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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