19F with Decreased Appetite

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I've 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 a diagnosis and treatment plan.

Name :- kattekola sathwik 

Roll no:- 75 

Case report 

19 year old female came with complaints of  

        1.decreased appetite since 5 years

       2.Indigestion and passage of stools on consumption of non veg food and milk products since 5 years

       3. Lethargy and easy fatigubility since 5 years 

HOPI:

 Patient was apparently asymptomatic 5 years back , when she was in 9 th class started experiencing decreased appetite ( takes meal 3 times /day but less quantity) , associated with passing of stools after food intake after breakfast altering consistency ( semisolid, non foul smelling ,not bulkier,sometimes passes the particles of food whatever she eats, small volume (obesrved when she eats fruits, dairy products) , frequency increases with intake of non -veg ,after passing stools she feels lethargic and takes rest most of the day,

No H/O steatorrhea,

Growling sounds in stomach present  during night times , associated with nausea and dizziness ( on and off ) , weight loss of 5 kgs since 5 years.

H/o easy fatigubility present

H/o bloating present

Not associated with pain abdomen, vomitings, blood or mucous in stools, no constipation symptoms in between.

She had visited to outside hospitals in view of decreased appetite and prescribed multivitamin syrup

Her appetite was not improved 

Menstrual history: Regular, 5 days per cycle every 30 days associated with clots and dysmenorrhoea 

Family History:

She belongs to a middle class family and is the second child in the family with one elder sister and one younger sister and one younger brother 

Her father is a Shop keeper

by occupation 

She is happy going girl with no family stressors

DIETARY HISTORY:

Quantity               Calories

MORNING 

1 CUP PUFFED RICE   56

1 CUP TEA.                   45

AFTERNOON 

1CUP COOKED RICE   206

1CUP DAL                     198

   

1FISH.                               24

1/2-1CUP VEGETABLE. 180

DINNER

1CUP COOKED RICE.      206

1CUP DAL.                        198

1FISH. ..                                24

                                                一一一       

                                                1139 

Calorie deficit :- 710 K cal                                     

On examination : 

Pt-c/c/c 

Thin built , moderately  nourished 

PR : 78 bpm 

Bp: 100/60 mm of hg 

No icterus, cyanosis, clubbing, lymphadenopathy, edema 

CVS- S1,S2 heard

RS- BAE heard

P/A : soft, no tenderness,Bowel Sounds present

CNS- NFND

 Investigations:

Hemogram

Ultrasound of abdomen and pelvis

Obstetrics and gynaecology referral was taken on 18/3/23 i/v/o dysmenorrhoea

Gastroenterology opinion was taken i/v/o Malabsorption

Diagnosis: 

Anorexia secondary to Malabsorption 

Treatment:

Tab. MULTIVITAMIN PO/OD

Tab. MEFTAL SPAS PO/SOS

Plenty of oral fluids

Discharge Summary:

Diagnosis:

MALABSORPTION ?CELIAC DISEASE WITH MILD IRON DEFICIENCY ANEMIA 

 

Case History and Clinical Findings

COMPLAINTS:

     DECREASED APPETITE SINCE 5 YEARS

     INDIGESTION AND PASSAGE OF STOOLS ON CONSUMPTION OF NON VEG FOOD AND MILK PRODUCTS SINCE 5 YEARS

      LETHARGY AND EASY FATIGUBILITY SINCE 5 YEARS

PRESENT ILLNESS:

PATIENT WAS APPARENTLY ASYMPTOMATIC 5 YEARS BACK , WHEN SHE WAS IN 9 TH CLASS STARTED EXPERIENCING DECREASED APPETITE ( TAKES MEAL 3 TIMES /DAY BUT LESS QUANTITY) , ASSOCIATED WITH PASSING OF STOOLS 2-3 TIMES /DAY AFTER FOOD INTAKE ALTERING CONSISTENCY ( SEMISOLID, NON FOUL SMELLING ,NOT BULKIER,SOMETIMES PASSES THE PARTICLES OF FOOD WHATEVER SHE EATS, SMALL VOLUME (OBESRVED WHEN SHE EATS FRUITS, DAIRY PRODUCTS) , FREQUENCY INCREASES WITH INTAKE OF NON -VEG ,AFTER PASSING STOOLS SHE FEELS LETHARGIC AND TAKES REST MOST OF THE DAY,

NO H/O STEATORRHEA,

GROWLING SOUNDS IN STOMACH PRESENT DURING NIGHT TIMES , ASSOCIATED WITH NAUSEA AND DIZZINESS ( ON AND OFF ) , WEIGHT LOSS OF 5 KGS SINCE 5 YEARS.

