A 30 yr old female with acute gastritis with giddiness

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February 2,2023

This is an online E-log book to discuss our patient de-identified health data shared after taking his/ her guardians sign informed consent

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve those patient clinical problem with collective current best evidence based inputs.

This E-log also reflects my patient centered online learning portfolio.

Your valuable inputs on 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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a  diagnosis and treatment plan.


CASE
A 30 yr old female, agriculture worker ,presented to the casualty with complaints of
VOMITINGS SINCE 3 DAYS
GIDDINESS SINCE 3 DAYS


HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 5 days ago then she developed watering of eye from right eye while working in the field and attended kantivelugu program in nalgonda for watering of eyes and was told to her to take eyedrops(ciprofloxacin) thrice daily but she took 5,6 times daily .
Next day she was brought to our hospital (31/1/23) with complaints of vomitings(7episodes) and got discharged after few hours. Next day(1/2/23) she had no episodes of vomitings and on 2/2/23 she presented with complaints of vomitings (2 episodes) associated with nausea 
Small amount, food particles as content, non projectile, non bilious, non blood stained
Giddiness on and off since 3 days so she used to sleep whole day.
No pain abdomen, loose stools, fever, cough ,cold
No burning micturition 

HISTORY OF PAST ILLNESS:

Not a known case of DM,HTN,TB ,Epilepsy ,Asthma,CAD CVD 
History of tubectomy 7yrs ago
PERSONAL HISTORY:
Diet : Mixed
Appetite :decreased since 3 days 
Sleep : Adequate
Bowel and bladder movements :Regular
No allergies and no Addictions 

FAMILY HISTORY:
Not significant 

GENERAL PHYSICAL EXAMINATION :

Patient is thin built and is moderatly nourished.
There is no pallor, icterus,cyanosis, clubbing, edema of feet and lymphadenopathy.






VITALS:
Temp-98.6F
PR- 76bpm
BP:90/60mm HG
Postural hypotension presented on the day of admission 
Supine-100/70mmHg
Standing- 80/60mmHg
GRBS-106mg/dl
RR- 16cpm

SYSTEMIC EXAMINATION :

Cardiovascular System : S1, S2 heard, no murmurs

Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.Position of trachea central.

Per abdomen : soft, non tender. No organomegaly. 

Central Nervous System : Conscious; Speech normal ; 

Gait is normal.

  

MOTOR SYSTEM


Tone        RT.                 LT 

UL            Hypertonic     N

LL.             N.                    N


Power     

UL             5/5                5/5

LL.              5/5.             5/5


Reflexes         

Biceps-.  Exaggerated   exaggerated

Triceps-.exaggerated.   exaggerated

Supinator-

                  Exaggerated.  Exaggerated

   Knee-.     Exaggerated. Exaggerated

Ankle-.    Exaggerated.   Exaggerated

Plantar-. 

                  Babinski+.  Flex

Jaw jerk +


 *Sensory system*


spino thalamic.      Rt.    Lt

Crude touch.           N.     N

Pain.                         N.     N

Temp.                       N.     N


Posterior column

Fine touch.              N.    N

Vibration.                 N.    N 

Position sense. 

          UL.   10/10.   10/10      

           LL    5/10.    10/10  

Romberg sign- swaying       more to right side


Cortical.       Rt.           Lt 

 Graphaesthesia-. N.             N   

Stereognosis- N.             N   


Cerebellar signs 

 No dysdiadokokinesia 

No finger nose incoordination 

No finger finger incoordination


Autonomic nervous system


Postural hypotension:-


Supine - 110/70 mm hg 

Standing- 100/ 60 mm hg 


Pulse:-

Supine - 80 bpm

Standing- 101 bpm 


Signs of meningeal irritation:-

No neck stiffness

Kernig's sign- negative

Brudzinski's sign- negative

INVESTIGATIONS:















MRI BRAIN



USG ABDOMEN:


2D ECHO:


ECG:


CHEST XRAY:


ENT REFERRAL:







PROVISIONAL DIAGNOSIS:

ACUTE GASTRITIS WITH GIDDINESS 
NYSTAGMUS PRESENT(HORIZONTAL GAZE)

TREATMENT:
On 2/2/23

IV Fluids NS,RL@100ml/hr

INJ.PAN 40mg IV OD

INJ. Zofer 4mg IV TID

Tab. PCM 650mg PO SOS

INJ. NEOMOL 1gm IV SOS(if temp >101F)

INJ. OPTINEURON 1AMP IN 500ml NS IV OD

WATCH FOR HYPOTENSIVE SYMPTOMS


On 3/2/23

IV Fluids NS,RL@100ml/hr

INJ.PAN 40mg IV OD

INJ. Zofer 4mg IV TID

Tab. PCM 650mg PO SOS

INJ. NEOMOL 1gm IV SOS(if temp >101F)

INJ. OPTINEURON 1AMP IN 500ml NS IV OD

WATCH FOR HYPOTENSIVE SYMPTOMS


On 4/2/23

IV Fluids NS,RL@100ml/hr, DNS @75ml/hr

INJ.PAN 40mg IV OD

INJ. Zofer 4mg IV TID

Tab. PCM 650mg PO SOS

INJ. OPTINEURON 1AMP IN 500ml NS IV OD

INJ. Promethazine 25mg IM/OD

WATCH FOR HYPOTENSIVE SYMPTOMS


On 5/2/23

IV Fluids NS,RL@100ml/hr, DNS @75ml/hr

INJ.PAN 40mg IV OD

INJ. Zofer 4mg IV TID

Tab. PCM 650mg PO SOS

INJ. OPTINEURON 1AMP IN 500ml NS IV OD

INJ. Promethazine 25mg IM/OD

WATCH FOR HYPOTENSIVE SYMPTOMS


On 6/2/23- discharged



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