32 yr female

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

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 come up with diagnosis and treatment plan. 

Prasuna Reddy 
Roll no. 59

32/F
C/O VOMITINGS - 6 EPISODES NON PROJECTILE, NON FOUL SMELLING, NON BILIOUS AND
EPIGASTRIC PAIN AGGREVATED AFTER HAVING FOOD  SINCE YESTERDAY NIGHT 
BURPS +
NO C/O LOSE STOOLS, BURNING MICTURATION, FEVER, GIDDINESS, HEADACHE
N/K/C/O DM, HTN, ASTHMA, TB, EPILEPSY, CVA, CAD 
H/O RIGHT SALPINGOOPHORECTOMY 10 DAYS BACK WITH 1 UNIT BLOOD TRANSFUSED

PERSONAL HISTORY:
APPETITE NORMAL 
DIET MIXED
SLEEP ADEQUATE
BOWEL AND BLADDER REGULAR
ADDICTION: NIL

FAMILY HISTORY: NOT SIGNIFICANT 

PT IS C/C/C
NO PALOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA 

BP: 110/80
PR: 84
GRBS: 95
CVS: S1,S2 HEARD
RS: BAE+, NVBS HEARD
PA: SOFT, NT, BS+
CNS: NFND

INVESTIGATIONS:



PROVISIONAL DIAGNOSIS:
ACUTE ENTERITIS

TREATMENT:
IVF NS AT 50ML/HR
INJ ZOFER 4MG IV TID
INJ PAN 4OMG IV OD
MONITOR VITALS

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