Patient is having stomach ache from 5-7 days, and loose bowel, UTZ seems to be normal, what could be the possible reasons ?
ls /tmp/skills/pdf/ 2>/dev/null && echo "---" && ls "/tmp/workspace/attachments/73076211-eff7-4d1e-8aa4-fcf019e91a91/"
python3 -c " import pdfplumber with pdfplumber.open('/tmp/workspace/attachments/73076211-eff7-4d1e-8aa4-fcf019e91a91/DocScanner 21-Jul-2026 12-27 PM.pdf') as pdf: for i, page in enumerate(pdf.pages): text = page.extract_text() if text: print(f'=== PAGE {i+1} ===') print(text) tables = page.extract_tables() for t in tables: print(f'--- TABLE ---') for row in t: print(row) "
python3 -c " import pypdf, pdfplumber # Try pdfplumber with better settings with pdfplumber.open('/tmp/workspace/attachments/73076211-eff7-4d1e-8aa4-fcf019e91a91/DocScanner 21-Jul-2026 12-27 PM.pdf') as pdf: print(f'Pages: {len(pdf.pages)}') for i, page in enumerate(pdf.pages): print(f'=== PAGE {i+1} dimensions: {page.width}x{page.height} ===') # Try different text extraction methods text = page.extract_text(x_tolerance=3, y_tolerance=3) print(repr(text[:500]) if text else 'NO TEXT EXTRACTED') # Check for images imgs = page.images print(f'Images on page: {len(imgs)}') "
python3 -c " from pypdf import PdfReader import base64, json reader = PdfReader('/tmp/workspace/attachments/73076211-eff7-4d1e-8aa4-fcf019e91a91/DocScanner 21-Jul-2026 12-27 PM.pdf') page = reader.pages[0] # Get the embedded image xobjects = page['/Resources']['/XObject'] print('XObjects:', list(xobjects.keys())) for name, obj in xobjects.items(): o = obj.get_object() print(f'{name}: subtype={o.get(\"/Subtype\")}, filter={o.get(\"/Filter\")}, w={o.get(\"/Width\")}, h={o.get(\"/Height\")}') data = o.data print(f' data size: {len(data)} bytes') # Save it filt = o.get('/Filter') if '/DCTDecode' in str(filt): ext = 'jpg' elif '/FlateDecode' in str(filt): ext = 'png' else: ext = 'bin' outpath = f'/tmp/workspace/page_image.{ext}' with open(outpath, 'wb') as f: f.write(data) print(f' Saved to {outpath}') "
python3 -c " from pypdf import PdfReader reader = PdfReader('/tmp/workspace/attachments/73076211-eff7-4d1e-8aa4-fcf019e91a91/DocScanner 21-Jul-2026 12-27 PM.pdf') page = reader.pages[0] xobjects = page['/Resources']['/XObject'] for name, obj in xobjects.items(): o = obj.get_object() data = o._data outpath = '/tmp/workspace/page_image.jpg' with open(outpath, 'wb') as f: f.write(data) print(f'Saved {len(data)} bytes to {outpath}') "
python3 -c " # Try to serve the image locally - actually let's just convert it to base64 for display import base64 with open('/tmp/workspace/page_image.jpg', 'rb') as f: data = f.read() print(f'Image size: {len(data)} bytes, is JPEG: {data[:2] == bytes([0xFF, 0xD8])}') # Save as accessible path import shutil shutil.copy('/tmp/workspace/page_image.jpg', '/tmp/workspace/attachments/lab_report.jpg') print('Copied to /tmp/workspace/attachments/lab_report.jpg') "
Stomach Ache + Loose Bowel (5-7 days) with Normal Ultrasound - Differential Diagnosis
Why a Normal Ultrasound Narrows It Down
Most Likely Causes
1. Infectious Gastroenteritis (Most Common)
| Category | Common Pathogens |
|---|---|
| Viral | Norovirus, Rotavirus - watery, non-bloody, self-limited |
| Bacterial (toxin-mediated) | E. coli (ETEC/EAEC), Salmonella, Campylobacter, Staphylococcus aureus |
| Bacterial (invasive) | Shigella, Campylobacter jejuni, Yersinia enterocolitica - may cause bloody stool + high fever |
