Acute gastroenteritis

CBBLE UDHC SIMILAR CASES

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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 

March 29,2022

A 21 year old female student  by occupation, resident of cherlapally came with the chief complains of 

Loose stools since 3 days,vomitings since 3 days.

Patient was apparently asymptomatic 3 days back then she developed loose stools on 27/3/22 3:00 am to 28/3/22 8:am (10 episodes), watery in consistency. No blood in stools.

She developed vomitings which are 1 episode on 27/3/22(night) and 1 episode on 28/3/22(morning)- food particles as content,non bilious,non projectile.

Fever on 27/3/22 which is of low grade, continuous and relieved on  medication. Not associated with chills and rigor 

PAST HISTORY:

No h/o   HTN, DM,TB Asthma, Epilepsy,CVD.

She had similar complaints in the past 1 yr back(3-4 episodes of loose stools) which was lasted for 1 day and relieved on medication. 

PERSONAL HISTORY:

DIET - MIXED,

APPETITE -REDUCED SINCE birth

BOWEL MOVEMENT - REGULAR , 

BLADDER MOVEMENTS - REGULAR,

NO ADDICTIONS 

TREATMENT HISTORY:

NON SIGNIFICANT 

O/E:

PATIENT IS CONCIOUS , COHERENT COOPERATIVE

No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA, 

VITALS - 

TEMPERATURE - 98

PULSE RATE - 108BPM

BLOOD PRESSURE - 

130/80 MM OF HG SUPINE

RESPIRATORY RATE - 19

SPO2 - 99 % AT ROOM AIR

SYSTEMIC EXAMINATION - 

PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/

RIGIDITY-PRESENT.

CARDIOVASCULAR SYSTEM : 

S1 AND S2 HEARD  , NO MURMURS

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS

CENTRAL NERVOUS SYSTEM : NAD

HEMOGRAM (29/3/22)

HB-12.3

TLC-9800

N/L/M/E-77/18/2/3

PLT-2.54

RBC-4.5

 

SERUM CREATININE-0.7

Na-139,k-3.5,Cl-98

LFT:TB-0.5,DB-0.14,AST-17,ALT-10,ALP-145,TOTAL PROTEIN-6.3,ALB-3.5A/G: 1.31

RBS-146

SEROLOGY- HIV,HBSAG NEGATIVE.

Mp-negative

Mp strip- negative

DENGUE NS1 ANTIGEN-NEGATIVE 

Diagnosis-ACUTE GASTEROENTERITIS

Treatment-

1.IVF NS,RL 75ML/HR

2.INJ.OFLOXACIN 200MG IV BD (1--×--1)

3.INJ.METROGYL 100ML IV TID( 1 --1--1)

4.ORS SACHET IN 1 LIT WATER 

5.TAB.SPOROLAC -DS PO TOD 2--2--2

6.TEMP/BP/GRBS MONITORING