July 1, 2022
NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.
A CASE OF ABDOMINAL PAIN SINCE 2 YEARS
A 34 year old male patient, barber by profession and a resident of koochbihar(WB) came to the OPD with chief complaint of :
Loose stools since 2 years, abdominal pain since 2 years,
Reduced appetite since 2 months,
Burning sensation after food intake.
HISTORY OF PRESENT ILLNESS:
Loose stools since 2 years once in 2 days (food particles),
Diffuse abdominal pain since 2 years,
Rashes over upper and lower limbs and itching since 3 months,
Cough since 2 months,
Reduced appetite since 2 months,
Burning sensation after food intake.
HISTORY OF PAST ILLNESS:
Not a k/c/o HTN, DM, CAD, CVA, Asthma, TB.
PERSONAL HISTORY:
Married
Occupation - barber
Appetite - reduced
Diet - mixed
Bowels- Loose stools
Micturition- normal
Addictions- alcohol occasionally since 10 years,
Smoking occasionally since 10 years (1 cigar/day).
FAMILY HISTORY: No relevant family history
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative.
No pallor, icterus, cyanosis, clubbing of fingers, lymphadenopathy and oedema of feet.
Vitals:
Temperature- 98.6F
BP - 110/80 mmHg
PR- 82 bpm
RR- 16 cpm
SpO2 - 98%
SYSTEMIC EXAMINATION
CVS: S1S2 heard, No murmurs
RS: dyspnoea- no
Wheeze - no
Position of Trachea- central
Breath sounds- vesicular
ABDOMEN
Shape- scaphoid
Non tender
No palpable mass
Hernial orifices- normal
No free fluid
Liver- not palpable
Spleen- not palpable
Bowel sounds - no
INVESTIGATIONS
USG of abdomen
ECG
Chest X-RAY
Hemogram
Microscopy of stool
Colonoscopy
JULY 1, 2022
PATIENT HISTORY: Pt is a 35 yr old male, a barber by profession. When he was in class 4, he had one episode of diarrhea. Used to vomit (watery, 2-3/day), black watery stool (15 -20 times/day), lower abdomen pain, and generalized body weakness. He was admitted to the hospital for 15 days and recovered with medicine.
In class 9-10 i.e 5 yrs later, he started suffering from dysentery. Each time he had to rush to the toilet with lower abd. pain just before fecal urgency. Abd. pain used to go away after defaecation. The stool was of loose consistency, with mucus and white specks, frequency - 10-12/day, and would be of little quantity each time, He started noticing undigested food. particles coming out with stool. He would be fine for 10-20 days, then again dysentery. No treatment was done.
2 yrs later, his previous symptoms changed - no abd. pain, the stool was of loose consistency, with mucus and white specks, frequency reduced to 7-8/day.
For the past 10 yrs, gastric problems (frequent burps after a meal with an after taste of the food eaten especially chicken, bloating). Burning senation in epigastrium after a meal.
NOTE: Bloatedness resolved with medication from Hyd.
In 2021, went to Dr. with c/o diffused abd. pain, loose stool 7-8/day, who prescribed medication after USG and blood test. Symptoms would resolve temporarily with medication, but if stopped will reoccur within 10-12 days. After 3 months, went to another Dr. who prescribed diff. medications, but the result was still the same, with no complete recovery.
So, he did Ayurvedic treatment. Had medicine for 1 month. Became completely normal for 7-8 months.
For the past 6 months started suffering from constipation. For 2-3 days won't pass stool at all. Then on the 4th day would pass hard stool (3-4 times). The first time passing stool was very difficult and painful. Had resolved with Duphalac.
5 months ago, because of an oral ulcer, decreased appetite and wt. loss went to a Dr. who prescribed medications. Mouth ulcer resolved
For the past 4 months 2-3 popular itchy rash on legs and hands.
For the past 3 months i.e 1 week prior to coming to Hyd, 1 episode of fever at night, went down with paracetamol within 2 days. Again another episode of night fever. He started feeling generalized body weakness, agitated, hot-tempered, no appetite, severe wt loss (from 65 kg to 45kg within 2 months), and deep sleep for only 2-3 hrs at night. Coughing with blood-stained sputum. Chest pain while coughing.
Went to Hyd. for consultation. chest Xray, colonoscopy was done. Internal hemorrhoids were detected. Also, recommended doing an HIV test.
After returning from Hyd. did HIV testing which turned out to be +ve.
Currently, under ART therapy under the NACO program, and cotrimoxazole
Pt. started smoking 5 yrs ago (3-4 bidis/day) due to peer pressure. Occasional alc. consumption started in the past 10 yrs. Would consume 200ml once in 2-3 months. Chewing tobacco for the past 10 yrs (10-12/day, 8-10 gms)
CURRENT CHIEF PROBLEMS AND PATIENT'S REQ.: Still experiencing frequent burps, but no more bloated feeling.
Generalized body weakness, wt. loss, no appetite, and irritability still persisting (easily loses temper).
FAMILY HISTORY: Pt. is unaware of any probable health issues of his parents.
Other family members are normal, and HIV -ve.
[3:28 pm, 19/04/2026] PPM 1: Please share the four hourly temperature recordings of your patient?
[3:32 pm, 19/04/2026] PA: Sir, amader kache to ai muhurte Thermometer nei, aktu pore dile dile ki kono asubidha hobe?
[3:44 pm, 19/04/2026] PPM 1: Thik achhe.
[3:50 pm, 19/04/2026] PA: Sir please, aktu amader bisoy ta dekhben, amra kichu bujhte parchina ki korbo.
[4:13 pm, 19/04/2026] PPM 1: Apatoto patient er roj kar ghontai ghontai ki korchen sheta janan ebong khawar thalar chobi share korun
Electronic Thermometer ta kine joto taratari sombhob char char ghontai janan
Parle ekta electronic BP ebong SpO2 dekhar jontro niyeo ekhane oguno mepe janate parle bhalo hoi
[4:28 pm, 19/04/2026] PA: Thik ache sir
11 pm Sir please এই টেবলেট খেলেই জরটা কমে অন্য ঔষুধ কোনো কিছু হয় না
9.11 pm 9.12 pm
[9:12 pm, 20/04/2026] PPM 1: Temperature guno kotar somoi newa hocche bojha jacche na
Protyek ta temperature kotai nicchen ektu janaben
[9:12 pm, 20/04/2026] PPM 1: P650 ta 6 hours baade baade try korechilen?
[9.43 am, 21/04/2026] PPM 1: 10 pm
8 am
[9:43 am, 21/04/2026] PPM 1: Fever reduced since 10 PM yesterday?
[1:08 pm, 21/04/2026] PPM 1: হ্যাঁ কমেছে কিন্তু রাত 3 টায় আবার খুব জ্বর এসছে, ঔষধ খাওয়ার পর এখোনো পর্যন্ত জ্বর নেই l
[1:08 pm, 21/04/2026] PPM 1: 12 PM
[1:08 pm, 21/04/2026] PPM 1: Ki oshudh? P650?
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