60/F WITH ACUTE GASTROENTERITIS

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Here is a case I have seen

Unit 6:

Case admitted on 27/2/2021.

Interns 

K. Nikhil reddy

M. Swarna 

K. Divya

 B.Manivarma 

Juveria 

Dr. Vinay(pgy1)

Dr. A. Vaishnavi (pgy2) 

Dr. Praneeth(pgy3)

Dr. Hareen (SR)

Dr.Praveen Naik( asst.prof.)

Dr.Rakesh Biswas (HOD)

   A 60 year old female, shepherd by occupation came with Chief complaints of vomiting, loose stools since yesterday.

  Patient was apparently asymptomatic since yesterday,later she complaints of vomitings since yesterday, 4-5 episodes/day , contains food particles,non bilious,non blood stained,subsided now.

 Loose stools since yesterday, 4-5 episodes , rice watery stools,small amount multiple times , non blood stained,non foul smelling. Associated with pain in epigastric region , colicky type , no aggravating and relieving factors.

 No H/o fever, melena.

No H/o recent travel, No H/o outside food consumption.

No H/o abdominal distension, burning micturition.

Past history:

  H/o pain abdomen for 1-2 days, 20 days back, no vomitings, no loose stools.

 Not a k/c/o DM, HTN , TB, asthma, epilepsy, CVA, CAD,thyroid.

No addictions.

 

Local examination:

 Dry tongue+.

 Pallor+.

No icterus, cyanosis, clubbing, lymphadenopathy,pedal edema.

Temp: afebrile

PR :84 bpm

BP:100/70 mmhg

RR: 18cpm

Spo2:97% at room air.

Systemic examination:

P/A: soft, tenderness noted in epigastric region.

         Bowel sounds+.

CVS: S1,S2  heard, no murmurs 

RS: BAE+, NVBS heard.

CNS: NAD.

Investigations:

Hemogram

CUE

LFT

RFT

USG ABDOMEN

PROVISIONAL DIAGNOSIS:

ACUTE GASTROENTERITIS

Treatment given:

1.IV FLUIDS 2NS, 1 DNS, 1 RL @ 100ml/hr.

2.INJ. PANTOP 40 mg /po/OD..

3. INJ.ZOFER 4 mg/IV/TID 

4. TAB. SPOROLAC -DS PO/TID.

5. ORS SACHETS 1 PACKET IN 1 LITRE , 200ML AFTER EACH STOOL.

6 INJ. BUSCOPAN 1  IV /SOS

7. TAB. CIFLOX 500MG PO/BD

8. INJ. METROGYL 500 MG /IV/TID

9. BP, PR CHARTING 2ND Hrly.

On 28/2/2021.

S:  Stool frequency decreased, pain abdomen             decreased,. No fresh complaints 

O: patient is conscious, coherent, cooperative.

     Temp:Afebrile

      BP:120/80 mmhg

      PR: 84bpm

      RR:18cpm

     P/A: soft, non tender

      CVS: S1,S2 heard, no murmurs.

     RS:BAE+, NVBS HEARD.

A:   ACUTE GASTROENTERITIS

P:  1.IV FLUIDS 2NS, 1 DNS, 1 RL @ 100ml/hr.

      2.INJ. PANTOP 40 mg /po/OD..

     3. INJ.ZOFER 4 mg/IV/TID 

     4. TAB. SPOROLAC -DS PO/TID.

    5. ORS SACHETS 1 PACKET IN 1 LITRE ,             200ML  AFTER EACH STOOL.

    6 INJ. BUSCOPAN 1  IV /SOS

   7. TAB. CIFLOX 500MG PO/BD

    8. INJ. METROGYL 500 MG /IV/TID

    9. BP, PR CHARTING 2ND Hrly.

On 1/3/2021

S:  Stool frequency decreased, pain abdomen             decreased,. No fresh complaints 

O: patient is conscious, coherent, cooperative.

     Temp:Afebrile

      BP:110/80 mmhg

      PR: 86bpm

      RR:18cpm

     P/A: soft, non tender

      CVS: S1,S2 heard, no murmurs.

     RS:BAE+, NVBS HEARD.

A:   ACUTE GASTROENTERITIS

P:  1.INJ. PANTOP 40 mg /po/OD..

     2. INJ.ZOFER 4 mg/IV/TID 

     4. TAB. SPOROLAC -DS PO/TID.

    5. ORS SACHETS 1 PACKET IN 1 LITRE ,             200ML  AFTER EACH STOOL.

   6 TAB. CIFLOX 500MG PO/BD

    7. INJ. METROGYL 500 MG /IV/TID

    8. BP, PR CHARTING 2ND Hrly.

   

Patient discharged on 2/3/ 2021 on request.