21 YEAR OLD FEMALE WITH ACUTE GASTROENTERITIS

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This is an online E logbook to discuss our patients' de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome. 

Name: Dr Sreshta J

21 YEAR OLD FEMALE CAME WITH THE CHIEF COMPLAINTS OF 
→VOMITINGS SINCE 1DAY
→STOMACH PAIN SINCE 1DAY
→LOOSE STOOLS SINCE TODAY EVENING 

HOPI:
PATIENT WAS APPARENTLY ASYMPTOMATIC ONE DAY AGO, THEN SHE CONSUMED HOSTEL FOOD FOLLOWING WHICH SHE DEVELOPED DIFFUSE STOMACH PAIN WHICH IS OF SQUEEZING TYPE.
SHE HAD 6 EPISODES OF VOMITINGS, NON BILIOUS NON PROJECTILE AND WITH FOOD AND WATER AS CONTENT.
LOOSE STOOLS - 4 EPISODES WATERY IN CONSISTENCY

NO H/O FEVER, HEMETEMESIS, BLOODY DIARRHOEA 

PAST ILLNESS: 
NOT A KNOWN CASE OF DM, HTN, CAD, CVD, EPILEPSY, TB , ASTHMA

PERSONAL HISTORY:
APPETITE- NORMAL
DIET- MIXED
BOWEL AND BLADDER MOVEMENTS- REGULAR (LOOSE STOOLS SINCE EVENING)
SLEEP-ADEQUATE
ADDICTIONS- NONE

ON EXAMINATION:
PATIENT IS CONSCIOUS COHERENT AND COOPERATIVE
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, PEDAL EDEMA 
BP- 110/70MMHG
PR- 112BPM
RR- 20CPM
SPO2- 98% @RA

CVS-S1 S2 HEARD
RS- BAE+
PA- SOFT AND NON TENDER 
CNS- NFND


PROVISIONAL DIAGNOSIS:
ACUTE GASTROENTERITIS 

INVESTIGATIONS:
10/02/2023


11/02/2023















12/02/2023









TREATMENT:
IVF 2 NS @100ML/HR
INJ ZOFER 4MG IV STAT
ORS SACHETS - 1 SACHET IN 1 GLASS OF WATER, 50ML AFTER EACH EPISODE OF LOOSE STOOLS STAT
INJ PAN 40MG IV SOS
INJ NEOMOL 1G IV SOS (IF TEMP>101F)
INJ OPTINEURON 1AMP IN 100ML NS IV OD 
T. REDOTIL 100MG PO BD
T. PCM 650MG PO 6TH HOURLY 


Soap notes
13/02/2023
AMC
Bed no:cubicle
Unit-4
Dr. . Nikitha (SR) 
Dr. Charan (Pgy3) 
Dr.Haripriya (Pgy2) 
Dr. Govardhini (Pgy1) 
S:
C/o 3 vomiting episods today morning 
Not passed stools
No fever spikes
O:
Temp- Afebrile 
Bp-110/70mm hg
Pr- 58bpm
Rr-14cpm
Spo2- 99% on RA

I/O charting:3200/1200ml
Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.
Central Nervous System : patient is conscious coherent and cooperative. Higher mental functions intact 
Per abdomen : soft, non tender. No organomegaly.
A:
Acute gastroenteritis secondary to food poisoning ?Salmonella
P:
IVF-NS with 1Amp OPTINURIN 
RL,DNS@75ml/hr
Inj.METROGYL 500mg IV TID
Inj.PAN 40mg IV OD
Inj. NEOMOL1gm IV SOS if temp> or =101f
Inj.CIPROFLACIN 200mg IV BD








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