| Parasitic | Giardia lamblia, Entamoeba histolytica, Cryptosporidium - especially if symptoms >5 days |
- Watery, no fever = toxin producer (B. cereus, S. aureus, V. cholerae, ETEC)
- Watery + cramps + low-grade fever = enteroadherent (Giardia, cryptosporidiosis, EPEC)
- Bloody + high fever = invasive organisms (Shigella, Salmonella, Campylobacter)
2. Irritable Bowel Syndrome (IBS) - Diarrhea Predominant
3. Food Intolerance / Dietary Causes
- Lactose intolerance - crampy pain + loose stool after dairy
- Fructose malabsorption
- New food introduction or dietary change
- Onset linked to a specific food exposure
4. Food Poisoning (Subacute)
- Bacillus cereus, Clostridium perfringens, Staphylococcus aureus toxins
- Usually self-limiting in 24-48 hrs, but bacterial persistence can prolong symptoms
5. C. difficile Colitis
6. Functional Dyspepsia
7. Less Common but "Must Not Miss"
- Inflammatory Bowel Disease (IBD - Crohn's or UC): New onset, especially with blood in stool, weight loss, elevated CRP/ESR - UTZ may be normal early on
- Celiac Disease: Chronic loose stool, bloating, triggered by gluten - normal UTZ
- Colorectal malignancy: Older patient + change in bowel habits + partial obstruction (can present with loose stool around a mass) - Yamada's Gastroenterology
Suggested Workup (if not already done)
| Test | Purpose |
|---|---|
| CBC with differential | Leukocytosis (infection/IBD), eosinophilia (parasites) |
| CRP / ESR | Elevated in IBD, invasive bacterial infection |
| Stool microscopy + culture | Identify bacteria, ova, parasites (Giardia, Entamoeba) |
| Stool for C. difficile toxin | If recent antibiotics |
| Stool occult blood | Rule out invasive/mucosal pathology |
| H. pylori testing | If upper GI symptoms predominate |
| Serum electrolytes + renal function | Assess dehydration |
| Thyroid function (TSH) | Hyperthyroidism can cause chronic loose stool |
Red Flag Symptoms Requiring Urgent Attention
- Blood in stool
- High fever (>38.5°C)
- Signs of dehydration (sunken eyes, dry mouth, reduced urine output)
- Significant weight loss
- Nocturnal diarrhea (waking the patient from sleep)
- Age >50 with new-onset change in bowel habits
That's the lab report of the above case
CBC Analysis - Mr. Yatin Godara (Age 16, Male) | 21/07/2026
Lab Values at a Glance
| Test | Patient Value | Normal Range | Status |
|---|---|---|---|
| TLC (WBC) | 3,700 /cmm | 4,500-10,000 | 🔴 LOW |
| Neutrophils | 60% | 40-75% | ✅ Normal |
| Lymphocytes | 32% | 20-50% | ✅ Normal |
| Monocytes | 6% | 2-10% | ✅ Normal |
| Eosinophils | 2% | 1-6% | ✅ Normal |
| Peripheral Smear | Normocytic-Normochromic, Leukocytopenia | - | ⚠️ |
| Haemoglobin | 13.7 g/dL | 13.5-18.5 | ✅ Normal |
| HCT | 35.7% | 34-53% | ✅ Normal (borderline low) |
| RBC | 4.31 mill/cmm | 3.5-5.6 | ✅ Normal |
| Platelets | 1.56 Lac/cmm (156,000) | 1.5-4.5 Lac | ✅ Normal (lower end) |
| MCV | 82.8 fL | 80-94 | ✅ Normal |
| MCH | 31.8 pg | 26-32 | ✅ Normal |
| Malaria Parasite | Negative | - | ✅ |
The Critical Finding: Leukocytopenia (Low WBC = 3,700)
Top Differential Diagnoses (Lab-Integrated)
🥇 1. Typhoid Fever (Enteric Fever) - Highest Suspicion
- Leukopenia is a hallmark of typhoid - "patients may develop leukopenia and elevated liver enzymes" - Tintinalli's Emergency Medicine
