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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
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
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