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80 year old female with sob

 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 on (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 inspiratoryfine basal crepts 

INVESTIGATIONS







Urine for ketone bodies - negative 

Urea -54 mg/dl 

Serum creatinine -2.8

RBS -271 mg/dl 

Serum osmality - 284

TREATMENT:

INJ.PAN 40mg/IM/STAT

INJ.ZOFER 40mg/IV/STAT

INJ.BUSCOPAN IM/STAT

INJ.LASIX 20mg/IV/BD


PROVISIONAL DIAGNOSIS:

Acute gastritis 

Shortness of breath secondary to ? Heart failure

With bilateral mild pleural effusion

With denovo DM type 2

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