A 40 YEAR OLD MALE WITH ACUTE GASTROENTIRITIS

 A 40year old male security guard by occupation  from narketpally was brought to casualty by his wife.


CHEIF COMPLAINTS:-
Cold since 3days
Fever since morning
Loose stools since morning
Pain abdomen since morning 

HISTORY OF PRESENT ILLNESS -

Patient was apparently asymptomatic 3days ago then he developed cold then he developed  high grade fever since morning which is associated with chills and rigors, no aggravating and relieving factors.
-c/o loose stools (10-12episodes) since morning.
-c/o nausea and pain abdomen (umbilical region), diffuse, pricking type of pain.
-No other c/o sob,orthopnea, pnd, chestpain, palpatations.
-No c/o giddiness and lightheadness

PAST HISTORY:

No similar complaints in the past.

No H/o Type II DM , Hypertension, TB, CAD , Epilepsy and Thyroid disorders.

PERSONAL HISTORY:-

Diet: Mixed

Appetite: Normal

Sleep: Adequate

Bowel & bladder: Regular

Patient was a occasionally alcoholic for about 15 years.Usually he consumes beer(1 bottle per one time).
Last intake - 7 days ago 

No allergies

DAILY ROUTINE AND LIFESTYLE:

He work as security guard, his routine is active lifestyle 
6AM - Wakes up 
9AM - Eats breakfast (rice and curry).
Does his duty upto 1pm 
2PM - Lunch(rice and curry).
5PM- Tea
Finishes his duty by 7pm and goes to house by 7:30pm 
8PM - Dinner(rice and some curry).

FAMILY HISTORY:

No significant family history 

GENERAL EXAMINATION:

Patient is conscious, coherent, co-operative to time, place and person and is moderately built and well nourished.

No pallor/icterus/cyanosis/clubbing/Generalized lymphadenopathy/pedal edema.
-Mild Dehydration is present.

VITALS:

Temp: 104°F

PR: 96 bpm

RR: 20cpm

BP: 130/80mmHg

Spo2: 98%@RA

GRBS: 111mg/dl














SYSTEMIC EXAMINATION:

CVS: S1 S2 heard, No murmurs

RS: BAE+

P/A: soft, non tender 

No organometally.

CNS examination: 

GCS- E4V5M6

Pupils -B/L NSRL

Deep tendon reflexes:
             Right.       Left
Biceps:  +2             +2

Triceps: +1             +1

Supinator:. +1        +1

Knee:      +2             +2

Ankle:    +1              +1

Plantar:    -                    -

PROVISIONAL DIAGNOSIS -
?ACUTE GASTROENTERITIS.

INVESTIGATIONS:-(12/7/2023)

BGT: B-POSITIVE

RBS - 85mg/dl

HEMOGRAM:
Hb: 15.4 gm/dl

TLC: 1100

Platelets :2.30

PBS:NC/NC with WBC leukocytosis

Urea: 18mg/dl

Serum Creatinine: 1.0mg/dl

SERUM ELECTROLYTES:

Na: 136

K:3.4

Cl:99

Ca:1.11

LFT:-

Total bilirubin-2.72

Direct bilirubin-0.50

AST-30

ALT-12

ALP- 159

Total protein-5.8

Albumin-3.67

A/G: 1.72

CUE: Albumin-nil

          Sugar- nil

          Epithelial cells - 2-4

          Pus cells -2-3

          Bile pigments-nil
    
          Bile salts-nil

SEROLOGY:

HBsAG - negative 

HCV- negative 

HIV 1/2 -negative

ECG:-


USG ABDOMEN -   No sonlogical abnormalities detected.



TREATMENT -

1)1SACHET ORS IN 1LIT OF WATER 200ML AFTER EACH LOOSE STOOLS EPISODE.

2)INJ.NEOMOL 1GM IV/STAT.

3)I.V FLUIDS 2*NS , 1*RL @100ML/HR.

4)INJ.PAN 40MG IV/BD(AT 8AM AND 8PM).

5)TAB.SPOROLAC DS PO/TID.


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