57 year old female with acute gastritis with type 2 diabetes mellitus

 



This is an online E logbook to discuss our patients' de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome. 




A patient of 57 years old female came with C/O loose stools since 2 days,

Fever since 2 days


And C/O vomitings since 2days


HOPI


Patient was apparently asymptomatic till 2 days back she ate fish which was cooked before day and then developed loose stools, watery in consistency , large in amount , yellowish in colour and foul smelling for which she went to local hospital and received IV gluids and antibiotics 


C/O vomitings , 10-12 episodes/day for 2 days , small in amount, watery in consistency, non bilious, non foul smelling.


Vomiting associated with nausea


Fever since 3 days high grade continuous associated with chills and associated with rigors .

present no cough sob and no burning micturition

 No h/o headache,stomach pain.


Past history 


K/C/O DM since 10 years On tab glipizide (5mg) and tab Metformin 50mg


N/K/C/O HTN, Epilepsy, CAD, CVS, TB, Asthma


Personal history 


occupation -house wife 


appetite -normal 


diet -mixed


bowel and bladder movements - loose stools 


no addictions 


family history insignificant




Menstural history 


age of menarche 13 years 


regular 5/30 day cycle 

2pads /day

With no clots and no pains




General examination 


patient is conscious cooperative coherent well oriented to time place person 


No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema



Per abdomen: 

Inspection -

Shape of abdomen : scaphoid

Umbilicus : inverted 

Movements of abdomen wall with respiration 

No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites 

On palpation -

No local rise of temperature 

Inspectors findings are confirmed 

Soft and non tender

No palpable mass 

Liver and spleen not palpable 

On percussion -

Resonance note heard

On auscultation -

Bowel sounds heard


R/S - inspection:

Trachea appears to be normal - Central 


shape of chest - elliptical 


Movements of chest appear to be bilaterally equal


No scars , sinuses present.

No drooping of shoulder

No engorged veins , swellings seen

No hallowing seen

No crowding of ribs


Palpation:

All inspectory findings are confirmed

No rise of temperature

No tenderness 

Trachea is in midline

B/L chest movements are equal

No swelling and palpable masses are felt

vocal fremitus are normal


PERCUSSION.                        RT.            LT

SUPRA CLAVICULAR       resonant.  resonant

INFRA CLAVICULAR.       resonant.  resonant

MAMMARY.                       resonant.  resonant

INFRA MAMMARY.           resonant.  resonant

AXILLARY.                         resonant   resonant

INFRA AXILLARY.             resonant   resonant

SUPRA SCAPULAR.        resonant   resonant

INFRA SCAPULAR.         resonant   resonant

INTER SCAPULAR.          resonant   resonant



Auscultation:


Normal Vesicular breath sounds heard


Cardiovascular system:

Inspection- 

No raised JVP

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse at 5th intercostal space

Palpation-

Apex beat is felt in the fifth intercostal space, 1 cm medial to the midclavicular line

Percussion -

Right and left borders of the heart are percussed 

Auscultation-

S1 and S2 heard, no added thrills and murmurs are heard 


Central nervous system:

Conscious

Normal speech.

No neurological deficit found.


Provisional diagnosis 


Acute gastroenteritis with K/C/O DM since 10 years















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