A 66/F WITH C/O FEVER(ON/OFF),INCREASED FREQUENCY OF STOOLS,NAUSEA AND VOMITINGS
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Unit 6:
Case admitted in female ward on 6/2/2021.
Interns
K.Divya Rachana
K. Nikhil reddy
M. Swarna
B.Manivarma
Juveria
Dr. Manasa(pgy1)
Dr. Rashmitha(pgy2)
Dr. A. Vaishnavi (pgy2)
Dr. Sai Radha(pgy3)
Dr. Hareen (SR)
Dr. Arjun Kumar(asst.proff)
Dr.Praveen Naik( asst.proff)
INCREASED FREQUENCY OF STOOLS-3 EPISODES/DAY SINCE 2 DAYS-NORMAL IN CONSISTENCY,NOT ASSOCIATED WITH BLOOD/ MUCUS.
NAUSEA AND VOMITINGS SINCE 2 DAYS-
10 EPISODES/DAY,NON PROJECTILE,NON BILIOUS,FOOD PARTICLES AS CONTENTS.
VOMITINGS AFTER HALF AN HOUR OF FOOD INTAKE
NO HISTORY OF SIGNIFICANT WEIGHT LOSS
HISTORY OF SIMILAR COMPLAINTS IN THE PAST-3 MONTHS AGO.
NOT A KNOWN CASE OF HTN,DM,TB,CAD,ASTHMA,CVA, THYROID DYSFUNCTION, EPILEPSY.
SHE'S MARRIED,FARMER BY OCCUPATION BUT STOPPED WORKING 2 YEARS AGO.
SHE CONSUMES MIXED APPETITE WITH NORMAL APPETITE.
SHE HAS REGULAR BLADDER AND BOWEL MOVEMENTS AND ADEQUATE SLEEP.
SHE CONSUMES BETEL NUT AND BETEL LEAF SINCE 10 YEARS.
ON EXAMINATION-
PATIENT CONSCIOUS COHERENT COOPERATIVE
NO PALLOR, ICTERUS CYANOSIS CLUBBING LYMPHADENOPATHY PEDAL EDEMA
SHE LOOKS MALNOURISHED
TEMP 100.2 F
BP 120/80 MM OF HG
PR-96 BPM
SPO2-99 @ ROOM AIR
GRBS 83 MG/DL
CVS-S1 S2 HEARD
RS-BAE+, VESICULAR BREATH SOUNDS
P/A-
SHAPE-OBESE
DIFFUSE TENDERNESS
NO ORGANOMEGALY
PROVISIONAL DIAGNOSIS-
ACUTE GASTROENTERITIS WITH AKI(INTRINSIC)
TREATMENT-
DAY 1-
IV FLUIDS- @ 100 ML/HR
1 PINT NS
1 PINT RL
1 PINT DNS
INJ PAN 40 MG IV/BD
INJ ZOFER 4 MG IV/TID
INJ METROGYL 100 ML/IV/TID
INJ CIPROFLOXACIN 500 MG IV/BD
TAB PCM 659 MG/TID
TEPID SPONGING ALSO ADVICED
INJ NEOMOL 1 GM IV/SOS IF TEMP > 101° F
INJ BUSCOPAN 2 CC IV BD
