General medicine Case 8

  A 45 year old female patient with repeated episodes of vomitings

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Date of admission:20th October 2021

Case:

A 45 year old female patient with repeated episodes of vomitings since 2 days.

History of present illness:

Patient was apparently asymptomatic 5 years back before standing illness.Then patient was admitted to the Casualty with the chief of repeated episodes of vomitings since 2 days i.e. 5-6 times/day

5 days before the admission into the hospital patient had taken alcohol in large quantities because of family problems (as told by patient's son)  which lead to vomitings followed by no intake of food for following 5 days. Patient had become unconscious 2 days back where she was taken to local hospital and there patient was not assessed and was shifted to our casualty.

Past history:

Patient had diabetes mellitus since 5 years.

4 years back patient had TB for which medications were taken for 2 months and was normal then.

No history of HTN/Epilepsy/Thyroid disorders

Patient had h/o tubectomy 20 years 

Personal history:

There is loss of appetite. 

Diet:mixed

Bladder and Bowel movements:normal 

No addictions 

Family history:

No history of DM/HTN/CVA/CAD/Asthma/thyroid disorders. 

No history of similar complaint in family. 

Treatment history :

Not significant. 

General examination:

Patient is conscious, coherent and cooperative. 

Pallor is present.

No icterus,no cyanosis,no clubbing,no lymphadenopathy. 

Vitals:

BP-Not recordable 

PR- 121 BPM 

RR-22 CPM 

SPO2-98 @

GRBS -254

Systemic examination:

CARDIOVASCULAR SYSTEM:

Inspection:

Chest wall is bilaterally symmetrical.

No precordial bulge

No visible pulsations, engorged veins, scars, sinuses

Palpation:

JVP: normal

Auscutation:

Normal with regular heartbeat

S1, S2 heard

No murmurs 

RESPIRATORY SYSTEM-

Position of trachea: central

Normal Bilateral air entry 

No AV sounds

PER ABDOMEN:

Normal. No mass is palpable. 

No organomegaly

CENTRAL NERVOUS SYSTEM:

Patient is Conscious 

Speech: normal

Reflexes: present

Investigations :

On admission

Ur : 63

Cr:1.9

UA:4.9

SERUM ELECTROLYTE 

Na-138

K-4

Cl-98

Aftr 1 session of dialysis (7pm)

Ur : 93

Cr:3.2

UA:3.9

SERUM ELECTROLYTE 

Na-134

K-3.9

Cl-98

post dialysis ( next morning)

Ur : 83

Cr:3.1

UA:3.9

SERUM ELECTROLYTE 

Na-134

K-3.9

Cl-98

on 26/10/21

Ur : 152

Cr:4.9

UA:5.8

ca-7

SERUM ELECTROLYTE 

Na-135

K-3.9

Cl-106

abg on 26/10/21

ph-7.249

pco2-28.4

po2-152

Amylase 46

Lipase 24

PROVISIONAL DIAGNOSIS:

PRE -RENAL AKI (RESOLVING) 2° to DEHYDRATION with HYPOVOLEMIC SHOCK with 

ALCOHOLIC KETOACIDOSIS (RESOLVED) with WERNICKES ENCEPHALOPATHY (RESOLVING) with 

ACUTE HEART FAILURE with EF-45% with REFRACTORY METABOLIC ACIDOSIS (RESOLVING)

with H/O PULMONARY KOCH'S (3Y BACK) with 

K/C/O ASTHMA (4Y BACK) with K/C/O DM(6Y BACK)

Treatment:

IVF 4 NS - bolus 

Inj Nor adrenaline 8ml/hr ( 2amp in 47 ml NS)

IVF NS,RL @ 100 ml /hr continuos 

Inj Sodium Bicarbonate 100meq /iv/ stat - 50 meq in 100 ml NS /IV / slow infusion over 2 hours 

Inj PANTOP 40 mg /iv /od 

Inj neomol 100ml /sos 

Inj ZOFER 4mg /IV / OD 

Inj Ceftriaxone 1 gm /iv/ bd 

Inj HAI (39 ml NS with 40 IU HAI ) 

Inj Sodium Bicarbonate 1 amp in 100 ml NS /Stat 

Inj Piptaz 4.5 gm /IV/Stat- Inj Piptaz 2.25 gm /IV / TID.