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Date of admission: 08/07/2023 
A 30 year patient, farmer by occupation came to casualty with complaints loose stools since 1 day 
Patient was apparently asymptomatic one day ago when he had consumed food (fried rice) from a new place after which he developed 27-28 episodes of loose stools.
The stools were large in quantity losse in consistency and non foul smelling 
Associated with complaint of burning micturition since one day
No Associated discolouration of stools,no decrease in urinary output, no blood in urine and stools, pus in urine seen 
Associated with diffuse abdominal pain 
Associated with high grade fever, intermittent duration 
No Associated rigor, chills, cough, SOB, sore throat 
Past history: 
The patient is not a known case of Diabetes/ hypertension/ asthma /TB/ CKD/CVD/Thyroid disorders
No h/o any blood transfusions 
No h/o surgery 
Personal History: 
DIET: mixed 
APPETITE: decreased 
SLEEP: adequate 
BOWEL AND BLADDER MOVEMENTS : 20- 25 episodes of loose stools per day 
ADDICTION: occasional consumption of alcohol 
ALLERGY :nil 
Treatment history: Not significant 
Family history: Not significant 
Consent: Consent was taken from patient before Examination 
General Examination:
Patient is conscious, coherent, cooperative and well oriented to time, place and person 
Moderately built andnourished 
No pallor, icterus, cyanosis, clubbing, koilonychia, pedal edema, bilateral lymphadenopathy
Vitals: on 08/07/2023 
•BP- 120/70 mmhg 
•Pulse- 64 bpm
•Respiratory rate- 16Cpm
•SpO2- 96%
•Temperature - 101°F
Systemic Examination: 
Abdominal Examination 
•Inspection: 
Truncal obesity is seen 
Position of umbilicus: central and inverted 
No Scars and sinuses , visible pulsations 
No visible peristalsis 
No engorged veins 
•Palpation
No tenderness 
No local rise of temperature 
No organomegaly seen 
•Auscultation
Bowel sounds are heard 
CVS 
S1,S2 heard 
No murmurs 
Respiratory system 
BAE present 
NVBS  heard 
CNS 
Reflexes are intact 
No functional deficit seen 
Provisional diagnosis: Gastroenteritis -?Toxin mediated
On 08/08/2023
Investigations
HEMOGRAM
Hb-14.5gm/dl
TLC-5,300cells/cumm
 Neutrophils:79
 Lymphocytes: 11
 Eosinophils:01
 Monocytes:09
 Basophils:00
PCV:42.4
MCV:88.3
MCH:30.2
RDW CV:11.9
RDW SD:38.9
RBC count:4.80
Platelet count:1.51lakh/cumm
COMPLETE URINE EXAMINATION
Colour:Pale yellow
Appearance:Clear
Reaction:Acidic
SP.gravity:1.010
Albumin:+
Sugar:Nil
Bile salts:Nil
Bile pigments: Nil
Pus cells:3-6
Epithelial cells:2-4
Red blood cells:Nil
Casts:Nil
Crystals:Nil
Amorphous deposits:Absent
Others:Nil
Blood urea: 26
Serum creatinine: 1.0
Hbs Ag RAPID:Negative
