CHRONIC VOMITINGS UNDER EVALUATION
C/0 vomitings since 2 months
Pain abdomen since 2 months
Generalized body pains
HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 2 YEARS BACK, SHE HAD INJURY TO RIGHT LEG WHICH TURNED TO ULCER AND HELAED WITHIN ONE MONTH.
SINCE 6 ME NTHS PATIENT HAD BLUSTERS AT THE SAME SITE OF INJURY FOLLOWED BY ULCERATION.DAILY DRESSINGS WAS DONE AT LOCAL HOSPITAL.
SINCE 2 MONTHS PATIENT HAS VOMITINGS, ON AND OFF ON AN AVERAGE OF 2 EPISODES OF VOMITINGS, NON PROJECTILE,NON BILIOUS WITH FOOD PARTICLES AS CONTENTS.
NO H/O FEVER, NO LOOSE STOOLS,
NOT A K/K/O HTN,DM,TB,BA
VITALS: AFEBRILE. PR-90. RR-18. BP-110/70. SPO2 98%
GASTRO-ENTEROLOGY I/V/O CHRONIC VOMITINGS: DIFFUSE GASTRITIS SMALL HIATUS HERNIA.
SURGERY REFERAL I/V/O AN ULCER-AN ULCER OF SIZE 10X7 CMS OVER R LEG-MEDIAL ASPECT,GREENISH DISCHARGE ORESENT,PALE GRANULATION TISSUE PRESENT.
Rx : DAILY DRESSINGS WITH OINTMENT MEGAHEAL.
TAB.PAN 40 MG OD
TAB.ONDEN 4MG BD 1-----X-----1
SYP.ARYSTOZYME 10ML/TID
TAB.ZINCOVIT OD. X-----1-----X
PSYCHIATRY REFERAL -ADJUSTMENT ISSUES DUE TO PHYSICAL ILLNESS.
INVESTIGATIONS: HAEMOGRAM,LFT,RFT,CXR,ECG,USG ABDOMEN
DIAGNOSIS: CHRONIC VOMITINGS UNDER EVALUATION SECONDARY TO GASTRIC OUTLET OBSTRUCTION.
TREATMENT:
1) IVF NS,RL,DNS. @75ML/HR
2)INJ.ZOFER 4MG/IV/TID
3)INJ.MONOCEF 1 GM/IV/BD
4)INJ.OPTINEURON 1 AMP IN 100 ML NS/IV/OD
5)TAB.PCM 650 MG /PO/SOS
6) DAILY DRESSINGS WITH MEGAHEAL OINTMENT
7)BP/PR/TEMP MONITORING AND GRBS CHARTING(12TH HOURLY)
(1)DAILY DRESSINGS WITH OINTMENT MEGAHEAL.
(2)TAB.PAN 40 MG OD FOR 5 DAYS
(3)TAB.ONDEN 4MG PO/BD FOR 5 DAYS
(4)SYP.ARYSTOZYME 10ML/TID FOR 5 DAYS
(5)TAB.ZINCOVIT po/ OD. FOR 14 DAYS
(6) TAB.PCM 500 MG SOS
REVIEW TO SURGERY OPD SOS. I/V/O ULCER
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