37 year male with IBS

This is an online E-log book to discuss our patient de-identified health data shared after taking his/ her guardians sign informed consent .Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve those patient clinical problem with collective current best evidence based inputs.

This E-log also reflects my patient centered online learning portfolio.

Your valuable inputs on comment box is welcome

I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan.came to the hospital with

CHEIF COMPLAINTS: of blood in stools since 2 months

 ( September 2022).

History of present illness: A 37 year old male, c/o  blood mucus in stools 3 episodes.

1 episode in September, 2nd episode on 27th and 3rd episode on 29th each episode was associated with blood and mucus, aggravated by spicy food intake, associated with analpain and itching.

No h/o fever/rash/burning micturation/palpitation

No change in stool consistency

Occasional h/o anxiety with palpitations/chest pain

Occasional GI problems (loose stools) abdominal cramps, bloating  present 

Patient complained about alteration of stool ie mucus in stool on consumption of crud from local vendor, and consumption of spicy food and wheat.

But he doesn't  have such issues on consumption of renowned  yoghurt brand , and has no complaints of mucus in stools on consumption of maida biscuits.

PAST HISTORY:

No comorbidities 

H/O motion sickness since 5 years is on medication  on T.Avomin

Not a k/c/o DM/HTN/CAD/TB/EPILEPSY/HYPOTHYROIDISM

https://ssahamedicalcases.blogspot.com/2022/10/patient-history-pt-is-37-yr-old-male.html

PERSONAL HISTORY:

DIET: Mixed

APPETITE: Normal

BOWEL MOVEMENTS: Irregular

BLADDER MOVEMENTS: Normal

ALLERGIES: Dust allergy

HABITS:  In 2004 Feb, started smoking cigarettes (3-4/day, occasionally 1-2 bidis)  in his college times due to peer pressure. In 2005, smoked 6-7 cigarettes/day.  Stopped smoking in 2018 June  due to health concerne

FAMILY HISTORY-

H/0 IBS& HYPOTHYROIDISM (MOTHER)

H/0 HYPOTHYROIDISM  (SISTER')

DEPRESSION ( PATERNAL AUNT)

 PHYSICAL EXAMINATION: 

NO pallor,

no icterus, no cynosis

no clubbing of fingers/ toes,

no lymphadenopathy,

No odema of feet 

Patient is MODERATELY built and MODERATELY nourishes 

Vitals: 

 MAMC: 25.4cm

At the level of lowest costal cartilage 80cm

At  the level of umbilicus 82cm

At the level of ASIS:91cm

Fat/MAMC:3.5

Temp- 98.6 F

Bp -. 120/70 mmhg

PR: 78 bpm

RR:16cpm

Spo2 - 98@RA

GRBS- 116 MG% in view of

SYSTEMIC EXAMINATION:

CVS: S1 , S2 HEARED

RS: BAE+

P/A : SOFT, NON TENDER ,BOWELSOUNDS+

CNS': HMF  INTACT NOFND

Surgery opinion  was taken   in view of blood in stools on and off since 1 month , and itching at perianal region. On per rectal examination , skin around the external anal meatus was normal on inspection , no skin tags and fissures seen 

On DRE: external anal spincter tone normal , no fecal staining of glowed finger.

On proctoscopy: rectal mucosa appeared normal.

No masses visible per rectum,no fissures,no skin tags.

 Colonoscopy:  colonoscopy was done under G.A 

Impression showing normal ileocolonic  muscosal study

Investigations 

Hemogram 

cue

USG abdomen & pelvis:

Colonoscopy:

 

chest x ray pa view:

Ecg

Diagnosis:  GENERALIZED ANXIETY DISORDER  NON ULCER DYSPEPSIA WITH IRRITABLE SYNDROMEBOWEL

TREATMENT: PAJR GROUP FOLLOW UP.