Case presentation 9

 11.11.21

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 problem through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence based input.

This e blog also reflects my patients centered online learning portfolio and your valuable inputs on the comment box is welcome.

Chief complaint:

A 70 year old male presented to OPD with c/o constipation since 20 days (on and off).he was nott passing stools and Flatus since 5 days 

Shortness of breath since 5 days.


History of present illness:

Patient was apparently asymptomatic 2 years back and then he developed pain in abdomen in epigastric region localized.

Since 1 year patient complains that he used to wake up in the middle of night and felt breathless for a while. Since 20 days patient complains of generalised weakness with loss of appetite and has constipation with small quantity of hard stools. Since 5 days patient complains he didn't pass stools and flatus which makes him discomfort associated with pain abdomen and developed shortness of breath.

Personal history:

Patient takes mixed diet and lost his appetite since 20 days and disturbed sleep because of pain in the epigastric region.

History of Smoking (Sutta) and BD since 50 years. chronic alcoholic drinks 90ml whiskey daily.

General examination:

Patient is conscious, coherent, cooperative.

No pallor, icterus, clubbing, lymphadenopathy, edema

Vitals: 

Temp: afebrile

Pr: 90 bpm

Rr: 20 cpm

Bp: 130/80 mm hg

Spo2: 98%

Grbs- 132 mg/dl

Systematic examination:

CVS: S1 and S2 heard

RS: BAE + 

P/A: soft , tender.

CNS: NAD

Diagnosis:

Constipation Uremic gastroparesis with RCA territory Akinesia

General examination:

Patient consious, coherent, cooperative.

No pallor, icterus, clubbing, lymphadenopathy, edema

Vitals: 

Temp: afebrile

Pr: 85 beats per minute

Rr: 20 cpm

Bp: 110/70

SPO2: 98%

Systematic examination:

CVS: S1 and S2 heard

RS: BAE + 

P/A: soft , non tender.

CNS: NAD

Investigations:














Diagnosis:

Constipation with gastroparesis and akinesia.

Treatment :

1. Ivf NS/RL/DNS continuous at 100ml/hr
2. Inj. PAN 40mg IV BD 
3. inj. ZOFER 4mg IV/SOS
4. Syp. LACTULOSE 20 ml PO/BD
5. Tab.ECOSPORIN 75 mg PO/OD
6. Tab.CLOPITAB 75 mg PO/OD
7. Tab. ATROVAS 10 mg PO/OD
8. Proctoclysis enema twice daily
9. BP/PR/TEMP monitoring 4th hourly.

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