- Age 16, likely from India (Hisar, Haryana) where typhoid is endemic due to poor sanitation and contaminated water
- Duration of 5-7 days fits the classic 1-3 week incubation
- Abdominal pain + loose stool are typical - typhoid classically presents with fever, headache, abdominal distention; in epidemic presentations, acute diarrhea is common
- UTZ being normal is consistent - structural changes (hepatosplenomegaly) appear later in the course
- Malaria has been ruled out (MP negative), and typhoid is the next most common cause of prolonged febrile illness once malaria is excluded
🥈 2. Viral Gastroenteritis (e.g., Norovirus, Rotavirus)
- Viruses commonly cause leukopenia (lymphocyte depression or neutropenia)
- Non-bloody watery loose stool is the pattern
- Normal Hb and platelets fit
- However, most viral gastroenteritis resolves in 2-4 days - duration of 5-7 days argues somewhat against a simple viral cause
🥉 3. Dengue Fever (Must Not Miss)
- Leukopenia + diarrhea + abdominal pain is a classic dengue triad
- "Laboratory abnormalities include leukopenia, thrombocytopenia, and hepatic dysfunction" - Tintinalli's Emergency Medicine
- His platelets are at the very lower end of normal (1.56 Lac) - borderline, and dengue can cause early platelet dip before frank thrombocytopenia
- Season (July = monsoon in India) - dengue is highly seasonal during monsoon in North India
- This must not be missed - can rapidly progress to dengue hemorrhagic fever
4. Other Viral Infections (EBV, CMV)
- Both cause leukopenia (or atypical lymphocytosis)
- Can cause GI symptoms including diarrhea and abdominal discomfort
- Less likely without pharyngitis, lymphadenopathy, or fatigue
5. Salmonellosis (Non-typhoidal)
- Can also cause mild leukopenia
- Diarrhea + crampy abdominal pain is the classic presentation
- Usually self-limited in 4-7 days in immunocompetent hosts
What the CBC Rules Out
| Condition | Why Excluded |
|---|---|
| Bacterial sepsis / severe bacterial infection | These typically cause leukocytosis (high WBC), not leukopenia |
| Parasitic GI infection (Giardia, Amoebiasis) | Usually eosinophilia (not leukopenia); eosinophils here are normal |
| Malaria | MP test is negative |
| Anemia-related causes | Hb and RBC are completely normal |
| IBD flare | Usually leukocytosis with raised inflammatory markers |
Recommended Next Tests (Urgently)
| Test | Reason |
|---|---|
| Widal Test / Blood culture (Salmonella typhi) | Confirm/rule out typhoid - most important next step |
| NS1 Antigen + Dengue IgM/IgG | Rule out dengue (monsoon season, low platelets, leukopenia) |
| Dengue serology repeat in 48h if negative today | NS1 can be false-negative early |
| LFT (Liver Function Tests) | Typhoid and dengue both cause elevated liver enzymes |
| Stool culture + microscopy | For Salmonella, Shigella, ova & parasites |
| CRP / ESR | Elevated in typhoid; relatively lower in dengue |
| Repeat CBC in 48-72h | Monitor platelet trend - critical in dengue |
Summary
The leukocytopenia (TLC 3,700) is the key finding here. In a 16-year-old male from Hisar with 5-7 days of abdominal pain + loose stool in the monsoon season, the top two diagnoses are Typhoid Fever and Dengue Fever - both of which classically cause a low WBC. Normal Hb and RBC make anemia-related or bone marrow pathology unlikely. Malaria is ruled out. Platelets at the low-normal borderline warrant close monitoring.