A 70 year old female with vomitings

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Chief complaints

70 year old female from narketpally housewife by occupation came with chief complaints of vomitings since 10 days generalized weakness since 10 days and pain abdomen associated with fever. 

HOPI

Patient was apparently asymptomatic 10 days back then she developed vomitings after comsuming food. Vomitus was non bilious non projectile, no hematemesis, watery in consistently food particles were present. She also has fever since 10 days intermittent  in nature, increases at the end of the day and at night. She consulted a local RMP and she took medications after which the fever subsided. She also has dull aching type of pain in the suprapubic region,which was persistent. 

Past history 

She slipped in the bathroom 2months back then she fractured her right 4th and 5th. She was plastered accordingly. She resumed her normal activities. 

K/c/o Asthma for which she's been treated with prednisolone. 

Personal history

N/k/c/o DM, HTN, TB, Epilepsy. 

Family history - insignificant

Menstrual history - normal menstrual cycles. 

General examination:

Pt is conscious coherent and cooperative. 

No palor, icterus, cyanosis, clubbing, lymphadenopathy and pedal edema. 

Vitals

Temp Afebrile

Bp 120/70 mm hg

PR 98 bpm 

RR 16 cpm

Systemic Examination

P/A distended, soft and non tender, suprapubic pain present(dull aching type). 

No organomegaly

CVS S1 S2 heard no murmurs

RS BAE + NVBS heard

CNS No focal neurological deficit. HMF intact. 

Lab investigations. 

ECG

USG reports

Provisional diagnosis : Acute gastritis?? 

Treatment

Inj. Optineuron

Inj. Zofer

Inj. Pantop

IV NS infusion. 

04/07/2023

S : 

 fever spikes + nausea+ vomiting +

O:  

Patient is conscious coherent and cooperative  

No pallor , icterus , clubbing, cyanosis, lymphadenopathy, oedema 

Vitals :   

BP- 190/1100mmHg 

PR -127 bpm 

RR-20 cpm 

Temperature -103.2 F

GRBS-128 mg/dl 

CVS: s1,s2 heard ,no Murmurs, 

RS:BAE,no added sounds ,NVBS,  

P/A: soft, non tender,No organomegaly 

CNS:NFND  

A:  

Acute gastritis ? Supraventricular tachycardia 

? Hypertensive urgency with orthostatic hypotension with? Denovo Hypertension 

P: 

Inj.ZOFER 4 mg IV/TID

Inj.PAN 40 mg IV/BD

Tab.TELMA 40 mg PO/OD 

Tab.MET-XL 25 mg PO/OD

Tab.CINOD 10 mg po/od

Inj.METOCLOPRAMIDE 10 mg /IV/OD

06/07/2023 

S : 

 fever spikes + 1 am 99.3 F

One episode of vomiting in the morning

O:  

Patient is conscious coherent and cooperative  

No pallor , icterus , clubbing, cyanosis, lymphadenopathy, oedema 

Vitals :   

BP- 150/80mmHg 

PR -96 bpm 

RR-20 cpm 

Temperature -99.3 F

GRBS-105 mg/dl 

CVS: s1,s2 heard ,no Murmurs, 

RS:BAE,no added sounds ,NVBS,  

P/A: soft, non tender,No organomegaly 

CNS:NFND  

A:  

Acute severe gastritis (resolving)

Denovo HTN with Hypertensive urgency (resolved)

Acute febrile illness

?Enteric fever

?Clinical malaria

Orthostatic hypotension?Autonomic dysfunction

P: 

Inj.ZOFER 4 mg IV/TID

Inj.PAN 40 mg IV/BD

Inj.METOCLOPRAMIDE 10 mg /IV/OD

Inj.MONOCEF 1 gm IV/BD

Tab.TELMA 40 mg PO/OD 

Tab.MET-XL 25 mg PO/OD

Tab.CINOD 10 mg po/od

Tab.DOXyCYCLINE 100 mg PO/OD

Tab.DOLO 650 mg PO/QID