Pain abdomen and loose stools since 12 years

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.


33 year female patient a attender in school came with the chief complaint of pain in abdomen and loose stools on and off since 12 years.

Patient was apparently asymptomatic 12 years back, then 7 months after her 2nd LSCS she developed abdominal discomfort, pain and blood in stools over 2 months period. 
She developed pain in abdomen, insidious onset, gradually progressive, colicky type, radiating to right loin and right hypochondrium.
She complaints of loose stools- soft, associated with blood and mucus, 10-15 episodes for 6 months back in 2008. 
She went around many hospitals over the next 1 year and finally was diagnosed with ulcerative colitis( biopsy proven). Her symptoms relieved after 45 days of treatment with MESALAZINE 800mg and METHYLPREDNISOLONE 16mg. She continued them for 5 years and no symptoms during this time. Later she stopped this medication and was symptom free for 6-8 months. Then in the last 7 years she had similar complaints on and off ( 5-6 to 10-15 episodes per day of loose stools with blood) associated with some food types( spices, chicken etc). She used the medication until the symptoms resolved and stopped it each time due to financial issues.
After abruptly stopping medications for 2 months even with symptoms, there is an increase in severity of complaints from last 3 months, but due the lockdown she wasn't able to consult a doctor. 
She consulted the OBG department on 29th September 2020 and on 3rd October to our OPD.
On admission detailed day-wise history  was taken.
Day 1 she had 8 episodes of loose stools with blood and associated with generalized weakeness and bilateral lower limb pain and heaviness.
Day 2 and 3 she had 6 episodes of loose stools and body pains were present
The following day she had only 2 episodes and she felt improvement in her symptoms.
Colonoscopy was done and her medications were changed.
Day 5 there was no episode of loose stools( until afternoon) and patient felt relatively better and she was discharged and adviced to come back after a week if no further improvement otherwise after a month for review.

No joint pains and tenderness
No H/O fever, vomitings
Shortness of breath grade 2-3 from last 2-3 years
No H/O chest pain, palpitations, orthopnea, PND

Past medical and surgical history
Patient is a hypertensive since 4 years, on regular medication TELMA 40mg OD
No H/O DM, TB, asthma, epilepsy, thyroid, CAD
Two LSCS 13 and 14 years ago
Tubectomised 13 years ago

Personal history
Mixed diet, normal appetite, adequate sleep, no addictions, regular bladder habits
Irregular bowel habits
The patient has gained 3-4kg/year over the past 12 years

General examination
Patient is consicous coherent cooperative
Pallor +ve
No icterus clubbing cyanosis lymphadenopathy and odema

Vitals: Temp- Afebrile  GRBS- 157mh/dl
            BP- 130/90mm Hg supine right arm                          PR- 92bpm regular rate rhythm volume

Systemic examination
CVS- S1 S2 heard, no murmurs
RS- BAE+, NBVS, No added sounds heard
CNS- GCS 15/15, NFND
P/A
INSPECTION: 
Shape- globular
Umbilicus- shape inverted, No herniation, no discharge
 Movements with respiration Normal
Skin over abdomen: smooth, no pigmentation
Vertical scar- LSCS done 
No engorged veins, visible pulsations
PALPATION:
Inspectory findings confirmed
Abdomen is soft
Tenderness in right illiac and hypogastrium
No organomegaly
No palpable masses: 
Auscultation- Bowel Sounds heard

Investigations
2008 
Day 1 3rd October 2020

Day 2 4th October 2020

Day 3 5th October 2020



Day 4 6th October 2020
Day 5 7th October 2020

Diagnosis- Severe ulcerative colitis

Treatment
TAB MESACOL 1.2g TID
TAB PANTOPRAZOLE 40mg OD
ANOBLIS cream for local application twice daily
TAB ZENFLOX OZ BD after food
SPOROLAC OS TID
TAB MVT OD
CAP REDOTRIL PO 100mg BD

After colonoscopy, gastroenterologist had adviced these medications
TAB OMNACORTIL 40mg PO 1 week 9am followed by tab OMNACORT PO 30mg 2weeks 9am followed by TAB OMNACORTIL 20mg 1 week 9am
MESACOL ENEMA 1.2g PO TID
CAP SPOROLAC DS PO BD 
CAP REDOTRIL PO 100 mg BD
TAB PANTOPRAZOLE 40mg PO OD
TAB MVT OD 



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