HIV 1/2 Rapid test:non
Reactive
LIVER FUNCTION TEST
Direct bilirubin:0.24gm/dl
Total bilirubin:0.86gm/dl
AST:27 IU/L
ALT:40 IU/L
Alkaline phosphatase:113 IU/L
Total protein: 6.4 gm/dl
Albumin:4.08 gm/dl
A/G Ratio:1.76
SERUM ELECTROLYTES
Sodium-141mEQ/L
Potassium -3.8 mEQ/L
Chloride-106 mEQ/L
Calcium-1.16 mmol/L
USG Abdomen: Borderline splenomegaly
TREATMENT: 
1) IV FLUIDS 2NS @75ML/HR
2) INJ.PCM 1GM IV/SOS
IF TEMP >101F
3) INJ OPTINEURON IN 100ML NS IV/OD
4) TAB.SPOROLAC PO/OD
5) TAB.PAN 40MG PO/OD
6) TAB.DOLO 650MG PO/sos
7) TAB. ZOFER 4MG PO/SOS
8) PLENTY OF ORAL FLUIDS 
9) MONITOR BP,PR,RR,TEMP EVERY 4TH HOURLY
On 09/7/23
Vitals:
Bp-120/80 mm of hg
PR-88 bpm
Temperature -97°F
RR-16cpm
Investigations
RENAL FUNCTION TEST 
Urea-20mg/dl
Creatinine-1.1mg/dl
Uric acid-4.6mg/dl
Calcium-9.8
Phosphorus -2.9
Sodium-138
Potassium -3.6
Chloride -102mEq/l
Hemogram
Hb: 13.7gm/dl
TLC: 4,200cells/cumm
 Neutrophils:73
 Lymphocytes: 17
 Eosinophils-01
 Monocytes:09
 Basophils:00
PCV:40
MCV:88.3
MCH:30.2
MCHC:34.3
RDW-CV:11.9
RDW-SD:39.2
RBC-4.53 million/cumm
Platelet count -1.5 lakh/cumm
TREATMENT: 
1) IV FLUIDS 2NS @75ML/HR
2) INJ.PCM 1GM IV/SOS
IF TEMP >101F
3) INJ OPTINEURON IN 100ML NS IV/OD
4) TAB.SPOROLAC PO/OD
5) TAB.PAN 40MG PO/OD
6) TAB.DOLO 650MG PO/sos
7) TAB. ZOFER 4MG PO/SOS
8) PLENTY OF ORAL FLUIDS 
9) MONITOR BP,PR,RR,TEMP EVERY 4TH HOURLY
On 10/07/2023 
 
Vitals:
Temperature: afebrile 
Bp:120/80 mmhg
PR:80 bpm
RR: 16 cpm
Temperature -97°F
Spo2-98 %@ room temperature
TREATMENT: 
1) IV FLUIDS 2NS @75ML/HR
2) INJ.PCM 1GM IV/SOS
IF TEMP >101F
3) INJ OPTINEURON IN 100ML NS IV/OD
4) TAB.SPOROLAC PO/OD
5) TAB.PAN 40MG PO/OD
6) TAB.DOLO 650MG PO/sos
7) TAB. ZOFER 4MG PO/SOS
8) PLENTY OF ORAL FLUIDS 
9) MONITOR BP,PR,RR,TEMP EVERY 4TH HOURLY
On 11/07/23
Vitals:
Temperature: Afebrile
Bp: 120/80mm of hg
PR: 84bpm
RR: 18cpm
Temperature -98.5°F
Spo2-98%@ room temperature 
Investigations 
Hemogram
Hb: 15.0gm/dl
TLC :4,000cells/cumm
 Neutrophils:40
 Lymphocytes: 48
 Eosinophils:02
 Monocytes:02
 Basophils:00
PCV:42.6
MCV:86.6
MCH:30.5
MCHC:35.2
RDW-CV:11.9
RDW-SD:38.5
RBC count:4.92million/cumm
Platelet count:1.65 lakhs/cumm
Renal function test:
Urea: 24mg/dl
Creatinine:0.9
Uric acid:4.0
Calcium:9.6
Phosphorus: 3.2
Sodium:140
Potassium: 4.2
Chloride: 103
TREATMENT: 
1) IV FLUIDS 2NS @75ML/HR
2) INJ.PCM 1GM IV/SOS
IF TEMP >101F
3) INJ OPTINEURON IN 100ML NS IV/OD
4) TAB.SPOROLAC PO/OD
5) TAB.PAN 40MG PO/OD
6) TAB.DOLO 650MG PO/sos
7) TAB. ZOFER 4MG PO/SOS
8) PLENTY OF ORAL FLUIDS 
9) MONITOR BP,PR,RR,TEMP EVERY 4TH HOURLY
                           FEVER CHART 
Date of discharge: 12/07/2023 
 
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