70yr 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.

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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