A 60 year old female with vomitings and loose stools since 2 months

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CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDERS

A 60 year old female, presented to the OPD with chief complaints of :

- vomitings and loose stools since 2 months 

- generalised weakness since 20 days

History of Presenting Illness :  The patient was apparently asymptomatic 2 months ago, then she developed vomitings, 5-6 episodes per day with food material as content, non bilious, non projectile, non blood stained releived with medications.

Complaint of loose stools since 2 months, 4-5 episodes per day, large volume, watery, non foul smelling, non blood stained releived with medications.

Complaint of joint pains since 20 years, first of the small joints of the foot and ankle, then the knees and then joints of the hands, wrist, elbow and shoulder joints .

Patient had undergone total knee replacement surgery for the right leg 8 yrs back and for the left leg 4 yrs back.

Pt has complaint of dry mouth and dry eyes since 20 yrs.

Complaint of itching of lower limbs and upper limbs since 4 yrs .

Complaint of loss of vision of left eye since 18-20 yrs and blurring of vision of right eye since 2 yrs.

Patient was diagnosed with hypothyroidism 20 years back when the pt had undergone a general checkup for weight gain and hair loss.

Pt is now using 75 mcg THYRONORM .

Patient was diagnosed with hypertension 1 year back on regular checkup, now using ATEN 25 mg PO/OD.

Past History :

Pt has history of Rheumatoid Arthritis since 20 yrs.

Pt has history of hypothyroidism since 20 yrs using 75 mcg THYRONORM.

Pt has history of hypertension since 1 year on ATEN 25 mg PO/OD.

History of hysterectomy surgery done 20 yrs back.

Not a known case of diabetes mellitus, epilepsy, asthma, CAD .

Personal history :

Diet - vegetarian 

Appetite - decreased since 2 months

Sleep - adequate

Bowel and bladder movements - regular

Addictions - none

Family history : not significant 

General Examination : The patient is conscious, coherent and cooperative . She is moderately built and nourished .

Pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy, peripheral edema - absent.

Bed sores

Systemic Examination :

CVS : S1, S2 heard. No murmurs.

RS : BAE present. NVBS heard.

CNS : No focal neurological deficits. Higher mental functions intact.

P/A : soft, no organomegaly.

Tenderness present at the supra pubic region.

Investigations :

                           30/01           01/02

Hb                        8.1               7.1

RBC                      2.96            2.62

Urea                       44               24

Creatinine              2.5               2.1

Uric acid                 9.2                8.4

Sodium                   135             138

Potassium              3.2                 3.5

Chloride                    102                105

RBS - 111 mg/dl

T3 - 0.55

T4 - 16.30

TSH - 8.57

Serum iron - 74

Serum ferritin - 198.3

Diagnosis : Gastroenteritis

K/C/O Rheumatoid Arthritis with

Secondary Sjogren 's syndrome with

Senile Xerosis with

Anemic Pruritis with Anemia of Chronic Disease with

Hypertension with

Hypothyroidism with

AKI on CKD with

Left eye Anterior Staphyloma

Right eye Keratoconjunctivitis Sicca with

Grade 2 and 3 Bed sores

Treatment :

Inj. ZOFER 4 mg IV/TID

Inj. PAN 40 mg IV/OD

Tab. THYRONORM 75 mcg po/od

Tab. OROFER po/od

Tab. TECZINE 10 mg po/od

Liquid paraffin L/A BD

Fucidic cream L/A BD

Lubrex eye drops 4 times/day

Tab. SPOROLAC DS SOS