80 year old female with gastric complaints

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CASE:

This is a case of a 80 year old female with complaints of 

1. vomitings (4-5 episodes)

2. abdominal discomfort since 08/04/2023.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 2 hours ago.She then had 4-5 episodes of vomiting which contained of food particles,non bile stained,not foul smelling and not blood stained.It is associated with giddiness and abdominal discomfort.

No complaints of fever,loose stools,shortness of breath,chest pain,orthopnea.

H/O consumption of alcohol 1 day back.

PAST HISTORY:

H/O similar complaints of giddiness and neck pain present. 

K/c/o cervical spondylosis

H/O travel to USA (stayed there for 5 months) and she returned back 1 week ago.

H/O upper GI endoscopy done 10 years ago for gastric ulcers and is on medication.

Not a k/c/o HTN,DM,CVA,CAD,TB,Asthma

PERSONAL HISTORY:

Diet:vegetarian 

Apetite: normal

Sleep:decreased 

Bowel and bladder:regular

Addictions: drinks toddy occasionally; she had one glass yesterday (08/04/2023).

GENERAL EXAMINATION:

Patient is drowsy,coherant and cooperative

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

Vitals:

 BP:130/80 mmHg

Temperature: afebrile 

PR:80bpm

RR:30cpm

GRBS:281 mg/dl

SYSTEMIC EXAMINATION:

CVS: S1 and S2 are heard

CNS: no focal neurological deficits

Abdomen: soft,obese and non tender

RS: B/L inspiratory fine basal crepts

INVESTIGATIONS:

X ray

ECG

TREATMENT:

• Inj.Augmentin 1.2g/IV/BD
• Tab. Metformin 500mg/PO/BD
• Tab.Lasix 20mg PO/BD
• Inj Pan 40mg/PO/BD
• SYP.Grilinctus 2Tbsp PO/TID
• nebulization

Ipravent -6th hourly, budecort -8th hourly

Mucomist-12th hourly

• GRBS monitoring 6th hourly
• Chest physiotherapy

PROVISIONAL DIAGNOSIS:

B/L lower lobe consolidation (with community acquired pneumonia)

With Heart failure

With preserved ejection fraction (58%)

With denovo DM Type 2