A 70 year old female with vomitings
This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.
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
Comments
Post a Comment