70yr old female with vomitings since 3- 4 days
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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.
Chief complaints -
Patient came with the complaints of vomitings since 3-4 days
Investigations on 30/6/23
HOPI-
Patient was symptomatic 3 days back she had vomitings 6-7 episodes since 3 days watery,non projectile,non bilious ,non muciod,not blood stained with food particles as content
C/o pain abdomen in hypogastrium
no c/o chest pain,sob, palpatations,pedal edema,facial puffiness,orthopnae,pnd
C/o constipation since 5-6 - passes stools once in 2- 3 days
C/o decreased urine output since 1 week (low oral intake)
Usually normal urine output
C/o general body pains
N/k/c/o DM,HTN, asthma,CAD,CVA, thyriod disorders
Personal history -
Diet - Mixed
Sleep - Adequate
Appetite - lost since 7 days
B&B - regular
addictions - betel leaf - sometimes
Menstrual history -
Menarche - 13 yrs
Menstrual cycle - 5/28
Attained menupause
Gravida - 5
Family history-
No significant family history
General examination -
Patient was conscious coherent co-operative
Pallor - present
No icterus, cyanosis, clubbing, lymphadenopathy, edema.
VITALS
BP- 120/80mmhg
PR -86 bpm
RR-16cpm
Spo2 99% at room air
Clinical images
Usg done on 1/7/23
System examination
CVS: S1 S2 heard ,no murmurs
RS: BAE present ,NVBS - present no added sounds
CNS: NFND
P/A: soft,Non tender
Provisional diagnosis
Acute gastritis
Treatment history
1) Inj.optineuron 1amp in 100 ml ns iv/od 2)inj.zofer 4mg in 500 ns iv/stat
3)inj.pantop 40mg iv/od
4)inj.zofer 4mg iv/bd
5)IV fluids Ns ,Dns @75ml /hr
