MEDICINE CASE DISCUSSION
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CASE SCENARIO:
A 30 year old female, anganwadi worker, came with complaints of
Vomiting since 30 days.
Headache since 28 days.
HISTORY OF PRESENT ILLNESS:
The patient was apparantly asymptomatic 30 days ago, then she developed vomitings, 5-6 episodes per day which were non-projectile, non-bilious, not blood stained, content was food particles and non-foul smelling, not relieving with medication and associated with abdominal discomfort which preceded vomitings. No pain/burning sensation. C/o belching, indigestion, no regurgitation symptoms.
C/o Headache since 28 days which was diffuse, holocranial, continuous throughout the day, associated with giddiness- spinning sensation lasting for 1-2 hours, relieved with rest, no blackouts, no tinnitus, no blurring of vision, no ear discharge.
C/o Generalised weakness since 30 days. Patient had decreased oral intake despite having a good appetite due to multiple episodes of vomitings.
PAST HISTORY:
No h/o similar complaints in the past.
No h/o herbal medicine.
Not a known case of DM, HTN, TB, asthma, epilepsy, CAD
PERSONAL HISTORY:
Diet - mixed
Appetite - normal
Sleep - adequate
Bowel and bladder movements - regular
Addictions - none
GENERAL EXAMINATION:
The patient was c/c/c
Afebrile
Moderately built and nourished
No Pallor, icterus, cyanosis, clubbing, lymphadenopathy
BP 120/70mm Hg
PR 96/min
CVS: s1, s2 heard
RS: BAE+
P/A: soft, non tender
CNS: NAD
INVESTIGATIONS:
- USG abdomen
- UPT : negative
- CBP
- CUE
- Serum Creatinine and Urea
- Serum Electrolytes
- RBS
PROVISIONAL DIAGNOSIS:
Vomiting- ? Non-ulcer dyspepsia
TREATMENT:
DAY ZERO:
1) IVF: 2. NS, 1. RL, 1. DNS @ 75ml/hr
2) Inj. PAN 40 mg IV/OD
3) Syp SUCRALFATE 10 ml PO/TID
4) Inj. ZOFER 4 mg IV/TID
DAY ONE:
1) IVF: 2. NS, 1. RL, 1. DNS @ 75ml/hr
2) Inj. PAN 40 mg IV/OD
3) Syp SUCRALFATE 10 ml PO/TID
4) Inj. ZOFER 4 mg IV/TID
5) Tab. DOLO 650 mg PO/BD
DAY TWO:
1) IVF: 2. NS, 1. RL, 1. DNS @ 75ml/hr
2) Inj. PAN 40 mg IV/OD
3) Syp SUCRALFATE 10 ml PO/TID
4) Inj. ZOFER 4 mg IV/TID
5) Tab. DOLO 650 mg PO/BD
Course in hospital:
30 yr old female admitted with complaints of vomiting from 30 days and Headache since 28 days. She had 5-6 episodes of vomitings, which were non-projectile, non-bilious and associated with abdominal discomfort. Along with vomitings, patient also had complaints of continuous, diffuse headache and generalised weakness.
The patient was managed conservatively. With improvement in overall condition and resolution of above mentioned symptoms pt was discharged adviced for follow up after 1 week.
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