General medicine e log -2 Acute gastrocenteritis
August 7 2021.
P. Sai kiran
Roll No:02( Old batch )
3rd semester
Under guidence of Dr manasa (intern)
This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission
I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including, history, clinical findings, investigations, and come up with a diagnosis and treatment plan.
Case :-
A 28yr old female came to casuality on 01/08/2021 with cheif complaints of 4episodes of Loose stools since- yesterday afternoon,5episodes of Vomiting since -yesterday evening ,Giddiness since - yesterday evening
HISTORY OF PRESENTING ILLNESS:-
*Patient was asymptomatic 1 day back she had 4 episodes of loose stools ( watery consistently)
* Then she developed pain abdomen for which she took mefanamic acid after that she had 3 episodes of vomiting (non projectile/non bilious)
*No fever / no cold / no cough
*No headache/no blury vision
HISTORY OF PAST ILLNESS:-
*Not a k/c/o DM, Asthama, HTN,Epilepsy, TB
TREATMENT HISTORY :-
None
PERSONAL HISTORY
*Married
*Normal appetite
*Bowel - loose stools irregular
*Mixed diet
*Non vegetarian
*Micturition normal
*No known allergies
*No alcohol habits
Family history :-
*No complications
GENERAL EXAMINATIONS
*No pallor
*No Icterus
*No Cyanosis
*No Clubbing
*No Lymphadenopathy
*No Edema
*No Malnutrition
*Temperature -98.7 C/F
*Pulse rate -106 /min
*Bp - 110/70 mm/hg
*Spo2 - 99 %
*GRBS - 124 mg%
SYSTEMIC EXAMINATION:-
CVS:
No Thrills
Cardiac Sounds - S1, S2 +
No cardiac murmurs
RESPIRATORY SYSTEM:
Dyspnoea - No
No Wheezing
Position of Trachea - Central
Vesicular sounds
ABDOMEN:
Shape - Obese
No tenderness
Palpable mass
No fluid,
Bowel sounds- present
Hernial Orifices - Normal
Liver Spleen - Not palpable
Genitals speculum examination
PV examination
P/R examination - Normal
CNS:
Level of consciousness - conscious
Speech - Normal
No signs of meningeal irritation
Cranial nerves - Normal
No motor or sensory deficit
Glassgow scale -normal
Provisional diagnosis:-
Acute gastrocenteritis
* vomiting and diarrhea are main signs/symptoms of gastroenteritis
*As the patient is having more than 3 loose stools episodes with vomiting
It may be viral or bacterial
TREATMENT:-
*Ivf -NS/RL/DNS -200ml/hr
*Inj PANTOP 400 mgIV/OD
* Inj ZOFER 4 mg IV/sos
* TAB METROGYL 400 mg po/TID
* T.SPROLAC- DS PO/BD
* ORS sachet-1 in litre water - take 100ml /stool
*BP/PR/Temperature/RR -4th hr
*GRBS-6th hr
Drinking lots of fluids with salts and sugar(oral rehydration )
Prevention : maintain hygiene
