36 year old with vomiting
This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
SERUM CREATININE- 0.6 mg/dl
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the 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 competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
Maheshwari Jagathkari
Case report
A 36 year old businessman by occupation resident of Kochi, WestBengal came t o our hospital with chief complaints of
Vomiting since 2 months
Generalized weakness since 2 months
Abdominal pain since 2 months
History of presenting illness:
Patient was apparently asymptomatic 2 months back then he experienced bloating, not wanting to eat food and Vomiting ( occurs 2-3 hours after consuming food) which is insidious in onset, food particle as content,4-5episodes/day,yellow to greenish in colour (non bilious), non projectile, non blood stained. It occurs with with both liquids and solids associated with nausea, belching, regurgitation.Initially appetite was normal but as time passed and the vomiting continued it decreased.
ABDOMINAL PAIN since 2 months which is insidious in onset, non progessive, diffuse in all regions, squeezing type , non radiating without any aggravating or relieving factors for which he was taken to a local hospital and was prescribed tablet, but apparently the patient had Vomiting even after consumption of tablets, since then he was not able to consume solid food and started to be on liquids and consumed protein powder. Despite seeking many medical advices it didn’t subside.
Now he has complaints of Vomiting
with food particle as content,non-bilious,non-projectile,non-foul smelling,non-blood tinged and abdominal pain which is insidious in onset, non progressive and present diffusely all over the abdomen,non radiating.
History of lethargy and weight loss of about 10 kgs in last 10 months
History of jaundice which was diagnosed incidently 2 months ago and visited a hospital in West bengal but no relief despite medications.
Also there is a history of ?psychiatric medication being taken by the patient apparently because he was all the time depressed, confused and crying.
No history of dysphagia, odynophagia, heartburn, indigestion, flatulence, diarrhoea, abdominal distention, hematemesis, melaena, urinary symptoms, chest pain, cold, cough.
When he was taken to a hospital in West Bengal investigations were done
Endoscopy - esophageal candidiasis, Lax LES, Pangastritis, Duodenitis.
CT abdomen
Daily routine:
He has weakness due to which he stopped doing his job.
Before this, Patient wakes up around 6 in the morning and freshens up. Has his breakfast and goes to work where he is a shopkeeper . Takes his lunch during work and comes back home around 9 and takes his dinner.
Past history:
Not a k/c/o HTN,DM,TB,Epilepsy,Asthma,CAD
Family history: Not significant
Personal history:
Diet:Mixed
Appetite: decreased
Bowel and bladder habits : decreased
Addictions:
General examination
Patient is concious, coherent and cooperative.
PATIENT IS POORLY BUILT AND POORLY NOURISHED
Pallor is present
No features indicating the presence of icterus, cyanosis, clubbing, edema lymphadenopathy.
Vitals :
Temperature - 96.8 ° F
Blood Pressure -80/60 mmHg
Pulse Rate -70 bpm
Respiratory Rate - 16 cpm
Spo2-98%@RA
SYSTEMIC EXAMINATION
PER ABDOMEN-
Inspection:
Shape - Scaphoid, with no distention.
Umbilicus - Inverted
Equal symmetrical movements in all the quadrants with respiration.
No visible pulsation,peristalsis, dilated veins and localized swellings.
Palpation:
No lacal rise of temperature
Inspectory findings are confirmed
No hepatomegaly
Spleen not palpable
Percussion:
Normal liver span
Fluid thrill and shifting dullness absent
puddle sign absent
Auscultation:
Bowel sounds present.
CVS:
Inspection:
There are no chest wall abnormalities
The position of the trachea is central.
Apical impulse is not observed.
There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses.
Palpation:
Apex beat was localised in the 5th intercostal space 1cm medial to the mid clavicular line
Position of trachea was central
There we no parasternal heave , thrills, tender points.
Auscultation:
S1 and S2 hears
There were no added sounds / murmurs.
