50 year old female came with Pain abdomen since 5 days ,Regurgitation of food since 5 days

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A 50year old female patient who resides at presented to casualty with complaints of  

- Pain abdomen since 5 days

- Regurgitation of food , pain during eating since 5 days

HOPI :

- Patient was apparently asymptomatic 15 years back then she had a episode of giddiness was  taken to hospital and diagnosed with Hypertension  and on regular medication MET-XL25 mg.

- 1 month back patient developed facial puffiness,pedal edema was taken to nearby hospital and  was told she is having Fatty liver managed conservatively from then she used to develop pedal edema on &off .

- Patient complaining of  loss of appetite, regurgitation of food, difficulty in swallowing

- 5 days back 

1 episode of vomiting bilious ,non projectile ,food as content, non blood stained, non foul smelling, relieved on medication.  

- 3 episodes of loose stools non sticky,foul smelling, yellow coloured, small quantity,not associated with blood  

- Abdominal pain squeezing type non radiating , continuous in nature,with no aggravating and relieving factors 

Pt presented to casualty on 3/6/23 evening 

On checking her GRBS it was found to be HIGH.

URINE for ketone bodies found to be positive.

Past History:

- 5 years ago she consulted a doctor for knee pains and was given analgesics ,from then she takes them daily one tablet in the afternoon.

- 2-3 years ago she went to the hospital with fever, weakness, pain abdomen then she was told to control her diet as she had some liver problem(?)

- She is using antacids from 2-3 years

-Not a k/c/o Tb, epilepsy,cad,CVD,Asthma, thyroid disorders.

Surgical History:

Hysterectomy 25 years ago due to some (?) mass 

Family History 

Not significant

Personal History:

Pt is having loss of appetite, bowel movements increased ,micturition- 7-8 times /day ,sleep - inadequate,No allergies and addictions.

Daily routine:

Patient used to be a maid 6 years back and stopped working due to bilateral knee joint pain and is now staying at home

Patient wakes up at 6:30 am ,does her daily activities and drinks Java at around 7:30 , breakfast by 8 am ,watches Tv will have her lunch by 2 pm ,takes Tea by 6 pm and dinner by 9 pm and sleeps by 10 pm.

General Examination:

Pt is conscious, coherent,cooperative 

Pallor present

no icterus,cyanosis, clubbing,generalised lymphadenopathy,edema.

VITALS:

Bp-130/80 mm Hg

Pr-97 bpm

Rr-25 cpm

Temperature:Afebrile

Spo2: 98%@RA

GRBS- HIGH

SYSTEMIC EXAMINATION:

P/A:

Inspection:

Abdomen is obese

Infraumblical vertical scar present

No sinuses, pulsations, visible peristalsis.

Umbilicus is central and inverted

All quadrants of Abdomen move equally  with respiration.

Palpation:

No local rise of temperature

Tenderness present in the Right ,Left Hypochondrium and Epigastrium.

No fluid thrill 

Liver is not palpable

Spleen not palpable

Percussion:

Tympanic note is heard on percussion

 shifting dullness negative

Auscultation:

Bowel sounds are heard.

CVS :

S1,S2 heard 

No murmurs

CNS:

No focal neurological deficit 

RS :

Bae+

Normal vesicular breath sounds heard.

INVESTIGATIONS:

Provisional Diagnosis:

?Diabetic ketoacidosis ?Starvation ketoacidosis with Acute Gastroenteritis with Denovo DM2.

Treatment:

1.IVFluids NS @100ml/hr

2.Inj.HAI infusion 1ml(40U)in 39 ml NS@4ml/hr increase or decrease according to GRBS

3.IV 5Dextrose@50ml/hrincrease or decrease according to GRBS

4.Strict I/O CHARTING

5.monitor Vitals Hourly