35 yr old male with fever and dysentery

July 24, 2022

NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.

PATIENT HISTORY: Pt is a 35 yr old male, a barber by profession. When he was in class 4, he had one episode of diarrhea. Used to vomit(watery, 2-3/day), black watery stool (15 -20 times/day), lower abdomen pain, and generalized body weakness. He was admitted to the hospital for 15 days and recovered with medicine.

In class 9-10 i.e 5 yrs later, he started suffering from dysentery. Each time he had to rush to the toilet with lower abd. pain just before fecal urgency. Abd. pain used to go away after defaecation. The stool was of loose consistency, with mucus and white specks, frequency - 10-12/day, and would be of little quantity each time, He started noticing undigested food. particles coming out with stool. He would be fine for 10-20 days, then again dysentery. No treatment was done.

2 yrs later, his previous symptoms changed - no abd. pain, the stool was of loose consistency, with mucus and white specks, frequency reduced to 7-8/day.

For the past 10 yrs, gastric problems (frequent burps after a meal with an after taste of the food eaten especially chicken, bloating). Burning senation in epigastrium after a meal.

NOTE: Bloatedness resolved with medication from Hyd.

In 2021, went to Dr. with c/o diffused abd. pain, loose stool 7-8/day, who prescribed medication after USG and blood test. Symptoms would resolve temporarily with medication, but if stopped will reoccur within 10-12 days. After 3 months, went to another Dr. who prescribed diff. medications but the result was still the same, with no complete recovery.

So, he did Ayurvedic treatment. Had medicine for 1 month. Became completely normal for 7-8 months.

For the past 6 months started suffering from constipation. For 2-3 days won't pass stool at all. Then on the 4th day would pass hard stool (3-4 times). The first time passing stool was very difficult and painful. Had resolved with Duphalac.

5 months ago, because of an oral ulcer, decreased appetite and wt. loss went to a Dr. who prescribed medications. Mouth ulcer resolved

For the past 4 months 2-3 popular itchy rash on legs and hands.

For the past 3 months i.e 1 wk prior to coming to Hyd, 1 episode of fever at night, went down with paracetamol within 2 days. Again another episode of night fever. He started feeling generalized body weakness, agitated, hot-tempered, no appetite, severe wt loss ( from 65 kg to 45kg within 2 months), and deep sleep for only 2-3 hrs at night. Coughing with blood-stained sputum. Chest pain while coughing.

Went to Hyd. for consultation. chest Xray, colonoscopy was done. Internal hemorrhoids were detected. Also, recommended doing an HIV test.

After returning from Hyd. did HIV testing which turned out to be +ve.

Currently, under ART therapy under the NACO program, and cotrimoxazole

Pt. started smoking 5 yrs ago (3-4 bidis/day) due to peer pressure. Occasional alc. consumption started in the past 10 yrs. Would consume 200ml once in 2-3 months. Chewing tobacco for the past 10 yrs (10-12/day, 8-10 gms)

CURRENT CHIEF PROBLEMS AND PATIENT'S REQ.: Still experiencing frequent burps, but no more bloated feeling.

Generalized body weakness, wt loss, no appetite, and irritability still persisting (easily loses temper).

FAMILY HISTORY: Pt. is unaware of any probable health issues of his parents.

Other family members are normal, and HIV -ve.