70 year old female with vomitings

 

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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.

70 year old female from natketpally came with the Chief complaints of vomitings since 10 days,generalised weakness, pain in right lower Abdomen associated with fever

HOPI

Patient was apparently asymptomatic 10 days back when she developed vomitings which was with food particals in consistency non bilious non projectile, non blood stained. Also had fever since 10 days which was intermittent not associated with chills and rigors increased during end of day and at night. She consulted local RMP and took medication. She has pain in the hypogastric region which was persistent. 

C/o constipation past 5-6yrs, passes stool once in 3 days

Past history

She slipped in washroom and fell of 2 months back then she got fracture in right 4 and 5th toe. She got plastered normally. She resumed her normal activities

K/c/o Asthma for which she is taking medications(Prednisolone)

N/k/c/o DM, HTN, TB, Epilepsy

Personal History

Diet: mixed

apetite: normal

Bowel and bladder: deficates once in 3 days

Sleep: normal

Occasional consumption of pan

No history of surgeries

Family history

Insignificant

General examination

Patient is conscious coherent and well oriented to time and place

Moderately nourished 

No signs of  icterus,clubbing,cyanosis,lymphadenopathy ,pedal oedema

Vitals

Temp: 102 F

PR: 110

Rr: 24/ min

Bp:120/70 mm Hg. 

Spo2: 94%

Systemic examination

CVS: S1,S2 heard, no murmurs heard 

Resp: Bilateral vesicular breath sound+

         Inspiratory Crepts on both sides

CNS :NAD 

Investigations

Provisional diagnosis

Acute Gastritis, Acute febrile illness

Treatment

1.Inj. OPTINUERIN 1Amp
           100 ml NS / IV
2. Inj.ZOFER 4Mg
3. Inj.Pan 40 mg IV/OD
4. Inj.ZOFER 4mg IV/BD
5. IV Fluids NS/DNS
       @75ml/hr
6. Respiratory Rate, Blood pressure,Pulse Rate monitoring every 4th hourly