CNS:
HIGHER MENTAL FUNCTIONS-
Normal
Memory intact
CRANIAL NERVES :Normal
SENSORY EXAMINATION
Normal sensations felt in all dermatomes
MOTOR EXAMINATION
Normal tone in upper and lower limb
Normal power in upper and lower limb
Normal gait
REFLEXES
Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited
CEREBELLAR FUNCTION
Normal function
No meningeal signs were elicited
RESPIRATORY EXAMINATION:
Shape of chest is elliptical, b/l symmetrical.
Trachea is central. Expansion of chest is symmetrical
Bilateral Airway Entry - positive
Normal vesicular breath sounds
Course in our hospital
- Surgery referral was taken i/v/o jejunal obstruction
Intially on examination:
Patient is thin, malnourished
Per abdomen- soft, mild tenderness present in epigastric region
No distention, no guarding, rigidity
Scaphoid abdomen is seen
Bad oral hygiene
No signs of intestinal obstruction
PROVISIONAL DIAGNOSIS
ORAL CANDIDIASIS
ANEMIA
?ILEOCAECAL TUBERCULOSIS
?SUBACUTE SMALL BOWEL OBSTRUCTION
? INFLAMMATORY BOWEL DISEASE
- Gastroenterology referral-
Upper GI endoscopy was done
Impression- esophageal candidiasis was resolved
Plenty of bilious fluid in the stomach
?Proximal small bowel obstruction
- Initially ultrasound was done → Impression- No sonological abnormality
But when the repeat ultra sound was done → Impression-
LONG SEGMENT SMALL BOWEL EDEMA(?JEJUNAL LOOPS)
E/O 40x35mm MASS IN THE PELVIS JUST ABOVE THE URINARY BLADDER
? BOWEL MASS ? MASS IN PELVIC MESENTERY
- To confirm the presence of mass colonoscopy was done
REVIEW OF THE CT REPORT THAT WAS DONE IN APRIL
Erect Abdomen X-ray on 12/06/23
Other investigations
Dated 12/06/23
SERUM UREA- 39mg/dl
Surgery referral:
Per abdomen- on inspection scaphoid in shape, umbilicus - central and Inverted, no visible scars and sinuses, engorged veins, no visible pulsations,peristalsis,all quadrants moving appropriately with respiration
PALPATION:
Abdomen soft, no local rise of temperature,mild tenderness + in Rt hypochondria
Vertically oval swelling.palpable in rt hypochondrium, becomes less prominent on leg rising
No guarding, no rigidity
PERCUSSION:
Tympanic note heard
AUSCULTATION:
Bowel sounds heard
PER RECTAL EXAMINATION: no external skin tags, fissures, fistulae noted, no masses protruding per rectum
DIFFERENTIAL DIAGNOSIS-
?Inflammatory bowel disease
?Abdominal tuberculosis
ADVICE - CECT ABDOMEN WITH ORAL AND IV CONTRAST
Biopsy report- Ascending colon
FINAL DIAGNOSIS
MODERATELY DIFFERENTIATED ADENOCARCINOMA IN ASCENDING COLON
RECTAL POLYP
CHRONIC ANEMIA(IRON DEFICIENCY ANEMIA)
Discharge summary
This is a case of 36 year old male complaining of vomiting since 2 months not being relieved by any medication came from West Bengal finding answers for his sufferings.
Patient was apparently asymptomatic 2 months back then he developed vomiting which is insidious in onset, food particle as content,4-5episodes/day,yellow to greenish in colour (non bilious), non projectile, non blood stained. It occurs with with both liquids and solids associated with nausea, belching, regurgitation, abdominal pain that is squeezing type.
Patient then started losing weight, he almost lost about 10kg in 2 months.
Course in the hospital
Patient was investigated further, and was found to have a bowel mass and on further investigation and biopsy, he is diagnosed with moderately differentiated adenocarcinoma in ascending colon, rectal polyp.
Also he has chronic anemia-iron deficiency anemia.
Now the patient is being referred to a higher centre to relieve him of his agony.
Comments
Post a Comment