A 32 year old female with vomitings and pain in epigastric region
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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.
CASE PRESENTATION
A 32 year old female farmer by occupation came to general medicine OPD with chief complaints of vomitings of 4 to 5 episodes since 2 days associated with epigastric pain.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 1 month back. Then she developed fever and pain in lower abdomen from 25/11/2022. The pain was insidious and gradual in onset and lasted for more than 2 weeks. On consultation she was diagnosed with ovarian cyst and had a surgery on 7/12/2022. And she was discharged on 15/12/2022. After a week on 22/12/2022 evening around 10 pm she had 2 episodes of vomiting after 4 hours of food intake. On 23/12/2022 . Morning another 2 episodes of vomiting after intake of milk and coconut water.and few more episodes of vomiting till she came to the hospital. Vomiting was non projectile, non bilious,non foul smelling and has food as contents associated with epigastric pain .pain aggrevate after having food.No history of diarrhea, burning micturition, headache , giddiness and she was admitted on 23/12/202
PAST HISTORY
•Patient is not a k/c/o diabetes mellitus, hypertension, asthma, T.B, epilepsy, CAD.
• Surgical history of right salpingo oophorectomy on 7/12/2022.and 1 unit of blood transfusion was done.
FAMILY HISTORY
Not relevant
PERSONAL HISTORY
Mixed diet
Normal appetite
Adequate sleep
Bowel and bladder movements are normal
Addictions - occasional toddy drinker
No allergies
MENSTRUAL HISTORY
Age of Menarche :15 years
Menstrual cycle 4/30, regular
LMP: 22/11/2022
GENERAL EXAMINATION
Conscious, coherent and cooperative
Well oriented to time place and person
Normal gait
Examined in sitting position
Thin built
Moderately nourished
Pallor present
No icterus
No cyanosis
No clubbing of fingers
No Lymphadenopathy
No pedal edema
Vitals:
Temperature :afebrile
Pulse Rate: 80 beats per minute
Respiratory rate: 18 times per minute
BP: 120/70
SpO2 : 87% at room temperature
GRBS- 95 mg / dl
SYSTEMIC EXAMINATION
CVS
S1 and s2 heard
No murmurs
No thrills
RESPIRATORY SYSTEM
no dysnea
No wheeze
Position of trachea: central
Vesicular breathe sounds
ABDOMEN
Shape of the abdomen: scaphoid
No tenderness
No palpable mass
No organomegaly
Bowel sounds : heard
CNS
No facial asymmetry
All reflexes are normal
PROVISIONAL DIAGNOSIS
Acute enteritis
INVESTIGATIONS
Serum electrolytes:
Sodium- 139mEq/l > 138 >138
Potassium-4. 5mEq/l > 4.2 > 4.5
Chloride-103mEq/l > 103 > 105
Calcium ionised-0. 85mmol/l > 1.03 > 1.05
TREATMENT
1) IVF NS @ 50ml/hr
2) Inj. ZOFER 4mg/IV/SOS
3) Inj. PAN 40mg/IV/OD
4) vital monitoring
