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 (4 to 5 episodes/ day) 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

Right eye:

Left eye:

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

ECG:

Ultra sound

TREATMENT 

1) IVF NS @ 50ml/hr

2) Inj. ZOFER 4mg/IV/SOS

3) Inj. PAN 40mg/IV/OD

4) vital monitoring