21 year old with vomitings since 1 week, loose stools since 2days,pain abdomen since 2days
Unit 3:
Interns:
Dr Harsha
Dr Kalyan
Dr Jeeharika
Dr Sreeja
Dr Archana
Dr Raveen
Dr Aashita
Dr Aravind
Dr Vamshi
Dr Hareen SR
Dr Praveen Naik
Dr Rakesh Biswas
A 21 year man presented to the casualty with the complaints of
Vomiting since 1 week
Loose stools since 2 days
Pain abdomen since 2 days
He studied till Intermediate 2nd year after which he started working at a local restaurant as a waiter since 1 month. He got married 1 month back.
2 years back he apparently got admitted in a local hospital for 2 days for fever with thrombocytopenia.
Since the past 1 week, he says he has been having recurrent episodes of vomiting after consuming home - made fried rice. Initially for the first 2 days, he had 4 episodes of non projectile, watery vomitings containing food, non blood tinged. The following days he had around 7-8 episodes of vomiting.
Since 2 days he has been having pain abdomen , initially it was at the umbilical region, burning type but since morning he has been having burning type of pain at the epigastric region.
Since 2 days, he also started having loose stools, initially according to the patient they were watery, small in quantity and frequent. Since morning, he has been having dark coloured stools of around 7 episodes, occasionally blood tinged, not associated with tenesmus.
He is a thin built man
Dehydrated +
Pulse rate at 120bpm
Bp at 120/80mmhg
Temp -101 F
CVS - S1,S2+
Lungs clear on auscultation
Per Abdomen -
Tenderness + in epigastrium
Bowel sounds +
INVESTIGATIONS:
Diagnosis:
Acute Gastroenteritis
TREATMENT:DAY1
1.IVF 2UNITS NS AND ONE UNIT RL@100ML/HR CONTINUOUS
2 INJ.CEFTRIAXONE 1GM/IV/BD
3.INJ ZOFER 4MG /IV/TID
4.INJ.PANTOP 40MG/IV/OD
5.T.SPOROLAC -DS/PO/TID
6.T.DOLO 650MG/PO/SOS
7.ORS SACHET IN 1LITRE OF WATER SMALL SIPS AFTER EACH EPISODE
8.MONITOR VITALS
9.STRICT I/O CHARTING
10.TEMP CHARTING 4TH HOURLY TEPID SPONGING SOS
11.W/F BLEEDING MANIFESTATIONS
DAY 2:
TREATMENT:
1.IVF 2UNITS NS AND ONE UNIT RL@100ML/HR CONTINUOUS
2 INJ.CEFTRIAXONE 1GM/IV/BD
3.INJ ZOFER 4MG /IV/TID
4.INJ.PANTOP 40MG/IV/OD
5.T.SPOROLAC -DS/PO/TID
6.T.DOLO 650MG/PO/SOS
7.ORS SACHET IN 1LITRE OF WATER SMALL SIPS AFTER EACH EPISODE
8.MONITOR VITALS
9.STRICT I/O CHARTING
10.TEMP CHARTING 4TH HOURLY TEPID SPONGING SOS
11.W/F BLEEDING MANIFESTATIONS
DAY 3:
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