ct enteroclysis/enterography
reffered to pshchiatry:diagnosis-1]mild depression.2]hypochondriasis
psychiatry referral taken :
hopi: patient was apparently asymptomatic 10 years ago when he experienced gastric problem in the form of belching during his 12th standard exam which reduced after he was done with exams.
from 2009 - 2012 he did his ba from a college in calcutta where due to routine night outs he frequently had gastric
trouble and also due to consumption of hostel food so he changed from hostel to another mess and his gastric
bloating and belching decreased after that he went back to his home town in bengal and his m.a. long distance during
this time their was his altercation betwen his parents stresser +
in 2015 he did b.d. and he even got a contract job as lecturer as a part time lecturer and earned 15,000 during this time
he liked a girl and wished to marry her but as he didnt have a govt job the girl left him
they had a break up in 2017 after that his mood would be low didnt not search for any job would say at home couldnt
concentrate on his preparation on competetitive exams sleep and appetite also disturbed
but he over came the phase by himself and never visited a pyschiatrist
in 2017 he got a job in a bank Job the timing were long he quit it after 2 and half months
in 2019 during this period , one of his school friend got a job in a bank so he decreased interaction with him during
this time he again experienced belching bloating which would subside after taking few meidication or after eno
the frequency was for 3-4 times a week which lasted for an hour
and was mostly experienced during lunch time
in 2018 he visited asian institute of gastro hyd along with his mother as he was experiencing belching loose stools and
bloating and 1 episode of green stools
colonoscopy ands endoscopy were done reported to be normal
he was given medication which he used for few days and stopped
in 2019 he wanted to appear for competitive exams which would help him to secure a government job but the exam got cancelled he was taking tution for appox 80 students working as lic agent and earned a salary of 50000
in 2020 feb he came across his ex -girl friend photo in the profile of his common friend and came to know that she got married again he thought he was rejected by her as he didnt got a govt job and he started feeling low again
in march due to lock down he stopped taking tutions lic company was closed he was recording his classes online and sendng it to students
April 2020
the belching increased which was accompanied by epigastric pain burning sensation in stomach and constipation
it was for 6 times a week
and also sob he took treatment from a general doctor was even referred to ent surgeon took treatment for 15 days and
stopped it
may 2020
he got to know that one of his friends uncle expired due to gastric cancer since then he thinks that he might also have
some progressive disorder (cancer) the same gastric symptoms persisted
june2020
patient had pain in left lumbar region occasionally which spread to entire body and it remained for 30 mins to 1 hour
and subsided on its own for this he consulted a physician
he had disturbed sleep
epigastric pain belching ocassional sweating palpatations dry month
only once he felt scared impending doom present
he was scared to stay alone at home during this time
last attack was 3 months back
july 2020
for the above symptoms he consulted a physcian and was diagnosed with ibs
he was put on medications for 15 days
there was 30% improvement
mean while he cosulted another physician online
he was prescribed tab.zolfresh 5mg for sleep disrturbance which he used occasionally as there was not much reduction
of symptoms he went to another doctor he changed medication who even referred to pyschiatrist and
gastroenterologist there was 50% improvemnt in symptoms the burning sensation would occur once a day and subside in 30
mins he even experienced burning micturtion and burning near anal region after defecation
aug 2020
he went to gastroenterologist and took treatment and reported 70% -80% improvement burning and bloating sensation decreased
he even experienced burning in limbs due to which nerve conduction was done and the was normal
after 1 month as he didnt get the appointment from previous doc tor he went to another doctor but there was not much improvement
so he went back to first one
he was asked to get endoscopy and duodenal biopsy done but he didnot do.
oct 2020
he consulted a pyschiatrist again and was put on tab. nexito5mg and t.meltonan 2.5mg which he took for 15 days and stopped during the course of treatment which the above symptoms his sleep was reported to be normal he was taking gastro medications when he came to kims narketpally
sleep- disturbed appetite low
no history of any substance use
head injury seizures self talking self smiling grandiosity suspiciousness
repitative thoughts
no history of hypertension , diabetes , thyroid no hospital admissions in past was jovial as child would respect
parents inter persoanl relations maintained.
* CBP:
HB-13.3 G%
TC-6,800 /mm3
N-62
L-29
E-4
B-0
PCV-38%
MCV-82.4 MM3
MCHC-34.9
MCH-28.8
PLT-1.53 LAKHS
CRP- NEGATIVE
*CUE:
COLOUR : Yellow
APPERANCE
ALBUMIN - +
SUGAR- NIL
PUS CELLS- 3-4
EPITHELIAL CELLS- 3-4
*FBS: 82 mg/dl
*THYROID PROFILE
T3- 2.21
T4- 15.93
TSH- 0.71
*SEROLOGY_ HIV , HCV , HBsAg- Negative
*Stool for occult blood- Negative
*Ultrasound Abdomen : No sonological abnormality detected
DIAGNOSIS:
?IRRITABLE BOWEL SYNDROME, ?CELIAC DISEASE
TREATMENT:
TAB.B.COMPLEX OD
TAB.MIRTAZAPINE 15MG H/S
TAB.PANTOP 40MG BFF OD
TAB.LOPERAMIDE 2MG SOS
Comments
Post a Comment