31year male with nausea ,loose stools and abdominal pain

31 year male with nausea, loose stools and abdominal pain


July 10, 2023

Hello, I am Harika Madala, a 5th sem medical student.
THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS/HER GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT

CHIEF COMPLAINTS:
A 31year male patient farmer by occupation resident of lingotam came to the hospital with chief complaint of loose stools since 1day

DAILY ROUTINE:
Patient is a 31 year old male. He is married and has 3 kids. He is a farmer by occupation. He wakes up at 6am everyday and freshens up and goes to his farm. He comes back home at 8am and has breakfast and returns to farm. He sometimes has his lunch at 1:00pm and the other times he skips it and has a early dinner. He comes back home at 7:00pm and spends time with his family. He eats dinner at 8pm and sleeps at 11:00pm.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic since 1 day then he consumed outside food(fried rice) after which he developed nausea and loose stools of 20-25 episodes per day cause of abdominal pain 
Loose stools of large quantity and non foul smelling
Fever since 1day not associated with chills and rigor, high grade and intermittent
No history of cold,cough ,sob ,throat pain,chest pain,decreased urine output, hematuria, pyuria.

PAST HISTORY:
N/k/c/o diabetes, hypertension, CAD,tuberculosis, epilepsy, asthma

PERSONAL HISTORY:

married 
Appetite - normal
Diet - mixed
Bowl movement - irregular
Micturition -normal
Sleep- normal
No allergies
addictions alcohol - occastional
Smoked 2yrs back occasionally 

FAMILY HISTORY:

Father and mother- diabetes

GENERAL EXAMINATION:

Pt was conscious, coherent and cooperative 
Moderately built and nourished 
Pallor- absent
Icterus- Absent
Cyanosis- Absent
Clubbing- Absent
Lymphadenopathy- Absent
Pedal oedema- Absent





Vitals:

Temperature : 101F
Pulse rate : 64/min
Respiratory rate : 16 per minute 
Blood pressure : 120/70 mm of Hg
sPO2 : 96% 
Systemic examination:
ABDOMINAL EXAMINATION:
On inspection:
-Truncal obesity is seen. 



-Umbilicus is central and inverted. 
-There are no visible pulsations, peristalsis, sinuses or engorged veins. 
PALPATION: 
-There is no local raise of temperature 
-No organomegaly. 
AUSCULTATION:
Bowel sounds are heard. 

RESPIRATORY SYSTEM EXAMINATION 
-Bilateral air entry is present, normal vesicular breath sounds heard. 

CNS EXAMINATION: 
No functional deficits
Normal speech 

Cardiovascular System-
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs
Respiratory System 
 no dyspnea 
No wheezing
central trachea
vesicular breath sounds

Reflexs               
                       Right. Left
Biceps. +2. +2
Triceps. +2 +2
Supinator. +1 +1
Knee. +2. +2
Ankle. +2. +2

Investigations:

Ultrasound:
Borderline spleenomegaly 
HEMOGRAM
Haemoglobin:14.5gm/dl
Total count:5,300cells/cumm
Neutrophils:79
Lymphocytes: 11
Eosinophils:01
Monocytes:09
Basophils:00
PCV:42.4
MCV:88.3
MCH:30.2
RDW CV:11.9
RDW SD:38.9
RBC count:4.80
Platelet count:1.51lakh/cumm

COMPLETE URINE EXAMINATION
Colour:Pale yellow
Appearance:Clear
Reaction:Acidic
SP.gravity:1.010
Albumin:+
Sugar:Nil
Bile salts:Nil
Bile pigments: Nil
Pus cells:3-6
Epithelial cells:2-4
Red blood cells:Nil
Casts:Nil
Crystals:Nil
Amorphous deposits:Absent
Others:Nil

Blood urea:26
Serum creatinine: 1.0
Hbs Ag RAPID:Negative
HIV 1/2 Rapid test:non
Reactive

LIVER FUNCTION TEST
Direct bilirubin:0.24gm/dl
Total bilirubin:0.86gm/dl
AST:27 IU/L
ALT:40 IU/L
Alkaline phosphatase:113 IU/L
Total protein: 6.4 gm/dl
Albumin:4.08 gm/dl
A/G Ratio:1.76

SERUM ELECTROLYTES
Sodium-141mEQ/L
Potassium -3.8 mEQ/L
Chloride-106 mEQ/L
Calcium-1.16 mmol/L

Renal function test:
Urea: 24mg/dl
Creatinine:0.9
Uric acid:4.0
Calcium:9.6
Phosphorus: 3.2
Sodium:140
Potassium: 4.2
Chloride: 103







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