A case discussion on an interesting case with atypical presentation

1. AnInterestingcase
ofdiarrhoea
Prof.Dr.MohammedRafiM.D
HODofGeneralMedicine
VII medical Unit
Dr.Ravi M.D

2. PatientDetails
• Name – Mr.Selvakumar
• Age -33
• Sex-male
• Address- Thoothukudi
• Occupation:Driver

3. Chief Complaints
C/o loose stools for 10days

4. Histroy of presenting illness
The patient was apparently normal before 10 days then he had
history of loose stools 4-6 episodes per day for 10 days which was
watery in consistency
• Not foul smelling
• Not blood tinged
• Associated with generalised abdominal pain,which was intermittent,non
radiating,pain not relieved after defecation ,no aggravating or relieving
factors

5. • History of nausea and vomiting:2-3episodes per day for 10 days, non-
projectile,not associated with pain, Not associated with blood
stained, Not associated with headache, contains partially digested
food particles.
• H/o coughX3days,which was insidious onset,progressive associated
with whitish sputum,mucoid in nature not foul smelling,not blood
stained.

6. • No H/o abdominal distension
• NoH/o swelling of both legs
• NoH/o difficulty in swallowing
• No H/o yellowish discoloration of skin
• No H/o fever
• No H/o weight loss
• No H/o altered sleep pattern

7. • No h/o hematemsis/ melena
• No h/o decreased urine output
• No h/o pruritis/ rash
• No h/o difficulty in breathing
• No H/o native drug intake
• No h/o recent travel
• No h/o tattooing

8. • No h/o altered level of consciousness
• No h/o chest pain/ palpitations/ syncope
• No h/o headache/ blurring of vision/ difficulty in moving limbs
• No h/o blood transfusion

9. • Notaknowncaseofdiabetesmellitus/hypertension/coronary
arterydisease
• Notaknowncaseoftuberculosis
• K/c/oseizuredisorder
• Historyofrecurrentrespiratorytractinfectionpresentinthepast
PersonalHistory
• Nonvegetariandietconsumer
• Normalbowelandbladderhabits
• Deniesadversesocialhabits
Past
History

10. • Conscious
• Oriented
• Afebrile
• Hydration fair
• No pallor, not icteric
• No cyanosis, no clubbing
• No lymphadenopathy
• No pedal edema
• No supraclavicular fullness
• No signs of liver cell failure
General Examination

11. Vitals
• BP – 100/60 mmHg ,measured in R upper limb
• PR- 92 / min, regular rhythm, normal volume, no radio- radial and radio
femoral delay, felt equally in peripheral vessels ,
vessel wall thickness-Normal
• Spo2- 98% in room air
• JVP- Not elevated

12. Systemic Examination -
Abdomen
Oral cavity- normal
Inspection
• Umbilicus- midline , slightly inverted, no discoloration or
nodules around the umbilicus
• Abdominal wall-All quadrants moves equally with respiration
• No abdominal distension/dilated veins / visible
pulsations/visible peristalsis
• No scars,sinuses
• No divarication of recti
• Hernial orifices – free
• External genitalia-normal

13. Measurement
• Abdominal girth- 59 cm
• Xiphisternum to umbilicus- 16cm
• Umbilicus to pubic symphysis- 15 cm

14. Palpation
Superficial palpation
• No warmth/tenderness
• No guarding or rigidity / abdominal wall
edema
Deep palpation
• No organomegaly
• No free fluid
• No inguinal lymph nodes palpable

15. Percussion
Liver span-12cm
• No free fluid
• Bowel sound present
• No bruit ,venous hum or friction rub
PR examination- normal
Examination of external genitalia-normal
Examination of supraclavicular fossa-normal
Auscultation

16. Other system examination
• CVS – S1S2 present, no murmur
• RS- Bilateral air entry present, vesicular sounds
heard,no added sounds
• CNS – conscious, no focal neurological deficit,

17. CBC 18/2 20/2 24/2 29/2 7/3
Tc 10800 15800 19800 16000 9000
HB 15.8 17 16.4 16 14
Plt 2.19 2.92 3.94 3.9 1.94
MCV 80 78.4 80 79 81
DC 75/15/9 66/17/11 82/10/8 76/10//2 71/13/5
Hct 50.8 56.4 52 51 43
Investigatio
n

18. RFT 20/2 21/2
RBS 60 100
Urea/ cret 16/0.8 13.8/0.6
Na/ K 138/3.7 136/3.7
LFT 18/2 20/2 22/2
Total
bilirubin
0.5 0.4 0.5
Indirect/
direct
bilirubin
0.3/0.2 0.2/0.2 0.2/0.3
OT/PT 62/56 18/34 19/35
ALP 91 76 78
Albumin 3.6 4.0 3.9
Total
protein
4.8 5.3 5.4
Globulin 1.2 1.3 1.5

19. • PT- 18.9
• aPTT- 33.5
• INR- 1.4
• ESR-5
• CRP-60
• TFT-normal
• CT abdomen-normal study

20. • HBsAg- neg
• Hcv – negative
• HIV- non reactive
• Peripheral smear- normochromic Normochromic with neutrophilia . No atypical
cells
• Stool for ova cyst-no ova,cyst
• Stool for occult blood -POSITIVE
• Stool for c&s- no growth
• Sputum c&s- Klebsiella oxytoca grown in culture,sensitive to Meropenam,
Piperacillin tazobactum,ciprofloxacin
• Blood c&s-no growth

21. Chest
Xray
ECG

22. OGD Scopy

23. HPE of OGD biopsy specimen
• Specimen type-multiple grey white soft tissue fragment
measuring0.25cc.Section studied shows-small intestinal
mucosa with polypoidal lesion lined by columnar
cells,numerous proliferating mucosal glands having bland
Normochromatic nuclei infiltrated with dense chronic
inflammatory infiltrates and congested blood vessels.
• No definitive evidence of dysplasia / micro organisms.

24. OGD scopy Report:
• Multiple polyposis noted in entire small
intestine
• Esophageal candidiasis
• Colonoscopy Study-Normal

25. CASEISOPEN
FOR
DISCUSSION