A 32 year old female, farmer by occupation came to medical OPD with complaints of vomitings since 4 days
December 26,2022
General medicine case discussion
E LOG MEDICINE CASE
26/12/2022
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Name: K. Supraja
Roll no : 60
2020 Batch
I''ve 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 comeup with Diagnosis and Treatment plan.
Case presentation:
A 32 year old female came to general medicine OPD with chief complaints of:
4-5 episodes of vomitings since 22/12/2022
Pain below the chest since 22/12/2022
History of present illness:
Patient was apparently asymptomatic 1 month back. Then she developed fever and pain in lower abdomen from 25/11/2022. The pain was insidious and gradual in onset and lasted for more than 2 weeks. On consultation she was diagnosed with ovarian cyst and had a surgery on 7/12/2022. And she was discharged on 15/12/2022. After a week on 22/12/2022 evening around 10 pm she had 2 episodes of vomiting after 4 hours of food intake. On 23/12/2022 . Morning another 2 episodes of vomiting after intake of milk and coconut water.and few more episodes of vomiting till she came to the hospital. Vomiting was non projectile, non bilious and has food as contents associated with epigastric pain after intake of food.
No history of diarrhoea, burning micturitipn, headache, giddiness. she was admitted on 23/12/2022.
Past History:
No history of similar complaints in the past.
No history of epilepsy,HTN, DM, Bronchial asthma.
History of blood transfusion prior surgery.
Surgical history:she has a history of right salpingo oopherectomy on 7 -12-2022
Family History:
H/O HTN -mother
Personal History:
Mixed diet
Loss of appetite
Adequate sleep
No Burning micturition
Bowel- regular
No known allergies
Addictions - toddy (occasionally)
Drug allergies:
No known drug allergies
Menstrual history:
AOM:15 years
Regular 4/30 cycles
LMP: 22-11-2022
Physical Examination:
General Examination:
Conscious, coherent and cooperative
Well oriented to time place and person
Normal gait
Examined in sitting position
Thin built
Moderately nourished
Pallor present
No icterus
No cyanosis
No clubbing of fingers
No Lymphadenopathy
No pedal edema
Vitals:
Temperature :afebrile 
Pulse Rate: 80 beats per minute
Respiratory rate: 18 times per minute
BP: 120/70
SpO2 : 87% at room temperature
GRBS- 95 mg / dl
Systemic Examination:
CVS
S1 and s2 heard
No murmurs
No thrills
RESPIRATORY SYSTEM
no dysnea
No wheeze
Position of trachea: central
Vesicular breathe sounds
ABDOMEN
Shape of the abdomen: scaphoid
No tenderness
No palpable mass
No organomegaly
Bowel sounds : No
CNS
No facial asymmetry
All reflexes are normal.
Provisional diagnosis:
Acute enterogastritis
Investigations:
Serum electrolytes:
Sodium- 139mEq/l > 138 >138
Potassium-4. 5mEq/l > 4.2 > 4.5
Chloride-103mEq/l > 103 > 105
Calcium ionised-0. 85mmol/l > 1.03 > 1.05
TREATMENT :
1) IVF NS @ 50ml/hr
2) Inj. ZOFER 4mg/IV/SOS
3) Inj. PAN 40mg/IV/OD
4) vital monitoring
