45 YEAR OLD FEMALE WITH VOMITINGS

 

THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S 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 WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT .

CHIEF COMPLAINTS: 

A 45 yr old female who is a housewife and  resident of Nagarjuna sagar  came to OPD with chief complaints of nausea and vomiting since 2days  , heavy menstrual bleeding since 1 1/2 yr.

HOPI:

Patient was apparently asymptomatic 2 days ago then she developed vomiting which is bilious in nature, preceded by nausea,food as its content, aggravated on taking food and water,10 to 15 episodes per day and not relieved on medication.

she also has heavy menstrual bleeding associated with clots [7/20;4 pads per day].Not associated with pain. She went to a local RMP.The symptoms have subsided for a month.Then she had same complaints within a month.

She also has a history of weight loss.She lost around 14 kgs [she was 46kgs kgs one year back and now she is 32kgs].

She also developed right ear discharge 12yrs back which is insidious in onset, intermittent in nature, mucoid and profuse discharge. Relieved temporarily on medication.H/o ringing sensation in right ear.H/o postnasal drip.She also has deviated nasal septum towards left.

She also has H/o blurred vision since 1 1/2 yr.

No H/o fever, pain abdomen, loose stools

MENSTRUAL HISTORY:

LMP: 13/07/22

Menarche at 14 yrs

Past cycles:  4/30[regular],no pain and clots,1 to 2 pads per day

Present cycles:Heavy menstrual bleeding a/w clots, no pain , 7/20,4 pads per day.

PAST HISTORY:

K/C/O DM since 13 yrs. On medication since then [Glimiperide].On insulin since 3 days

H/o Tubectomy 20 yrs ago

Not a k/c/o HTN,asthma,epilepsy,CAD

PERSONAL HISTORY:

Appetite - Normal

Diet- Vegetarians 

Sleep- Adequate

B&B- Regular

Addictions - Nil

TREATMENT HISTORY:

On OHA [Glimiperide], on insulin since 3 days

FAMILY HISTORY:

Father is a k/c/o diabetes.

GENERAL EXAMINATION:

Patient is conscious ,coherent and cooperative and well oriented to time, place and person.

Ill built and malnourished.

Vitals:

Temperature - 98.4 F

PR :- 80 bpm

RR :-18 cpm

BP :- 120/60 mm Hg

SPO2 :- 95%

GRBS :- 189 mg / dl

Pallor- Present

No icterus, cyanosis, clubbing, No Generalised lymphadenopathyo, No b/l pedal edema.

 Mid arm circumference:

SYSTEMIC EXAMINATION:

CVS-S1, S2 heard,no murmurs

Respiratory System:-

 BAE- present 

NVBS- heard

Per abdomen:-

 soft , non tender.

CNS- NAD

EAR DISCHARGE: 

DNS TOWARDS LEFT 

INVESTIGATIONS:

CBP ON 7/8/22 

TREATMENT:

I.V fluids NS @ 100ml/hr

Inj. PAN 40mg/iv/od 

Inj. Zofer 4mg /iv/tid 

Insulin

Inj.5% dextrose @ 100 ml/ hr if GRBS < 200 mg/ dl

PROVISIONAL DIAGNOSIS:

DKA 2° to inadequate insulin 

Adenomyosis

Anaemia under Evaluation 

Type 2 DM since 13 years.