65yr old female with APD and Ckd stage 3B

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I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan.

Unit -1 

Ward case 

DOA:15/5/23

65yr old female ,home maker ,residence of Nalgonda came with c/o abdominal distension and bloating since 4 days

HOPI: she was apparently asymptomatic 10 days ago then she developed fever ,insidious in onset,low grade ,intermittent type ,not associated with chills and Rigors ,no aggravating factors,relieving on medication,associated with body pains.

No h/o burning micturition,headache,cold and cough 

C/o vomitings in these 10 days ,5-6 episode(presently had 1 episode ,with food particles as content ,non projectile ,non bilious ,non blood stained 

C/o burning sensation in oral cavity since 10days(becoz of which she is unable to eat) ,no h/o dysphagia,loss of appetite and weight loss 

No h/o pain abdomen ,constipation or loose stools 

No h/o sob,chest pain ,pedal edema and palpitations and decreased urine output 

Now since 4 days c/o abdominal distension with bloating and belching 

Associated with regurgitation of food ,aggravating on lying down after taking food and no relieving factors 

Past history:

K/c/o DM2 since 6 yrs on regular medication tab.vidagliptin 50mg+metformin 500mg Po/BD

HTN since 6 years on tab telma-H (40-12.5)po/OD

General examination: 

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

Vitals :

Temp :afebrile 

PR:80bpm

RR:16cpm

Grbs:138mg/dl

No pallor ,icterus,clubbing ,cyanosis ,lymphadenopathy,oedema 

Systemic examination:

CVS:s1,s2 heard ,no murmurs

RS:BAE+,NVBS +

P/A: distended ,umbilicus :inverted 

Non tender ,no organomegaly 

No shifting dullness and fluid thrill 

Bowel sounds +

Gastro opinion taken for endoscopy:

Impression:Atrophic fundal gastritis 

opthal opinion taken I/v/o retinal changes for DM AND HTN :

Impression: on fundus examination of eye no changes of Hypertesion and diabetic retinopathy noted .

Nephrology opinion taken I/v/o deranged RFT(BU:45mg/dl and serum creatinine:1.7mg/dl)

Advised:

1.W/H tab.telma -H 

2.Consider tab.cinod 10mg Po/OD

3.Consider Inj.HAI sc/TID ,

If patient is uncooperative continue same diabetic medication.

Provisional diagnosis :

APD-Acid peptic disease

Investigations:

Hemogram:

RBS:

Blood urea:

Serum creatinine:

Serum electrolytes:

LFT 

HbA1C:6.8%

CUE:

Appearance :clear 

Albumin:+

Sugar :nil

Pus and epithelial cells:2-3 

RBC:Nil

Serology:negative 

ECG:

CXR:

2D echo:

FINAL DIAGNOSIS:

ACID PEPTIC disease- atrophic  gastritis with k/c/o HTN and DM since 6years

CKD:stage 3B

Treatment given :

1)Tab.RAZO -D 40mg Po/OD before breakfast 

2)Syp.sucrafyl-o Po/TID 15mins before food

3)Tab.CINOD 10mg Po/OD 

4)Tab.vidagliptin 5omg+metformin 500mg Po/BD

5)ZYTEE gel LA/TID

Advice at discharge:

1.Tab.RAZO-D 40mg Po/OD before breakfast 

2.Tab.CINOD 10mg Po/OD 

3.Tab.vidagliptin 5omg+metformin 500mg Po/BD

4.ZYTEE gel LA/TID

Follow up: 

Review to general medicine opd after one week with RFT report