A 55yr old female with Acute Gastritis with type 2 Diabetes mellitus..

This is an online E log book to discuss our patients deidentified health data shared after taking his/her/guardians signed informed consent.

Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.

This E log book also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

Here is a case I have seen

Unit 4 Admission
Interns
Amrutha
Supriya
Sowmya
Sanjay
Mohitha

Dr.Durga krishna Pg1
Dr.Ajith pg2
Dr.laxma pg3
Dr.Manasa pg4
Dr.vijayalaxmi Ast pro

A 55yr old female came with c/o fever since 7 days intermittent a/w chills and rigors & not relievied on medication
Neck pain, Vomitings 2 episodes
Pt was apparently asymptomatic 7 days back,then developed fever associated with chills and rigors and also developed  neck pain during the attack of fever..
She also developed Vomitings which is non bilious,non projectile containing food particles..
No H/O burning micturition,loose stools, headache,pain Abdomen,chest pain, palpitations, weight loss, night sweats..

Past History
H/O HTN since 4 years and on T-METXL 50mg
H/O DM since 4 years and on T.GLIMIPIRIDE 1mg
No H/O CAD, ASTHMA, CVA, EPILEPSY,TB

Family history
No similar complaints in family..

On examination :
Pt is conscious, coherent, co-operative
No pallor, icterus, cyanosis, clubbing lymphadenopathy, pedal Oedema..

Vitals
Temperature: Afebrile
PR:66bpm
BP:100/70mmHg
Spo2:98%
RR-22/min
No signs of dehydration

CVS: S1 S2 heard
RS: BAE present
       NVBS present
Abdomen : Soft,Non tender
                     Bowel sounds present
CNS: Normal

Investigations:
provisional Diagnosis :
Acute Gastritis with type 2 Diabetes mellitus..

Treatment plan:PLBS reports awaited
IVF 1 unit NS @ 75ml/hr
       1 unit RL @75 ml/hr
Inj.Optineuron 1amp in 100ml/NS/IV/OD
                    1-x-x
Inj.Zofer 4mg/IV/TID
               1-1-1
Inj.NEOMOL 1g/IV(only if temperature >102°F)
T.PCM 650mg PO/SOS
T.MET XL 50mg PO/OD
Inj.HAI S/C according to GRBS
Inj.PAN 40mg IV/OD





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