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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 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
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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