H/O EASY FATIGUBILITY PRESENT

H/O BLOATING PRESENT

NOT ASSOCIATED WITH PAIN ABDOMEN, VOMITINGS, BLOOD OR MUCOUS IN STOOLS, NOCONSTIPATION SYMPTOMS IN BETWEEN SHE HAD VISITED TO OUTSIDE HOSPITALS IN VIEW OF DECREASED APPETITE AND WAS PRESCRIBED MULTIVITAMIN SYRUP AND HER APPETITE WAS NOT IMPROVED

 PAST ILLNESS:

NO SIMILAR COMPLAINTS IN THE PAST

NOT A K/C/O DM,HTN,EPILEPSY,ASTHMA,THYROID,TB

 EXAMINATION:

PT-C/C/C 

HEIGHT:155CMS

WEIGHT:34.8KGS

BMI:14.5KG/M→NEEDS 1849 calories/day

THIN BUILT , MODERATELY NOURISHED

PR : 78 BPM

BP: 100/60 MM OF HG

RR:18CPM

SPO2:97%@RA

PALLOR PRESENT

NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA

CVS:S1S2 HEARD

NO CARDIAC MURMURS

P/A:SOFT,NON TENDER,

CNS:NFND

RS:BAE PRESENT

DIETARY HISTORY:

Quantity Calories

MORNING 

1 CUP PUFFED RICE 56

1 CUP TEA. 45

AFTERNOON 

1CUP COOKED RICE 206

1CUP DAL 198

1FISH. 24

1/2-1CUP VEGETABLE. 180

DINNER

1CUP COOKED RICE. 206

1CUP DAL. 198

1FISH. 24

                                                一一一       

                                                1139

CALORIE DEFICIT =710                                

 COURSE IN THE HOSPITAL:

AFTER ADMISSION PATIENT WAS GIVEN NORMAL DIET.

STOOL WAS SENT FOR MICROSOPY WHICH WAS NORMAL WITHOUT ANY PUS CELLS AND

OVA , CYSTS

PATIENT WAS ASKED TO COLLECT 72HRS STOOLS AND WAS PLANNED TO BE SENT FOR

ANALYSIS

GASTROENTROLOGIST OPINION WAS TAKEN I/V/O SUSPICION OF MALABSORPTION

ENDOSCOPY WAS DONE ON 21/3/23

ENDOSCOPY- ESOPHAGUS- NORMAL

STOMACH-NORMAL

DUODENUM- D1-NORMAL

D2- SCALLOPED DUODENAL

IMPRESSION-SCALLOPED DUODENAL FOLDS

RULE OUT MALABSORPTION SYNDROME

GASTROENTEROLOGIST ADVISED TO RULE OUT MALABSORPTION SYNDROME AND WAS

ADVISED

ANTI TISSUE TRANSGLUTAMINASE ANTIBODIES

ANTI GLIADIN ANTIBODIES

T3,T4,TSH

COLONOSCOPY

IRON STUDIES,B12,FOLATE

ASKED TO REVIEW WITH ABOVE REPORTS

 Investigation:

STOOL CUTURE -NO PUS CELLS SEEN

NO OVA /CYSTS SEEN

 

USG ABDOMEN AND PELVIS WAS DONE

                       IMPRESSION:B/L RENAL CALCULI

 

HEMOGRAM:

HB-10.4%

PCV-32.9vol%

TLC-9000cells/cumm

PLT-1.6LAKHS

RBC-4.09million/cumm

MCV-80.4fl

MCHC-25.4fl

Normocytic normochromic

 Treatment Given:

TAB.MULTIVITAMIN PO/OD

PLENTY OF ORAL FLUIDS

 Advice at Discharge:

TAB.MULTIVITAMIN PO/OD

TAB.OROFER XT/PO/OD

 Follow Up:

FOLLOW UP TO GASTROENTEROLOGY OPD WITH REPORTS