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

Thank you:)



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