45 year old female with acute gastroenteritis

A 45 year old female , resident of miryalaguda  presented with the complaints of 

vomiting since 1 month, 
epigastric pain since 1 month , 
Loose stools since 10 days

History of present illness:

She was diagnosed to be hypertensive 2 years back and on  medication.

She first developed fever along with headache 1 month back which lasted for 2 days followed by vomiting everyday 1-2 episodes / day for the last 25 days . Since  last 1 week she has been experiencing 10-12 episodes of non projectile ,non bilious,non blood tinged vomiting containing food particles.

Loose stools - green colour ,watery, small stools, no tenesmus

H/O facial puffiness, B/ L pedal edema  and decreased urine output for 10 days.

Past history:
K/c/o hypertensive since 2 years

H/O hysterectomy 25 years back

Personal history:

Normal appetite

Decreased urine output

Normal bowel movements

H/O occasional toddy comsumption 

On examination:

 The patient is conscious,coherent and cooperative 

moderately built and nourished


Vitals: 
BP: 90/60 mmHg
PR: 123bpm
Temp: 98.4 F 
SpO2 : 98% at RA
GRBS : 142mg% 

P/A: soft ,non tender

CVS: S1,S2 heard

RS: decreased breath sounds in B/ L ISA ,IAA

 CNS: normal


INVESTIGATIONS:

 CHEST X RAY



HEMOGRAM

   


                                                           




SERUM AMYLASE




ABG


SERUM LIPASE



 
HEMOGRAM



ANTI HCV ANTIBODIES-RAPID



HIV 1/2 RAPID TEST



HBsAG-RAPID




T3,T4,TSH


POST LUNCH BLOOD SUGAR




RFT:
serum electrolytes:
   Na :137
   K :3.3
   Cl :98
Serum creatinine:0.9
Blood urea:14

LFT:
Direct bilirubin:0.72
Total bilirubin:2.07
ALT:27
AST:64
ALP:113
Albumin:3.1
Total protein:5.9
A/G ratio:1.11

Endoscopy upper GI:
Shows small hiatus hernia 
Erosive gastritis
 
Psychiatric referral:

Pychogenic vomiting
Adjustment illness due to medical illness
Nicotine dependence syndrome

Provisional diagnosis:
Acute severe erosive gastritis with small hiatus hernia 
 K/c/ o hypertensive since 2 years



TREATMENT:
DAY1:

1.IVF- 2 NS at 100 ml/ hr
         1 RL
          DNS
2.Inj. ZOFER 4 mg/ iv/ tid
3.Inj. METROGYL 500 mg / iv/ tid
4.Inj. CIPROFLOXACIN 500 mg / iv/ bd
5.inj.PANTOP INFUSION at 1 ml/ hr continuously for 24hrs
6. Tab.DOLO 650 mg  po/ SOS
7. Sup. SUCRALFATE 15 mg / PO before meal

Day2:

1.IVF- 2 NS at 100 ml/ hr
         1 RL
          DNS
2.Inj. ZOFER 4 mg/ iv/ tid
3.Inj. METROGYL 500 mg / iv/ tid
4.Inj. CIPROFLOXACIN 500 mg / iv/ bd
5.inj.PANTOP INFUSION at 1 ml/ hr continuously for 24hrs
6. Tab.DOLO 650 mg  po/ SOS
7. Sup. SUCRALFATE 15 mg / PO before meal

Day 3:

1.IVF- 2 NS at 100 ml/ hr
         1 RL
          DNS
2.Inj. ZOFER 4 mg/ iv/ tid
3.Inj. METROGYL 500 mg / iv/ tid
4.Inj. CIPROFLOXACIN 500 mg / iv/ bd
5.inj.PANTOP INFUSION at 1 ml/ hr continuously for 24hrs
6. Tab.DOLO 650 mg  po/ SOS
7. Sup. SUCRALFATE 15 mg / PO before meal

Day 4:
1.IVF- 2 NS at 100 ml/ hr
         1 RL
          DNS
2.Inj. ZOFER 4 mg/ iv/ tid
3.Inj. METROGYL 500 mg / iv/ tid
4.Inj. CIPROFLOXACIN 500 mg / iv/ bd
5.inj.PANTOP INFUSION at 1 ml/ hr continuously for 24hrs
6. Tab.DOLO 650 mg  po/ SOS
7. Sup. SUCRALFATE 15 mg / PO before meal

Day5:

