A 52 year old male with background of myocardial infarction ,and pain abdomen

  

This is an online E log book 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 series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. 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. 

A 52 YEAR OLD MALE ,PRESENTED WITH CHIEF COMPLAINT OF PAIN ABDOMEN SINCE 20 YEARS 

Decreased bowel movements (constipation) since 20 years 

PATIENT WAS APPARENTLY ASYMPTOMATIC 20 YEARS BACK 

ABOUT 20 YEARS BACK HE MET WITH AN ACCIDENT [ HE WAS HIT BY AN AUTO WHILE HE WAS GOING ON A CYCLE]

PATIENT GIVES HISTORY WHICH IS SUGGESTIVE OF LEFT HIP DISPLACEMENT/FRACTURE head of femur ?

He did not receive any TREATMENT ...which resulted in change in the gait ,prior to the trauma he used to walk normally ,the change in the gait secondary to trauma is linked below 

FOLLOWING The trauma PT COMPLAINTS OF PAIN ABDOMEN 

BRIEFING THE C/O PAIN ABDOMEN-

Pt complains of diffuse abdominal pain since 20 years ,insidious onset ,gradually progressive 

The severity of pain has increased since 2 months which made him come to our hospital . 

PT TYPICALLY GiVES H/O OF PAIN AROUND THE UMBILICUS,insidious onset gradually progressive 

PAIN RADIATING TO THE BACK [BUT PAIN IN THE BACK IS OF DECREASED INTENSITY]

PAIN SUBSIDES ON TAKING MEDICATION[?]

THE INTENSITY OF PAIN NEITHER INCREASES NOR DECREASES ON TAKING FOOD

PT ALSO C/O BLOATING 

 BRIEFING ON REDUCED BOWEL MOVEMENTS-

PATIENT C/O REDUCED BOWEL MOVEMENTS SINCE 2 MONTHS

PASSES STOOLS ONCE IN EVERY 2-3 DAYS

FEELING OF INCOMPLETE EMPTYING OF BOWEL?

BLOOD IN STOOLS [WHENEVER He Strains to pass stools]

 NOT A/W VOMITING,FEVER

NO C/O BURNING MICTURITION

Timeline of events-

PAST HISTORY-

H/O MI 6 MONTHS BACK

N/K/C/O DM,HTN,EPILEPSY, TB ,ASTHMA

PERSONAL HISTORY-

DIET-MIXED

APPETITE-NORMAL[BUT FEELING OF NLOATING DOESNT ALLOW HIM TO EAT WELL]

BOWEL MOVEMENTS -REDCUED

BLADDER MOVEMENTS -NORMAL

SLEEP-ADEQUATE

ADDICTIONS -USED TO SMOKE 1 BEEDI /DAY

STOPPED SMOKING FROM 6 MONTHS

Treatment history-

He’s on -1)Aspirin gastro resistant and atorvastatin capsules (75mg/10mg) since 6months (after the episode of MI )

2)Tab pan 40mg 

FAMILY HISTORY-NOT SIGNIFICANT

DAILY ROUTINE-

WAKES UP AT 6 AM -> GETS READY FOR THE DAY->BREAKFAST[AT 10 AM][TEA,RICE WITH ANY VEG/NONVEG CURRY]->goes to work[?]->lunch at 3PM [RICE WITH ANY VEG/NON VEG CURRY]->AT 8 PM COMES BACK FROM WORK->10 PM dinner [rice with curry]-> 11 pm goes to bed 

The daily routine has been same before 20 years when he was absolutely alright and it’s same even  after the h/o trauma 

On examination -

Pt is C/C/C well oriented to Time ,place and person 

No pallor,icterus,cyanosis,clubbing,or generalised lymphadenopathy 

Afebrile

BP-110/70 mmHg

PR-84 bpm

RR-16cpm

AC-77cm(at the level of umbilicus )

       Rt     Lt 

MAC -24cm    24cm

CVS-S1S2 heard 

R/S - BAE +

CNS-NFND

1. HIGHER MENTAL FUNCTIONS:

    Patient sitting on the bed and responding to oral commands and questions

    Speech-normal 

2.CRANIAL NERVES: INTACT

3.Power

Rt UL-5/5. Lt UL-5/5

Rt LL-4/5.  Lt LL-4/5

Tone -

Rt UL -N

Lt UL-N

Rt LL-N

Lt LL-N

Reflexes:                    Right                    Left. 

Biceps.                          ++.                    ++

Triceps.                         ++                    ++

Supinator.                      ++                     ++

Knee.                             ++                     ++

Ankle.                            ++                     ++

4.SENSORY

crude touch                    N                  N

           pain                       N                N

           Temp                     N                N

    

          fine touch                  N                   N

          vibration                    N                   N

            

5.CEREBELLAR

       Gait?

        Coordination

             Finger nose test :+

             

CNS examination video link

https://youtu.be/rBu6ZHH7WYA

 

P/A

Inspection-

Shape of abdomen normal

Umbilicus -central and inverted

No visible scars,sinuses,dilated veins

Hernial orifices normal 

Palpation -no local rise of temperature 

Tenderness present in epigastric and umbilical region 

No guarding,rigidity,rebound tenderness 

No hepatomegaly,spleenomegaly

Percussion-

Resonant 

Auscultation-

Bowel sounds +

 Investigations- 

Hb-10.6

TLC-7,300

Neutrophils-48

Lymphocytes-37

Eosinophils-05

Monocytes-10

Basophils-00

Platelet count-1.31

CUE-

Serum creatinine -1.1 mg/dL

Blood urea-13 mg/dL

LFT-

Total bilirubin -0.91 mg/dL

Direct bilirubin-0.20

AST-32 IU/L

ALT-16 IU/L

Alkaline phosphate- 137 IU/L

Total proteins-6.8 gm/dL

Albumin-4.0 gm/dL

A/G ratio-1.46

Serum electrolytes and ionised calcium-

Sodium-138 mEq/L

Potassium-4.1

Chloride-103

Calcium ionised-0.97 mmol/L

Serology (anti hcv ab,HbsAg ,HIV 1/2 rapid) :negative 

ECG -

2decho-

USG abdomen-

Stool sample -sent for leukocytes

(No pus cells ,no ova/cysts seen )

Upper GI endoscopy done(on 21/10/22):

https://youtu.be/wisd9K1__3E

Treatment-

1.Tab .Ecosprin 75 mg /PO/OD

2.Liquid Parafin 10mL/HS

3.Vital monitoring

4.Inform SOS

Discharge summary:(22/10/22)