A 57yrs old female with acute gastroenteritis

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CHIEF COMPLAINT: 

A female patient aged 57 years came to the opd with the chief complaints of 

• Fever since 5 days 
• Loose stools(10 episodes) since 5 days 
• Vomitings(2 episodes) since 5 days 
• Generalized body weakness since 5 days 

HISTORY OF PRESENT ILLNESS: 

Patient was apparently asymptomatic 5 days back, then she had 5 episodes of diarrhea and a spike of fever along with pain abdomen ( which was diffuse from the next day) , the next day she had 2 episodes of vomiting and 4 episodes of diarrhea. 

3 days back, she had 8 episodes of diarrhea( watery and bilious stools) 

She had history of consumption of outside food 5 days back. 

No h/o chest pain, palpitations, headache 

HISTORY OF PAST ILLNESS: 

K/c/o HTN since 2 years 

Not a k/c/o DM, CAD, asthma, epilepsy 

TREATMENT HISTORY: 

No relevant treatment history 

PERSONAL HISTORY: 

• Married 
• Appetite- normal 
• Having mixed diet( Non vegetarian) 
• Bowels- regular
• Micturition- normal
• Alcohol intake- teetotaler 
• No habit of smoking 
• No other habits/ addictions 

GENERAL EXAMINATION:

Patient is moderately built and nourished  

Absence of  pallor,Icterus, Clubbing, Cyanosis, Pedal edema, lymphadenopathy 

                        

VITALS:

1.Temperature: Afebrile 

2.Pulse rate: 123 beats per min

3.Respiratory rate: 20 cycles per min 

4.BP: 140/45 mm Hg

5.SpO2: 98%@Room air 

6.GRBS: 261mg  % 

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

• S1, S2 heard
• No thrills, No murmurs

RESPIRATORY SYSTEM:

• Normal vesicular breath sounds
• Position of trachea is central
• Dyspnea is absent 
• No wheeze

EXAMINATION OF ABDOMEN:

• Shape- scaphoid
• tenderness- absent 
• No palpable pass
• Normal hernial orifices 
• No free fluid
• No Bruits
• Liver is not palpable
• spleen is not palpable
• Bowel sounds heard

CENTRAL NERVOUS SYSTEM:

• Patient was consious 
• Speech is normal
• No focal neurological defect

PROVISIONAL DIAGNOSIS:

ACUTE GASTROENTERITIS 

WITH  ?AKI

DENOVO DM 

INVESTIGATIONS: 

                       

ECG 

Ultrasound report 

2D echo 

TREATMENT: 

1. IVF 10NS 

           10RL @100ml/hr 

2. Inj. METROGYL 500mg IV/TID 

3. Inj. CIPLOX 200mg IV/BD 

4. Inj. ZOFER 4mg IV/BD 

5. T. METFORMIN 500mg PO/OD 

6. T. SPOROLAC DS PO/TID 

7. T. REDOTIL 100mg PO/BD 

8. ORS sachets 1 packet in 1 litre of water, 200ml after each loose stool 

9. Plenty of oral fluids 

10. GRBS monitoring every 6th hrly 

11. CEPIRAM-DS PO/BD 

12. TAB. ZINC 10mg PO/OD 

13. TAB. LOPERAMIDE 4mg PO/STAT