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.
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