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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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