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Date of admission: 08/02/2022
A 19 year old male , student by profession came to OPD with
Chief complaints of
•Pain in abdomen since 3 days
•Vomiting 2 episodes since 3 days
•Loose stools since 3 days, 5 to 6 episodes per day
History of presenting illness:
•Patient was apparently asymptomatic 3 days back, then he developed lower abdominal pain, sudden in onset, continous colicky in nature and radiating to left lower abdomen, aggravating pain before defecation associated with 2 episodes of vomiting, non bilious, non projectile, food as content
•H/O loose stools since 3 days ,5 to 6 times per day ( watery stools )
•H/O fever 1 episode associated with chills and rigor after which he went to local hospital for above complaints where conservative management was done
•H/O of intake of Mutton in function 3 days back
•No history of similar complaints in the past
History of past illness:
•No history of DM/Hypertension/ Asthma/TB/CVA/CKD/Thyroid
Personal History:
•Diet: mixed
•Appetite: normal
•Sleep: normal
•Bowel: diarrhea (last episode was around 10 am and stopped after medications)
•Bladder: normal
•Addictions:
▪︎Patient has history of occasional consumption of toddy since young age (around 2 glasses of disposable glass)
▪︎Consumes during festivals
▪︎Last consumption was on 4th February (one glass of disposable glass)
Family history:
No relevant history
General Examination:
•Patient is conscious, coherent and cooperative
•No pallor,icterus,cyanosis,clubbing,
koilonychia, lymphadenopathy and pedal edema
Vitals:
•Pulse rate :115 bpm
•BP:110/70 mmhg
•Temperature: Afebrile
Systemic Examination:
□CVS:
S1,S2 heard
No Murmurs or thrills
□Respiratory system:
•NVBS- present
•BAE- present
□CNS:
Patient is conscious, coherent and orients to time, place and person
□Per abdomen:
Inspection:
•Obese abdomen
•Umbilicus is central and inverted
•No engorged veins, scars seen
•No visible pulsations
Palpation:
•Mild tenderness at left iliac fossa
•No hepatosplenomegaly
Percussion:
•No free fluid
Auscultation:
•Bowel sounds heard
Clinical images:
Provisional diagnosis:
Acute gastroenteritis? Viral hepatitis
Investigations:
Ultra sound (Abdomen)
ECG
Treatment:
Day 1
1)Inj.PAN 40 mg iv
2)Inj.Zofer 4 mg iv
3)IV fluids -NS and RL 70ml/hr
Day 2
S:
Tenderness decreased at left iliac fossa when compared to yesterday
O:
Patient is conscious, cohesive and coherent.
PR: 82 BPM
BP: 110/ 70 mmhg
P/A: Tenderness decreased at left iliac fossa
A: GASTROENTERITIS
P:
1) Inj. PAN 40 mg iv
2) Inj. ZOFER 4 mg iv
3) iv fluids - NS and RL 70 ml/hr.
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