Skip to main content

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

Comments

Post a Comment

Popular posts from this blog

Self assessment

 K.pavan  ROLLNO. 77 Did sleep study in my UG , learned how respiration (spo2) changes accordingly with sleep .Thus awoken my interest in medicine. And started asking how ? Why? For everything  During UNIT duties  https://167pavankotha.blogspot.com/2023/04/45f-with-bl-knee-pains.html  1) what is the cause for her morning stiffness  2)  is occupation the reason for her symptoms? 3) what is the preventive aspect of such disease? https://167pavankotha.blogspot.com/2023/03/this-is-online-e-log-book-to-discuss.html 1) what is the cause for his ascites ? 2) can his lifestyle be one of the cause for his condition ? https://167pavankotha.blogspot.com/2023/03/67m-dementia-with-headache.html 1) what are the differentials for unilateral head aches ? 2) what is the cause for his unilateral headache? https://167pavankotha.blogspot.com/2023/04/chief-compliants-vomitings-since.html 1) how do you confirm that his symptoms are due to the consumption of an unknown compo...
Post a Comment
Read more

COVID CASE REPORT LOGS FOR MAY 2021

  1) Covid 19 with co morbidity (Pulmonology/Rheumatology) https://nikhilasampathkumar. blogspot.com/2021/05/covid- pneumonia-in-pre-existing- case-of.html Q1) How does the pre-existing ILD determine the prognosis of this patient?  In patients with preexisting ILD, COVID-19 infection has led to acute exacerbation of underlying ILD.  The criteria for ILD exacerbation include: 1) subacute worsening of dyspnea  2) hypoxemia  3)new pulmonary infiltrates on imaging   4)absence of pulmonary emboli 5)cardiac failure 6) other non-pulmonary causes Thus it leads to a poor prognosis Q2) Given the history of autoimmune disease in the patient, how does the administration of steroids for COVID affect her RA and hypothyroidism?  Corticosteroids  manages the  disease flares and for initial treatment of RA  glucocorticoids are significant risk factor for bacterial infections.  Glucocorticoid use doubled the rate of serious bacterial infections ...
Post a Comment
Read more

60 YEAR OLD FEMALE WITH AKI SECONDARY TO CONSUMPTION OF UNKNOWN COMPOUND

  This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have 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 diagnosis and treatment plan CHIEF COMPLIANTS vomitings since evening 4hrs - 3episodes  Loose stools 2 episodes HOPI Patient was apparently asymptomatic 4hours back then developed vomitings 3 episodes food as content non bilious non blo...
Post a Comment
Read more