CHRONIC DIARRHEA IN A 36 YR OLD DIABETIC PATIENT

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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.

CASE OF CHRONIC DIARRHEA IN DIABETIC PATIENT. 

A 36-year-old male patient, weaver by  occupation, came to OPD with cheif complaints of loose stools and  is associated with generalised weakness since 4 to 5 months. 

History of presenting illness

Patient was apparently normal 5-months ago, then he developed loose stools following every meal ,8-10 episodes per day, watery in consistency, small in volume, non blood stained, foul smelling. 

No symptoms of fever, abdominal pain or distension. 

Past History 

 Patient developed diminision of vision in both eyes 1yr back,  then consulted ophthalmology department , where he was diagnosed with b/l cataract (pre-senile cataract?). During the investigations done for proceeding to his surgery, his blood glucose levels were found yo be highly elevated. FBS around 480mg/dl , Postprandial around 490mg/dl. Then he was started on oral hypoglycemic agents. 

After about a month of strict sugar control he was shifted to injection human mixtard and left eye cataract surgery was done. 

        *He also had complains of severe pricking sensation (pins and needles) in the lower limbs, for which he consulted neurologist. 

        *Known case of diabetes since 1yr and on treatment. 

        *Not a known case of HTN, COPD, epilepsy, TB, CAD. 

Personal history:

* Appetite: Normal

* Diet:  Mixed

* Sleep : Adequate 

* Bowel and Bladder movements: Regular

* Additions: Absent

Treatment history:

  *Inj. Human Mixtard

General examination:

Patient is conscious coherent and cooperative.

He is well oriented to time, place and person.

He is moderately built and under nourished.

Weight: 46 kg

Vitals:

Temperature: Afebrile 

Pulse Rate: 80 beats per minute 

Blood pressure: 130/80 mm of Hg(supine) 

                              100/75 mm of Hg(standing). 

Respiratory Rate: 18 cycles per minute 

Pallor : present (mild) 

pallor - nail bed

No Icterus

No Cyanosis

No Clubbing

No Lymphadenopathy

No Edema 

Sunken eyes +

Skin turgor: Decreased

Systemic Examination:

CVS - S1, S2 heard 

           no murmurs 

RS - BAE + , 

        Vesicular breath sounds heard 

         No added sounds 

P/A : Soft , Non tender, no evidence of                     organomegaly. 

CNS : No Focal neurological deficits. 

Investigations:

CBP

FBS

Post lunch blood sugar

Radiological report 

Stool examination

Provisional diagnosis:

* Chronic diarrhea -gastroenteritis under evaluation

Secondary to ?

 -Uncontrolled sugars ? 

 -Diabetic autonomic neuropathy? 

Current Treatment plan:

*IVF -NS RL @75ml/hr

*Inj.OPTINEURON 1amp in 100ml NS/IV/OF

*Tab. PAN 40mg/PO/OD

*Inj. Human mixtard s/c b

*Tab. VILDAGLIPTIN 50mg/PO/OD

*Tab. REDOTIL 100mg/PO/OD

*Monitor vitals 4th hourly