23Y/M with vomitings and loose stools
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A 23 year old male patient came with cheif complaint of vomiting since 3 days, loose stools since 3 days associated with pain abdomen
HOPI
The patient was apparently asymptomatic 3 days back, then he had vomitings- non bilious, non projectile, containing food particles and loose stools- (7-8 episodes/day) initially non mucoid, from today mucoid associated with pain abdomen.
No H/o fever, chest pain, palpitations, pedal edema, Decreased urine output, headache, altered sensorium.
H/o outside food consumption (non-veg) 4 days ago.
PAST HISTORY
N/k/c/o Hypertension, Diabetes mellitus, TB, Epilepsy, RVA, CAD
PERSONAL HISTORY
Diet -mixed
Appetite - normal
Bowel habits - regular
Bladder habits - regular
Sleep - adequate
No addictions
General examination
Patient is conscious, coherent, cooperative, well built and well nourished.
Mill pallor present
No icterus, cyanosis, clubbing, lymphadenopathy, Edema.
Vitals:
Pulse rate - 80 bpm
Temperature- 97.2 degree Fahrenheit
RR - 24 cpm
BP - 130/80 mmHg
Systemic examination :
CVS : S1 S2 + , no added murmurs
RS :BAE + ,NVBS heard
P/A :soft , tender
CNS: No FND
Provisional diagnosis
Acute Gastroenteritis
INVESTIGATIONS
TREATMENT
IVF NS/RL @100ML/HR
INJ.CIPROFLOXACIN 200MG IV BD
INJ. METROGYL 500MG IV TID
INJ. BUSCOPAN 10MG IV SOS
INJ. PAN 40MG IV OD
INJ. ZOFER 4MG IV TID
TAB. SPORLAC DS PO/TID
BP, PULSE RATE, SPO2 MONITORING 4TH HOURLY
ORS SACHETS 1 PACKET IN 250ML WATER (ALLOW IN SIPS AFTER EACH EPISODE OF LOOSE STOOL)
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