30F recent pain abdomen anemia vomiting diarrhoea since 1 month
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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
Presenting complaints
C/o pain abdomen since 3 days
C/o vomitings 3 episodes since morning
C/o generalised weakness on and off since 1 month
Hopi:
Patient was apparently asymptomatic 1 month back. She developed generalised weakness and vomitings of 5 - 6 episodes per day for 3 days, 5-6 episodes of loose stools per day and consulted in our pod. On evaluating the case further her Hb was found to be 5.2 gm/dl and admission in the hospital, but she denied admission and opted for treatment on out patient basis. At present patient came with C/o pain abdomen since 3 days , diffuse in nature, insidious in onset associated with vomitings - 3 episodes since today morning, containing food particles and coconut water as content, non projectile, green coloured liquid (bilious vomiting) not associated with headache
Past illness
H/o fever + in the past 10 days back and got treatment from a private hospital relieved after taking medication. Patient is taking tab roofer xt po/ od since 1 month
N/k/C/o htn, DM tb, asthma, epilepsy, Cva, cad.
Treatment :
Blood transfusion done during 2nd LSCS
Personal history:
Married
Agricultural labour
Mixed diet
Normal bowel and bladder
No addictions
Family history: mother is diabetic since 8 years
General examination:
Pallor +
No signs of icterus, cyanosis, clubbing, lymphadenopathy, edema.
Vitals:
Bp: 110/80
Pr: 92bpm
Rr: 20 cpm
Temperature: 98F
SPO2 : 99%
GRBS: 111mg%
Systemic examination:
CVS: s1 s2 heard, no murmurs
Rs: bae+ , NVBS
P/a: soft, non tender
Cns: no FND, HMF +
Clinical images
Investigations
Acute gastritis (resolved)
With anemia (dimorphic anemia)
With right small kidney
With hyperkalemia (resolved)
Treatment:
IV fluids ns at 75 ml/hr
INJ pan 40 mg IV / od
INJ zofer 4 mg IV/sos
INJ optineuron 1 amp in 500ml ns/IV / od
T. PCM 650 mg po/sos
Syp. Sucralfate 10ml po/ tid
Syp. Cremaffin citrate 15 ml po/ h/s
INJ vitkofol 1000mcg/IM/ od
T.orofer xt / po/ od
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