An interesting case of diarrhoea

1. AN
INTERESTING
CASE OF
DIARRHOEA
First Medical Unit
HOD & Chief: Prof. Dr. L. Rajagopala Marthandam MD.

2. CHIEF COMPLAINTS
• A 46-year-old female patient named Lakshmi presented to the Emergency department with
complaints of
• Loose stools for 2 days
• Drooping of eyelids for 1 day

3. HISTORY OF PRESENT ILLNESS
• The patient was apparently asymptomatic 5 days back, then she developed loose stools x 2 days
• 3-4 episodes per day
• small amount
• watery in consistency
• Not containing blood or mucus or fat
• Not associated with abdominal pain or fever or vomiting
• Resolved after taking over the counter medication
• Following diarrhea patient developed constipation which lasted for 3 days

4. • After 3 days of loose stool she noticed drooping of left eyelid while seeing herself in the mirror
which was insidious onset, progressed to involve right eyelid after 1 day, in a manner such that
patient noticed drooping is worsening on frequent movement of eyes not associated with double
vision.
• H/o difficulty in raising the left arm above shoulder for 1 day
• H/o difficulty in reaching for the objects placed overhead
• No h/o difficulty in mixing the food
• No h/o difficulty in holding the glass
• No h/o difficulty in using the hands for toilet purposes
• No h/o difficulty in buttoning and unbuttoning the blouse
• No h/o difficulty in getting up from squatting position
• No h/o difficulty in raising from the chair

5. • No h/o difficulty in wearing slippers.
• No h/o slippage of slippers while walking.
• No h/o rolling over side to side on bed
• No h/o difficulty in raising the head from pillow
• No h/o suggestive of radicular or funicular pain
• No h/o pins and needle sensation or numbness
• No h/o cotton wool sensation
• No h/o difficulty in perceiving the sensation of clothes over the body
• No h/o difficulty in perceiving the hot and cold sensations while bathing
• No h/o difficulty in recognizing the mosquito bite

6. No h/o unsteadiness while walking in the dark
No h/o tight band-like sensation over the body
No h/o electric shock like sensation while bending the neck
No h/o altered sensorium/ involuntary movements/ blurring of vision
No h/o behavioural or emotional disturbances
No h/o sleep disturbances
No h/o hallucinations/ illusions/ delusions
No h/o difficulty in perceiving smell
No h/o diminution of vision
No h/o double vision
No h/o difficulty in colour vision

7. No h/o difficulty in moving the eyeballs in all directions
No h/o difficulty in chewing
Able to perceive the sensations over the face
No h/o taste disturbances
No h/o deviation of angle of mouth
No h/o drooling of saliva
No h/o stasis of food in the mouth
No h/o difficulty in wrinkling the forehead
No h/o hearing difficulty/ ringing sensation in the ears/ unsteadiness
No h/o nasal regurgitation of food
No h/o nasal twang in voice
No h/o hoarseness of voice

8. No h/o difficulty in swallowing
No h/o difficulty in turning the head from side to side
No h/o difficulty in shrugging the shoulders
No h/o unsteadiness while standing or walking
No h/o tremulousness while reaching for objects
No h/o difficulty in walking through a narrow path
No h/o spillage of food while eating
No h/o involuntary movements
No h/o speech disturbances
No h/o giddiness on standing suddenly from lying or stting position
No h/o excessive sweating

9. No h/o bladder disturbance
No h/o headache/ neck stiffness/ fever
No h/o ear discharge
No h/o head injury
No h/o chest pain/ breathlessness
No h/o animal bite
No h/o recent vaccination

10. PAST HISTORY
• No similar complaints in the past
• H/o cough with expectoration for 10 months which was evaluated and diagnosed as bronchial
asthma 6 months back and she is on medication.
• Not a known case of Type 2 Diabetes Mellitus/ Systemic hypertension/ Tuberculosis/ Epilepsy/
coronary artery disease/ chronic kidney disease/ chronic liver disease/ syphilis/ malignancy

11. TREATMENT HISTORY
• H/o siddha treatment 8 months back for cough and expectoration

12. PERSONAL HISTORY
• Patient consumes both vegetarian and non-vegetarian diet
• No h/o sleep disturbances
• No addictive habits

13. MENSTRUAL HISTORY
• LMP- 02/03/23
• Regular 3/30 day cycles with normal flow

14. FAMILY HISTORY
• No similar complaints in family members

15. ON EXAMINATION
VITALS
• Pulse- 98/ minute, regular rhythm, normal volume, normal character, no radio-radial or radio-
femoral delay, no vessel wall thickening
• Blood pressure- 120/70 mm Hg measured in right upper arm in sitting position
• SpO2 - 98% @ room air
• Respiratory rate - 17/min, thoracoabdominal type

16. GENERAL EXAMINATION
• Patient is conscious, oriented, comfortable at rest
• No pallor/ icterus/ cyanosis/ clubbing/ generalised lymphadenopathy/ pedal edema
• No neurocutaneous markers
• No markers of TB, Syphilis, HIV
• No markers of atherosclerosis
• No peripheral nerve thickening

17. CNS EXAMINATION
HIGHER MENTAL FUNCTIONS
Patient is right handed
Consciousness normal
Oriented to time, place and person
Immediate, recent, and remote memory intact
Speech and language - Fluency
Comprehension
Naming
Reading
Writing
Repitition
Calculation
No hallucinations/ illusions/ delusion

