46,F

Diagnosis 

MILD ANTRAL GASTRITIS ? SJOGRENS / ? MIXED CONNECTIVE TISSUE DISORDER ANAEMIA SECONDARY TO INFLAMATORY DISEASE 

Case History and Clinical Findings 

CHIEF COMPLAINTS : PT CAME WITH C/O NAUSEA ,LOSS OF APPTITE ,AND DIFFICULTY BREATHING SINCE 15 DAYS . 

HOPI : PATIENT WAS APPARENTLY ASYMPTOMATIC 30 YEAR THEN SHE DEVELOPED DOV WHICH WAS PAINLESS AND GRADUAL PROGRESSIVE .

10YEARS YEARS BACK DEVELOPED JOINT PAINS ASSOCIATED WITH MORNING STIFFNESS.2YEARS BACK PATIENT HAS LOST HER VISION .

PATIENT WAS ADMITTED 1MONTH BACK AND EVALUATED .ANA PROFILE SHOWS f/s/o / ? SJOGRENS SYNDROME .

NOW SINCE 15 DAYS PATIENT HAD NAUSEA ,LOSS OF APPETITE .NO VOMITINGS ,NO PAIN ABDOMEN . 

PAST HISTORY : NOT K/C/O DM/HTN . PERSONAL HISTROY DIET MIXED , SLEEP ADEQUDATE

MICTURITION NORMAL BOWEL REGULAR 

NON ALCOHOLIC , NON SMOKER . 

O/E 

PT IS C/C/C AFEBRILE 

PR 78 BPM BP 100 /70 MMHG . 

CVS S1S2 PRESENT PNS NO ACTIVE DISEASE

 Investigation 

2D ECHO - NO RWMA EF 58 % NO AS /MS GOOD LV SYSTLIC FUNCTION 

Treatment Given

1.INJ OPTINEURON 1 AMP IN 100ML NS 1V /0D 2.INJ .PANTOP 40MG PO/OD 

3.INJ ZOFER 4MHG IV/ SOS 

4.TAB .WAYSOLONE 10MG PO/TIC 

5.TAB .OROFER XT PO/OD 

6.SYP .ARISTOZYME 25ML PO/TID 

Advice at Discharge 

1.TAB. OPTINEURON 1 AMP IN 100ML NS 1V /0D

 2.TAB..PANTOP 40MG PO/OD 

3.TAB.ZOFER 4MHG IV/ SOS 

4.TAB .WAYSOLONE 10MG PO/TIC 5.TAB .OROFER XT PO/OD 6.SYP .ARISTOZYME 25ML PO/TID

On follow up: sligh limitation in physical activity

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