December 18,2021.

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A 34-year-old female patient presented to the casuality with chief complaints of vomiting since three days which is associated with giddiness and generalised weakness


History of present illness:

34 yrs old female ,daily labourer by occupation, resident of Choutuppal got married at the age of 15 has three children. 

Patient was apparently assymtomatic six months back then she had complains of recurrent episodes of vomiting 2-3 episodes per day 

Vomiting containing food particles,  non-bilious, non-blood stained and it is of , non-projectile type. 

Not associated with pain abdomen, no loose stools, no fever, cough, SOB vomitings - associated with nausea and loss of appetite

Patient complains of vomiting immediately after food intake or even after intake of water within half an hour vomits everything even the water. 

Complains of weight loss

For the vomitings she visits to local hospital and RMP  and got symptomatic relief

No history of headache blurring of vision

No history of chest pain tightness

No history of difficulty in swallowing, weakness tingling

Past history:

No history of such complaints in the past. 

History of Surgery Tubectomy+

And 2 C-sections +

Personal history :

married

Occupation-daily wage labourer

Irregular bowel and bladder movememts:Constipation (once in 2 to 3 days)

No known allergies

Patient takes a mixed diet. 

Normal appetite. 

Altered sleep. 

No addictions. 

Poorly built. 

No significant family history

Menstrual history:

Regular cycles 3/30 
no history of Menorrhagia, Dysmenorrhea 

General examination :

patient is conscious, coherent and cooperative
Pallor present
No Icterus, Clubbing, Pedal Oedema

Vitals:
Temperature 98.2° F
PR 150 BPM
RR 25 CPM
BP 60 MMHG
SPO2 98@ RA


Systemic examination:

Cardiovascular system-

     Chest wall is bilateral symmetry. 
     No visible pulsations. 
     JVP is normal. 
     S1 and S2 are heard. 

Respiratory system-

     Bilateral airway. 
     Trachea is in midline. 
     No added sounds. 

Per abdominal

     Abdomen is soft and tender. 
     Bowel sounds are heard. 
     No palpable mass or free fluid. 

CNS- no FND














Investigations:
















Provisional diagnosis:
Acute hypertension 2° to dehydration/chronic vomitings
Chronic vomitings under evaluation
Microcytic hypochromic anemia due to improper diet. 
Plan of Treatment:

IVF 2 NS/IV/stat
IVF -NS, RL, DNS @100ML/hour
Inj. OPTINEURON 1amp in 100ML NS/IV/OD
Inj. PAN 40mg/ IV/ OD
Inj. ZOFER 4mg/ IV/ TID
Monitor vitals 4th hourly


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