62 yr female with vomitings since 1 day

 This an a 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:

A 62 year old female came with chief complaints of vomiting since last night 


HISTORY OF PRESENTING ILLNESS

Patient was apparently alright until last night then  had vomitings food as content , non bilious, non projectile , non blood stained . She went to RMP doctor where inj ZOFER was administered and bp at that time was 180/100 mm hg and she took tab. Telma 40mg. Patient came to general medicine op for further management.

No h/o headache, giddiness, fever

No h/o pain abdomen, loose stools

No h/o chest pain, sob, cough .








PAST HISTORY:

Known case of hypertension since 5 years on tab. Telma 40mg

N/k/c/o DM TB asthma CVA CAD


VITALS AT ADMISSION:

Patient is conscious coherent coperative

No Pallor, icterus, cyanosis, clubbing, generalized lymphadenopathy, edema

BP -110/70mmhg

PR -96bpm

RR - 18cpm

Temp- 98.6F

Spo2- 99 %


EXAMINATION:

CVS -S1 S2 heard

RS - BAE+ nvbs

CNS - HMF normal

Tone- normal

Reflexes-   RT          LT

 Biceps       ++         ++

Triceps         +          +

Supinator      +           +

Knee            ++         ++

Ankle             +          +

P/A - soft, non tender.


INVESTIGATIONS:



Chest x-ray 

ECG 

USG abdomen







TREATMENT:
IV FLUIDS NS@ 75 ML/HR
INJ ZOFER 4MG IV 8TH HRLY
INJ PAN 40 MG IV OD
TAB TELMA 40MG PO OD
TAB PREGABA M PO HS
TAB SHELCAL CT PO OD
TAB VIT D 3 PO WEEKLY ONCE
TAB SUPRADYN PO OD



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