80 year old female with gastric complaints











 This is an 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 solveb those patient's 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 the comment box is welcome.

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

Comments

Post a Comment

Popular posts from this blog

36 year old female with low backache and past ovarian tumor

Image
    This is an 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 solveb those patient's 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 the comment box is welcome. Case: This is a case of a 36 year old female with chief complaints of chest pain since 26/05/2023. HISTORY OF PRESENTING ILLNESS: In December 2020 Patient had complained of pain abdomen on the left side which was insidious in onset and gradually progressive. She went to the hospital and was diagnosed to have a huge cystic lesion in the pelvis extending into abdomen and ovarian cysts. In January 2021,  The histopathology report showed that she had a  left ovarian cyst
Read more

1801006016 - Long case

Image
  This is an 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 solveb those patient's 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 the comment box is welcome. Case: This is a case of 55 year old male with chief complaints of - deviation of mouth to left side since 2 days (11/03/2023) - slurring of speech since 2 days History of presenting illness: Patient was apparently asymptomatic 2 days ago. He then developed slurring of speech which was sudden in onset.He also developed bilateral blurring of vision which was sudden in onset and which lasted for an hour.On the same day his wife noticed deviation of mouth to left side and
Read more