70 yr old female with vomitings since 3-4 days
70yr old female with vomitings since 3- 4 days
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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
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GENERAL MEDICINE ASSIGNMENT
Name: K.ROHITH DHARMA Roll no : 165 Semester: 8 I have been given the following cases 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 diagnosis and come up with a treatment plan. 1) PULMONOLOGY CASE: 1 A)Link to the patient details : :https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html 1Q) what is the evolution of the symptomatology in this patient interms of an event timeline and where is the anatomical localisation for the problem and what is the primary etiology of the patient problem ? 1Ans)Evolution of symptomatology 1st episode of sob - 20 yr back 2nd episode of sob - 12 yr back From then she has been having yearly episodes for the past 12 yrs Diagnosed with diabetis - 8yrs back Anemia and took iron injections - 5yr ago Generalised weakness - 1 month back
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