36 Year Old Male with Osmotic Diarrhoea

This is an 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.


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.

36year old male patient presented to casuality with the cheif complaint of loose stools 

History of present illness : patient was apperantly asymptomatic 1year ago and experienced blurred vision due to his profession he had to visit LV Prasad hospital patient was suggested to undergo diagnostic investigations for eye and blood and he was given a diagnosis of having diabetes and white lesions in eye 

PAST HISTORY : no history of hypertension 

No history of epilepsy 

Known case of diabetes since one year 

PERSONAL HISTORY: adequate amount of sleep 

Normal micturation having Diarrhoea of 3,4times after meal 

Diet mixed 

Appatite normal 

Occasional consumption of alcohol 

FAMILY HISTORY : no similar familial resemblance 

TREATMENT HISTORY: not allergie to any known drugs 

GENERAL EXAMINATION: on general examination patient was coherent ,conscious,cooperative well oriented to time and place 

CVS: S1 and S2 are heard 

CNS: no known nervous abnormality 

No palpabile mass in abdomen no tenderness no distended abdomen 

No clubbing ,no cyanosis ,No lymphadenopathy,No ictreus 

LOCAL EXAMINATION: 

Temperature :afebrile 

Respiratory rate :16 

Bp :120/80

Pulse rate :80

Provisional diagnosis:

Chronic pancreatitis,diabetic autonomic neuropathy,
 osmotic diarrhoea 
Investigations

Complete blood picture:

















Treatment:

1.IVF -NS RL @75ml/hr
2.Inj.OPTINEURON 1amp in 100ml NS/IV/OF
3.Tab. PAN 40mg/PO/OD
4.Inj. H.mixtard s/c b
5.Tab. VILDAGLIPTIN 50mg/PO/OD
6.Tab. REDOTIL 100mg/PO/OD
7.Monitor vitals 4th hourly
8.Tab.SPOROLAC -DS /TID
9.Tab.Loperamide 2mg/PO/BD
10.ORS sachets 1sachet in 1L water; 200ml after each stool passed.

Comments

  1. Hari ChandranFebruary 24, 2022 at 3:57 AM

    This post is informative, about the Osmotic Diarrhoea. Thanks for the share!

    Get in touch with the Top Hospitals In Coimbatore

    ReplyDelete

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