50 year old female with vomitings and weight loss

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

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

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 50 year old female who is housewife


 CHIEF COMPLAINTS :

C/o Weight loss since 1 year (15-16 kg/year)

C/o heavy menstrual bleeding since 1 1/2 year

C/o nausea, vomiting since 2days


HISTORY OF PRESENT ILLNESS :

- Patient was apparently asymptomatic 2 years ago

- She is having a bout of vomiting every morning which was green colour(bilious) non projectile, no aggravating and relieving factors.

- C/o Heavy menstrual bleeding with clots since 1 1/2 year used medication but not subsided.

- C/o Weight loss since 1 year about 15-16 kg

- Since 2 days patient developed vomiting food as content preceded by severe nausea since.

- 20 to 30 episodes of vomiting occurred till now since yesterday afternoon 

- Nausea and mild bilious vomiting occured day before yesterday.

- Loss of appetite if not eaten - loose stools, fever , pain abdomen.

- If ate giddiness, excessive bletching.

- Previously pt was on oral hypoglycemic agents but since 15 days started on insulin as she went to doctor with weakness, giddiness and GRBS was 400 mg/dl.

- Patient did not take insulin dose yesterday night and today morning.

PAST HISTORY :

Diabetes - Since 10-15 years on OHA's

- Insulin since 15 days

10u ----- × ----- 8u mix with T.Glimi M2 afternoon 

- H/O uncontrolled sugar 3 months ago

- In 2016 pt was admitted in our hospital with vomitings and was told to have high sugar.

Hypertension - No

TB - No

Asthma - No 

Epilepsy - No

CVD - No

Chemo/Radiation Exposure - Nil

Surgical history - Nil


FAMILY HISTORY : Nil


PERSONEL HISTORY : 

Married

Diet - Mixed

Appetite - Normal

Bowel and bladder - Normal

Allergies -No

Addictions - Nil


MENSTRUAL HISTORY : 

History of heavy bleeding since 18 months.

Not subsided by medication.



GENERAL EXAMINATION :

Temperature - 98.6 °F

Pulse - 96 beats/min

BP - 110/80 mmHg

RR - 18 cycles/min

GRBS - 406 mg%

SPO2 - 98 %

Pallor - YES

Icterus - No

Clubbing - No

Cyanosis - No

Lymphadenopathy - No


SYSTEMIC EXAMINATION :


CVS :

No thrills

No murmurs

S1 and S2 heard


RESPIRATORY SYSTEM :

Position of trachea - Central

No Dyspnoea , Wheeze

Breath Sounds - vesicular

BAE - +ve


ABDOMEN :

Shape - Normal

No tenderness, palpable mass

Bowel sounds heard


CNS : Normal

- Patient is Conscious, Coherent well oriented to surroundings.


INVESTIGATIONS :

ABG -


SERUM ELECTROLYTES -


USG ABDOMEN -


COLOUR DOPPLER 2D ECHO -


ECG-





5/8/22 -


















6/8/22 -



















7/8/22 -




8/8/22 -









9/8/22 -









10/8/22 -



PROVISIONAL DIAGNOSIS :

? Acute Gastritis

 DKA

Adenomyosis

 Anemia with evaluation ( Secondary to menorrhagia )

With history of weight loss


TREATMENT :

5/8/22-



6/8/22 -











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