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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

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 

Investigations on 30/6/23




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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