A 50 YEAR OLD FEMALE PATIENT WITH NAUSEA AND VOMITING

 THIS IS AN ONLINE E LOG BOOK 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 

         

CASE REPORT:-

A 50-year-old female patient who is a Housewife came to the casualty with a 

CHIEF COMPLAINTS:-

• Vomiting for 2 days(10-12 episodes)
• Abnormal menstrual bleeding since 1 1/2 year

HISTORY OF PRESENT ILLNESS:-

She  was apparently asymptomatic then she got diagnosed with DM type 2 13 years back 

Before 13 years due to loss of consciousness, she went to a hospital where regular investigations are done to find her DM type 2.

For which she is under regular oral medication since then GLIMIPERIDE M2 

18 months back she developed heavy menstrual bleeding associated with clots for which she has been under medication prescribed by a local doctor since then but the symptoms did not get subsided.

She gives a history of loss of weight (15-16 kgs)i.e., 48-50 to 32 kgs in the past 1 year not associated with fever, cough, and decreased appetite.

Before 3 weeks she had a heavy menstrual bleed associated with clots but not associated with pain for which she went to a local hospital where routine investigations are done and found to have HB of 7 gm/dl.

3 weeks back they were changed to INSULIN( 10U-X-8U) with GLIMI afternoon when she went to local hospital with complaints of AUB, giddiness, weakness and 

Her GRBS was 400mg/dl.

For the past 2 days, she had 10-12 episodes of vomiting  per day which is bilious not projectile ( preceded by severe nausea) mainly food and water as content

They took medication from a local medical shop which did not subside on taking medication and increased on taking water.

Associated with mild giddiness and excessive bleeding. 

No HISTORY of fever, loose stools, pain abdomen, And no intake of outside food. 

THE DAY BEFORE:-

She did not take insulin before day admission and on the morning of the day of admission. 

PAST HISTORY:- 

DM type 2 since 13 years

Before 13 years due to loss of consciousness, she went to a hospital where regular investigations are done to find her DM type 2.

For which she is under regular oral medication since then GLIMIPERIDE M2 

3 weeks back they were changed to INSULIN( 10U-X-8U) with GLIMI afternoon when she went to the local hospital with complaints of AUB, giddiness, weakness and 

Her GRBS was 400mg/dl.

Right Ear discharge since 12 years insidious in onset intermittent, mucoid type, non-foul smelling and non-blood stained and relieves temporarily on medication not associated with pain, loss of hearing. 

NO history of HTN, TB, Asthma, leprosy, CAD, CKD. 

Surgical history:-

Tubectomy was done before 25 years

PERSONAL HISTORY:-

Diet:- veg ( egg)

Appetite - increased 

Sleep:- Adequate

Bowel and bladder:- Regular

Addictions:- NIL

FAMILY HISTORY:-

No significant family history 

MENSTRUAL HISTORY:-

LMP:- 13/7/22 

Age of menarche:-13 yrs

PAST CYCLES:-

4/30 regular cycles

Not associated with pain and clots 2 pada per day.

PRESENT CYCLES:- Since 18 months 

Heavy menstrual bleeding 

Associated with clots but not associated with pain. 4 pads per day.

Obstetric history:-

G3 L2 D1

IMMUNIZATION:-

Not immunized with the covid vaccine

ALLERGIC HISTORY:-

No known allergies to drugs or any kind of food. 

GENERAL EXAMINATION:-

She is conscious coherent and cooperative and well oriented towards time, place, and person 

Weakly built and weakly nourished. 

WEIGHT:- 32 kgs

VITALS:-

Temperature - 98.4 F

PR:- 80 bpm

R.R:-18 CPM

B.P:- 120/60 mm Hg

SPO2:- 95%

GRBS :- 189 mg / dl

PALLOR - Present

NO  icterus 

No cyanosis 

No clubbing

No lymphadenopathy

No edema

SYSTEMIC EXAMINATION:-

CARDIO VASCULAR SYSTEM:-

 :- S1; S2 heard; no murmurs

RESPIRATORY SYSTEM:-

 Bilateral air entry presents normal vesicular breath sounds are heard all over the chest

PER ABDOMEN:-

 soft, non-tender.

CENTRAL NERVOUS SYSTEM:-

no focal deformities,

No signs of meningeal irritation

Cranial nerves - Normal

Motor system - Normal

Sensory system - Normal

OBG Consultation:-

ENT Consultation:-

INVESTIGATIONS:-

ABG on 5/8/22:-

SERUM ELECTROLYTES on 5/8/22 at 11:00 am:

USG on 5/8/22:-

2D ECHO on 5/8/22:-

X-RAY:-

ECG on 5/8/22:-

BLOOD GROUP:- B +ve

BLOOD SUGAR on 5/8/22:-

SEROLOGY:-

CUE on 5/8/22:-

HAEMOGRAM on 5/8/22:-

LFT  on 5/8/22:-

SERUM CREATININE on 5/8/22:-

SERUM ELECTROLYTES:- on 5/8/22 at 11:45 pm

APTT on 6/8/22:-

FASTING BLOOD SUGAR on 6/8/22:-

LFT on 6/8/22:-

HAEMOGRAM on 6/8/22:-

ESR:-

PT ( prothrombin time):-

T3, T4, TSH:-

URINE FOR KETONE BODIES:-

ECG on 6/8/22:-

ABG on 6/8/22 at 6:00am:-

SERUM ELECTROLYTES on 6/8/22:-

HAEMOGRAM:- on 7/8/22

SERUM ELECTROLYTES on 7/8/22:-

SERUM ELECTROLYTES on 8/8/22:-

ABG on 8/8/22:-

CUE on 8/8/22:-

Urinary electrolytes on 8/8/22:-

SERUM ELECTROLYTES:-

Urine for ketone bodies on 8/8/22:-

Urine for ketone bodies on 9/8/22:-

DIAGNOSIS:-

DIABETIC KETOACIDOSIS SECONDARY TO INADEQUATE INSULIN, ADENOMYOSIS, ANEMIA UNDER EVALUATION WITH A HISTORY OF WEIGHT LOSS, TYPE 2 DM SINCE 13 YRS. 

TREATMENT:-

1. I.V fluids NS 100ml/hr
2. Inj pan 40 mg I.V /O.D
3. Inj Zofer 4 mg I.V/T.I.D
4. Inj HAI INSULIN 1 ml/hr
5. Inj 5% dextrose 100ml/hr
6. GRBS hrly
7. B.P and temp charting every 4 th hourly