1.IVF- 2 NS at 100 ml/ hr
         1 RL
          DNS
2.Inj. ZOFER 4 mg/ iv/ tid
3.Inj. CIPROFLOXACIN 500 mg / iv/ bd
4.inj.PANTOP INFUSION at 1 ml/ hr continuously for 24hrs
5. Tab.DOLO 650 mg  po/ SOS
6. Sup. SUCRALFATE 15 mg / PO before meal

Day 6:
 1.IVF- 2 NS at 100 ml/ hr
         1 RL
          DNS
2.Inj. ZOFER 4 mg/ iv/ tid
3.Inj. CIPROFLOXACIN 500 mg / iv/ bd
4.inj.PANTOP INFUSION at 1 ml/ hr continuously for 24hrs
5. Sup. SUCRALFATE 15 mg / PO before meal

Day 7: 
 1.IVF- 2 NS at 100 ml/ hr
         1 RL
          DNS
2.Inj. ZOFER 4 mg/ iv/ tid
3.Inj. CIPROFLOXACIN 500 mg / iv/ bd
4.inj.PANTOP INFUSION at 1 ml/ hr continuously for 24hrs
5. Sup. SUCRALFATE 15 mg / PO before meal

Day 8: 
 1.IVF- 2 NS at 100 ml/ hr
         1 RL
          DNS
2.Inj. ZOFER 4 mg/ iv/ tid
3.Inj. CIPROFLOXACIN 500 mg / iv/ bd
4.inj.PANTOP INFUSION at 1 ml/ hr continuously for 24hrs
5. Sup. SUCRALFATE 15 mg / PO before meal

Day 9: 
 1.IVF- 2 NS at 100 ml/ hr
         1 RL
          DNS
2.Inj. ZOFER 4 mg/ iv/ tid
3.Inj. CIPROFLOXACIN 500 mg / iv/ bd
4.inj.PANTOP INFUSION at 1 ml/ hr continuously for 24hrs
5. Sup. SUCRALFATE 15 mg / PO before meal
6. Tab DOLO 650 mg PO/ sos
8.Tab parozep  x - x - 1 for 2 weeks

9. Tab. Lonazep 0.25 mg 1 - x - x  for 1 week 

Comments

Post a Comment

Popular posts from this blog

GM assignment

Image
      Pulmonology (case -1) 1)What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem? Evolution of symptomology: 20 yrs back-First episode of shortness of breath(lasted for 1 week during January)and continued in the same pattern for 7 years ↓ 12 years back-Episode lasted for 20 days and continued in the same pattern till 30 days back ↓ Latest episode- lasted for 30 days and not getting relieved on medication ↓ Other symptoms 5 yrs ago-Anaemia 1 month back-Generalised weakness 20 days ago- Hypertension  15 days ago- pitting type of pedal edema and facial puffiness Anatomical localization of the problem: Bronchi and bronchioles of the lung  Primary etiology : The symptoms are probably due to the inhalation of Paddy dust Paddy dust is biologically composed of  plant material fungi: of genus epicocum, ...
Read more

42 Yr old male pt with SPESIS WITH MODS

Image
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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box A.Nikhil  1701006013 42 year old male came to casually with CHEIF COMPLAINTS OF fever since6 days  vomitings since 4 days ( on and off) SOB since 2 days Yellowish discolouration of body, urine since 1 day HOPI Pt was apparently asymptomatic 6 days back then developed fever which is high grade not associated with chills and rigors  Vomiting 2 days ago 1 episode with food as content ,non projectile, non bilious, non blood stained SOB- since 2 days yellowish discoloration of body , urin...
Read more

INTERN ONLINE ASSESSMENT -GRNERAL MEDICINE

Image
 DURING UNIT -4  DUTYS - CASE-1  https://avulanikhil09.blogspot.com/2022/08/gm.html MY ORIENTATION AROUND THIS CASE - 1. WHAT WAS THE POSSIBLE CAUSE OF ANEMIA?  Ans :- ? BLEEDING PER RECTUM  2. Is there any possibility that the patient could be having thalassemia since he has splenomegaly , thalassemia minor and intermedia can present  like an iron deficiency anemia too? Ans :-his HB  electrophoresis reports didn’t show thalassemia CASE -2  https://avulanikhil09.blogspot.com/2022/08/14-yr-male-with-bl-neck-swelling.html CASE -3 https://avulanikhil09.blogspot.com/2022/09/is-online-e-log-book-to-discuss-our.html 1 . What is the sensitivity and specificity of dengue rapid test vs ELISA?Which method is better ? Ans :-The rapid ICT test for IgM when compared with the IgM capture ELISA, it showed a  sensitivity of 92.57%, specificity of 98.53 % , Positive predictive value of 98.03 % and Negative predictive value of 94.37 % REFERENCE:- https://www.i...
Read more