45 year old female with Vomiting since 1 month

 This is online E log book 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 series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

AISHWARYA GANNOJI.

ROLL NO-35.

A CASE DISCUSSION OF VOMITING SINCE 1 MONTH.

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

 

CASE PRESENTATION:

CHIEF COMPLAINTS:

• Vomiting since 1 month.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 month back then she developed 

Vomiting  1-2 episodes per day for last 25 days. In the last 1 week she has been experiencing 10- 12 episodes of vomiting which is non- projectile,non- bilious, non blood tinged. Vomiting food contents.

Associated with 

• fever for 2 days.

• Headache since 1 month.

• loose stools since 10 days- green colour, watery and no tenesmus.

• Epigastric pain since 1 month. 

HISTORY OF PAST ILLNESS:

• Known case of HYPERTENSION since 2 years. On irregular medication. Tab.Atenolol 25 mg.

•  No History of DIABETES MELLITUS, EPILEPSY, TUBERCULOSIS,CORONARY ARTERY DISEASE.

• History of hysterectomy 25 years back.


PERSONAL HISTORY:

Diet: mixed.

Appetite:  decreased

Sleep: Adequate

Bowel :  loose stools.

Micturition: Regular

Occasionally Toddy consumption.

FAMILY HISTORY:

Not significant.

GENERAL EXAMINATION:

Patient is concious, coherent, co-operative.

She is well oriented to time,place and person. She is moderately nourished.

Pallor - present

No icterus

No cyanosis

No clubbing

No lymphadenopathy

No Edema.

VITALS: on 30-8-2021

Temperature: Febrile

Pulse rate: 123 bpm

Respiratory rate: 18/min

Blood pressure: 90/60 mm Hg 

SpO2 at room air: 98%

SYSTEMIC EXAMINATION:

 CARDIO VASCULAR SYSTEM:

• S1 and S2 are heard, no murmurs  heard.

RESPIRATORY SYSTEM:

• Bilateral air entry present

ABDOMINAL EXAMINATION:

• Soft and tender in Epigastric region.

  Bowel sounds are heard.

  No organomegaly.




CENTRAL NERVOUS SYSTEM:

• Reflexes are elicited.


INVESTIGATIONS:


HEMOGRAM ON 30-8-2021






 






HEMOGRAM ON 31-08-2021















HIV RAPID TEST













ANTI HCV ANTIBODIES




HBs Ag RAPID


SERUM ELECTROLYTES




LIVER FUNCTION TEST

 




SERUM CREATININE


BLOOD UREA


LIPASE


SERUM AMYLASE


ABG


T3,T4,TSH


POST LUNCH BLOOD SUGAR






Referred to ophthalmology for any features of HYPERTENSIVE RETINOPATHY




Impression: No features of HYPERTENSIVE RETINOPATHY

ULTRA SOUND  REPORT






• UPPER GASTROINTESTINAL ENDOSCOPY

Esophagus : small hiatus hernia

Stomach: multiple erosions noted in fundus and body

Duodenum: normal

Impression: SEVERE EROSIVE PAN GASTRITIS.


PROVISION DIAGNOSIS:

ACUTE GASTROENTERITIS 

TREATMENT

DAY 1

1.Injections of two bottles of NS and one bottle of RL @100ml/hr.
2.Inj.pan 40mg IV/OD
3..Inj.Zofer IV 4mg TID.
4.Tab.Dolo650mg PO/sos
5.inj.metrogyl500mg i.v. TID
6.Inj.ciprofloxacin 500mg iv/od
7.Monitor vitals.

                             DAY 2

   1.Injections of two bottles of NS and one bottle of RL @100ml/hr.

2.Inj.pan 40mg IV/OD

3..Inj.Zofer IV 4mg TID.

4.Tab.Dolo650mg PO/sos

5.inj.metrogyl500mg i.v. TID

6.Inj.ciprofloxacin 500mg iv/od

7.Monitor vitals.

                            DAY 3

1.Injections of two bottles of NS and one bottle of RL @100ml/hr.

2.Inj.pan 40mg IV/OD

3..Inj.Zofer IV 4mg TID.

4.Tab.Dolo650mg POy/sos

5.inj.metrogyl500mg i.v. TID

6.Inj.ciprofloxacin 500mg iv/od

7.Monitor vitals.

8.Allow water till tolerated orally.

9.Inj. Phenergan 25mg/IM/OD

10. Syrup Sucralfate 15ml/PO/ before meal.

                        DAY 4

1.Injections of two bottles of NS and one bottle of RL @100ml/hr.

2.Inj.pan 40mg IV/OD

3..Inj.Zofer IV 4mg SOS.

4.Tab.Dolo650mg PO/sos

5.inj.metrogyl500mg i.v. TID

6.Inj.ciprofloxacin 500mg iv/od

7.Monitor vitals.

8.Allow water till tolerated orally.

9.Inj. Phenergan 25mg/IM/OD

10. Syrup Sucralfate 15ml/PO/ before meal

11. Inj PANTOP infusion 8ml/hour.

           .  Day 4  9:15 am

One episode of vomiting after allowing oral sips of fluid

1.max dose 240mg/ day

   1 vial (5 ml) dilution---40 mg

Add 10 vials is 50 ml syringe

 50 ml --- 400mg

   1 ml --- 8 mg

1 ml/hour infusion continuosly for 24 hours

2. GRBS 6 th hourly.

3.Inj.Zofer IV 4mg TID.

4.Tab. Promethazine TID

5.inj.metrogyl500mg i.v. TID

6.Inj.ciprofloxacin 500mg iv/od

7.Monitor vitals.




DAY 5

Temperature: Febrile

Pulse rate: 82bpm

Respiratory rate: 15/min

Blood pressure: 120/80 mm Hg 

P/A soft and not tender

TREATMENT 

1.Injections of two bottles of NS and one bottle of RL @100ml/hr.
2.Inj.pan 40mg IV/OD
3..Inj.Zofer IV 4mg SOS.
4.Tab.Dolo650mg PO/sos
5.inj.metrogyl500mg i.v. TID
6.Inj.ciprofloxacin 500mg iv/od
7.Monitor vitals.
8.Allow water till tolerated orally.
9.Tab Promethazine TID
10. Syrup Sucralfate 15ml/PO/ before meal
11. Inj PANTOP infusion 1ml/hour

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