27 YR OLD MAN WITH FEVER,LOOSE STOOLS, VOMITING,PAIN ABDOMEN SINCE ONE WEEK

Unit 3 admission: 
Interns:
Dr Archana
Dr Sreeja
Dr Harsha 
Dr Kalyan 
Dr Sahithi 
Dr Jeeharika

Dr Raveen PGY1
Dr Aashita PGY2
Dr Aravind PGY3
Dr Vamshi PGY3
Dr Hareen SR
Dr Praveen Naik - Ass. prof


27 year old man electrician by occupation 

He presented with complaints of fever since one week ,loose stool since one week, vomitings since one week, pain abdomen since 1 week

Patient was apparently asymptomatic one week back after which he attended a function and had chicken biryani after which he developed vomitings and loose stools 4 episodes each and loose stools 4 episodes for 2 days, the vomitings were watery containing food contents with no blood, loose stools were watery, large volume of around 4 episodes, the patient also gives a history of fever with the with evening rise of temperature and subsided on medication, he was admitted on suspecting food poisoning and was discharged on not improving
He received fluids and Inj Metrogyl outside 
Now he presented to us with pain abdomen in epigastrium

Not a k/c/o type 2 DM/ HTN/asthma /epilepsy/TB

No known drug and allergic history

On examination 
patient is concious,coherent, cooperative
Thin built and moderately nourished 
No pallor/icterus/cyanosis/clubbing/general lymphadenopathy/pedal edema
Vitals:
BP:110/70MMHG
PR:52BPM
RR:18CPM
SPO2:98% at RA
Afebrile to touch

Systemic examination :
CVS-s1s2 heard,no murmurs
RS-BAE present,no added sounds
Per abdomen-soft,nontender
Bowel sounds+
CNS- normal
 Diagnosis:
 ? Enteric fever
? Acute GE
Investigations:
Diagnosis:
?Enteric fever
?acute gastro enteritis
TREATMENT:
1.IVF 2NS,1RL CONTINUOUS INFUSION @100ML/HR
2.INJ PANTOP 40MG IV OD
3.INJ ZOFER 4MG IV SOS
4.INJ TRAMADOL 1AML IN 100ML IV SOS
5.MONITOR VITALS I/O CHARTING
CONTINUED TREATMENT FOR 5DAYS

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