Case of a 31 years old man with epigastric pain and chronic diarrhoea.

September 12, 2022

Case of a 31 years old man with epigastric pain and chronic diarrhoea.

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This is the case of a 31 years old man, who is a tuition teacher by occupation and a resident of West Bengal.

CHIEF COMPLAINT

The patient has the chief complaint of-

Acidity from childhood.
Episodes of loose stools from 4 years.

HISTORY OF PRESENTING ILLNESS

The patient has had a history of frequent episodes of burning type of epigastric pain and dyspepsia from childhood .

4 years ago in 2019, the patient's problem of epigastric pain and dyspepsia aggravated. He had one episode every day. It was associated with belching and burning sensation of the throat which would be present in the morning and aggravated by stress and after eating chicken and egg. He would get relief after taking medication.

The patient also had frequent episodes of loose stools. He had 2-3 episodes a day, 2-3 times a week followed by a feeling of incomplete evacuation . The stools were not associated with blood or abdomen pain but were associated with mucus . These were also associated with weakness and dizziness. The loose stool aggravated by eating dairy foodstuff. The patient also complained of reduced appetite and loss of weight.

On going to the hospital he was diagnosed with Irritable bowel syndrome and GERD and was given medication and a diet chart , with the help of which his symptoms reduced . He also tried reducing his stress levels which also gave him releif. His appetite became normal and he started to put on weight again .His problem of dyspepsia , GERD and loose stools( one episode a week ) persisted , but their severity was reduced.

From 2021 , the patient has been experiencing increased weakness and dizziness after episodes of loose stools . He is also complaining of vertigo ( feeling of the room spinning ), tinnitus (ringing sound in the ear ) and a feeling of aural fullness while lying down .

The patient also complained of pain at the back of the neck .The pain was of dragging type ,which would aggravate after sitting down for too long or working on the black board for long or lifting heavy objects. It would reduce by physiotherapy and pain releif sprays.

On March 2022 , the patient started consuming homeopathic medicines , which gave him some releif.

After discontinuing the medication after few months and due to changes in his diet pattern, and increased levels of stress, his symptoms aggravated .

From the past one month he has been complaining of increased epiastric pain with burning sensation in the throat and belching. He has one episode every day. It is present in the morning and aggravates by stress and after eating chicken and egg. He would get relief after taking medication.

From the past one month , his he has had increased episodes of loose stools, 2-3 episodes a day, 2-3 times a week followed by a feeling of incomplete evacuation . The stools are not associated with blood or abdomen pain but are associated with mucus. He complains of increased weakness after every episode.

HISTORY OF PAST ILLNESS

The patient had an episode of jaundice when he was in 8th class.

Not a known case of DM,hypertension, asthma, TB, Thyroid condition, CVD, or Epilepsy.

FAMILY HISTORY

Father- Known case of DM and HTN

Mother- Known case of DM and HTN

PERSONAL HISTORY

DIET- Mixed diet

APPETITE- Normal

SLEEP- Adequate

BOWEL AND BLADDER MOVEMENTS - 2-3 episodes of loose stools per day, twice or thrice a week.

Normal micturition