CASE OF GASTRITIS

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I have been given this case 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. 

A 32 year old female came to OPD with chief complaints of pain abdomen and vomiting since morning.

HISTORY OF PRESENT ILLNESS :

- Patient was asymptomatic till the previous day

- Symptoms developed in the morning after intake of non veg the previous night.

- Pain abdomen was continuous , diffuse type with associated vomitings ( 5-6 episodes ) ; non projectile , non bilious ; content is food and water , not blood stinged.

HISTORY OF PAST ILLNESS :

- Patient was apparently asymptomatic till 6 years of age 

- Attained milestones and received vaccination as per age 

- At age 6 patient had headache heaviness with no history of trauma, vomiting,Loss of consciousness,seizures.

- MRI done showed hydrocephalus. Planned for ventriculoperitoneal shunt 

- Patient was put on medication for few days ( unknown ). After that patient was asymptomatic, studied till inter 2nd year , was an average student in class.

TREATMENT HISTORY :

Not significant

SURGICAL HISTORY :

Ventriculoperitoneal shunt in childhood.

PERSONAL HISTORY : Married

➣ Appetite - Normal

➣ Diet - Mixed

➣ Bowel and Bladder - Regular

➣ Addictions - No

➣ Allergies - No

FAMILY HISTORY :

➣ Not significant 

GENERAL EXAMINATION :

➣ Pallor - Yes 

➣ Icterus - No

➣ Cyanosis - No

➣ Clubbing of fingers or toes - No

➣ Lymphadenopathy - No

➣ Edema of feet - No

VITALS : 

➣ Temp - 97.6 °F

➣ BP - 110/70 mm Hg

➣ Pulse - 70 bpm

➣ RR - 21 cpm

➣ SPO2 - 99 % at room air

SYSTEMIC EXAMINATION :

CVS - 

➣ S1 , S2 heard 

➣ No thrills and murmurs 

RESPIRATORY SYSTEM -

➣ Dyspnoea and Wheeze not seen

➣ Position on Trachea is central.

ABDOMEN -

➣ Shape - Obese

➣ Tenderness - Yes ( Epigastric region )

➣ No Palpable mass 

➣ Bowel sounds - Yes

CNS -

➣ Pt is Conscious , Coherent.

➣ Speech - Normal

REFLEXES - 

                         Right              Left

Biceps.               2+                  2+

Triceps.             2+                   2+

Supinator         2+                   2+

Knee                  2+                   2+

Ankle                 2+                   2+

Cerebral Signs :

➣ Finger nose incordination - Yes

➣ Knee heal incordination - Yes 

Investigations : 

Serum lipase - 28 IU/L

Serum Amylase - 49 IU/L

Anti HCV antibodies ( ELISA ) - Not reactive

Hepatitis - B Surface Antigen - Negative

USG -

Other investigations -

Fever chart : 

Endoscopy - Erosions in fundus.

Provisional diagnosis : 

Acute Gastritis with History of Ventriculoperitoneal Shunt in Childhood

Treatment : 

Day - 1

INJ TRAMADOL 

INJ PANTOP 

INJ ZOFER 

Day - 2 

IVF NS / RL @75 ml/hr 

INJ PANTOP 40mg IV/OD 

INJ ZOFER 5mg IV/TID

INJ TRAMADOL 1AMP IN 100ml NS IV/BD 

INJ BUSCOPAN 2CC IV/BD 

INJ PCM 500 mg PO/ SOS 

I/O FEVER CHARTING 

MONITOR BP 4TH HOURLY 

TAB NEUROKIND LC/PO/OD 

Day - 3

IVF NS / RL @75 ml/hr 

INJ PANTOP 40mg IV/OD 

INJ ZOFER 5mg IV/TID

INJ TRAMADOL 1AMP IN 100ml NS IV/BD 

INJ BUSCOPAN 2CC IV/BD 

INJ PCM 500 mg PO/ SOS 

I/O FEVER CHARTING 

MONITOR BP 4TH HOURLY 

SYP LACTULOSE PO/HS 

TAB ULTRACET BD

Day - 4 

TAB ULTRACET BD 

TAB TAXIM 200mg PO/BD 

TAB PANTOP 40mg PO/OD

TAB LACTULOSE 15ml/PO/HS