A 70 Yr old female with vomitings since 3_4 days

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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.

Blog by Vasista Pranav

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 mucoid,not blood stained with food particles as content 

C/o pain abdomen in hypogastrium

no c/o chest pain,sob, palpitations,pedal edema,facial puffiness,orthopnea,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, thyroid 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 menopause

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-16 bpm

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