18. Cranial nerve Right Left
1 Olfactory Smell Normal Normal
2 Optic Visual acuity
Field of vision
Colour vision
Fundus
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
3,4,6 Oculomotor,
Trochlear,
Abducens
Palpebral fissure
Extraocular movements
Pupil size
Direct and indirect light
reflexes
Accommodation reflex
6 mm (decreased)
Restricted elevation,
depression, abduction
and adduction of both
eyes
3 mm
Reacting to light
Normal
7 mm (decreased)
Restricted elevation,
depression,
abduction,
adduction of both
eyes
3mm
Reacting to light
Normal
5 Trigeminal Sensations over face
Clenching of teeth
Corneal reflex
Conjunctival reflex
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal

19. Cranial nerve Right Left
7 Facial Wrinkling of forehead
Tight closure of
eyelid
Blowing of cheeks
Nasolabial fold
Taste in anterior
2/3rd of tongue
Normal
Normal
Unable to do
Normal
Normal
Normal
Normal
Unable to do
Normal
Normal
8 Vestibulocochlear Rinne’s test
Weber’s test
AC > BC
Not lateralised
AC > BC
9,10 Glossopharyngeal,
Vagus
Uvula
Ah test
Palatal reflex
Pharyngeal reflex
Midline
Normal palatal
elevation
Normal
Normal
Normal palatal
elevation
Normal
Normal

20. Cranial nerve Right Left
11 Accessory Shrugging of
shoulders
Turning of head
Normal
Normal
Normal
Normal
12 Hypoglossal Tongue protrusion
Movement against
cheek
Fasciculation
Normal
Normal
No
Normal
Normal
No

21. MOTOR SYSTEM
BULK Right Left
Upper arm 26 26
Fore arm 23 23
Thigh 40 40
Leg 30 30

22. TONE Right Left
Upper limb Normal Normal
Lower limb Normal Normal

23. POWER Right Left
Shoulder joint Flexion
Extension
Abduction
Adduction
Medial rotation
Lateral rotation
5
5
5
5
5
5
2
3
2
3
3
3
Elbow joint Flexion
Extension
5
5
2
3
Wrist Palmar flexion
Dorsiflexion
5
5
5
5
Fingers Flexion
Extension
Abduction
Adduction
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Handgrip 100% 100%

24. POWER Right Left
Hip joint Flexion
Extension
Abduction
Adduction
Medial rotation
Lateral rotation
5
5
5
5
5
5
5
5
5
5
5
5
Knee joint Flexion
Extension
5
5
5
5
Ankle joint Dorsiflexion
Plantar flexion
5
5
5
5
Toes Flexion
Extension
Abduction
Adduction
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal

25. SUPERFICIAL REFLEXES RIGHT LEFT
Corneal Present Present
Conjunctival Present Present
Palatal Present Present
Pharyngeal Present Present
Abdominal Normal in all quadrants
Plantar Flexor Flexor

26. DEEP TENDON REFLEXES RIGHT LEFT
Biceps ++ +
Triceps ++ +
Supinator ++ ++
Knee ++ ++
Ankle ++ ++

27. CO-ORDINATION
RIGHT LEFT
Upper limb Finger nose test Normal Normal
Finger finger test Normal Normal
Drawing circle in air Normal Normal
Dysdiadochokinesia Absent Absent
Lower limb Knee heel test Normal Normal
Drawing circle in air Normal Normal

28. SENSORY SYSTEM
RIGHT LEFT
Fine touch Normal Normal
Crude touch Normal Normal
Pressure Normal Normal
Superficial pain Normal Normal
Deep pain Normal Normal
Vibration Normal Normal
Proprioception Normal Normal

29. CORTICAL SENSATIONS RIGHT LEFT
Tactile localisation Normal Normal
Tactile discrimination Normal Normal
Stereognosis Normal Normal
Graphaesthesia Normal Normal

30. • Romberg’s test - Negative
• Gait - Normal
• No signs of meningeal irritation
• Skull and spine normal

32. OTHER SYSTEMS
• CVS- S1, S2 present, no murmurs
• RS- Normal vesicular breath sounds heard, no added sounds
• Abdomen- soft, scaphoid, no tenderness, no organomegaly, sluggish bowel sounds

33. CBC
06/03 10/03 15/03 16/03 17/03
WBC 12,700 13,800 11,500 13,700 14,300
DC 83/9/8 72/22/6 70/20/10 85/10/6 80/15 /5
RBC 4.78 4.52 4.56 4.8 4.18
HB 10.1 9.9 9.4 10.0 9.8
HCT 34.3 33.1 31.6 33.3 29.2
MCV 71.8 73.2 68.6 68.2 69.8
PLATELETS 2.95 3.44 1.69 3.93 3.02

34. RFT
06/03/23 08/03/23 09/03/23 10/03/23 16/03/23 17/03/23
RBS 105.1 101 110 93.6 88 95
SODIUM 137 136 138 138 138 141
POTASSIUM 3.6 2.8 3.4 3.8 3.98 4.0
UREA 27.1 30 26 48.4 40 37
CREATININE 1.13 1.10 0.8 0.85 0.9 1.15

35. LFT
06/03/23 17/03/23
TOTAL BILIRUBIN 0.9 0.85
DIRECT BILIRUBIN 0.3 0.55
INDIRECT BILIRUBIN 0.6 0.3
SGOT 43 29
SGPT 18 19
ALP 89 56
TOTAL PROTEIN 7.0 6.73
ALBUMIN 4.0 3.47
GLOBULIN 3.0 3.3

36. THYROID FUNCTION TEST
TSH 0.622
FT3 2.08
FT4 1.53
USG ABDOMEN
1. 06/03/2023 – Distended bowel loops - ?Paralytic ileus
2. 15/03/2023 - Normal Study

37. ECG

38. CHEST X-RAY

39. CT ABDOMEN

40. ALL THE RELEVANT OPINIONS OBTAINED

41. THANK YOU