CBBLE UDHC SIMILAR CASES

 GENERAL MEDICINE CASE

"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcomed


January 19, 2022

23Y/M WITH VOMITINGS AND LOOSE STOOLS

GENERAL MEDICINE CASE


"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome




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 

























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