45 year old female with acute gastroenteritis

This is Online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent .Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. 

CASE:
UNIT 1

A 45 year old female , resident of miryalaguda  presented with the complaints of 

vomiting since 1 month, 
epigastric pain since 1 month , 
Loose stools since 10 days

History of present illness:

She was diagnosed to be hypertensive 2 years back and on  medication.

She first developed fever along with headache 1 month back which lasted for 2 days followed by vomiting everyday 1-2 episodes / day for the last 25 days . Since  last 1 week she has been experiencing 10-12 episodes of non projectile ,non bilious,non blood tinged vomiting containing food particles.

Loose stools - green colour ,watery, small stools, no tenesmus

H/O facial puffiness, B/ L pedal edema  and decreased urine output for 10 days.

Past history:
K/c/o hypertensive since 2 years

H/O hysterectomy 25 years back

Personal history:

Normal appetite

Decreased urine output

Normal bowel movements

H/O occasional toddy comsumption 

On examination:

 The patient is conscious,coherent and cooperative 

moderately built and nourished


Vitals: 
BP: 90/60 mmHg
PR: 123bpm
Temp: 98.4 F 
SpO2 : 98% at RA
GRBS : 142mg% 

P/A: soft ,non tender

CVS: S1,S2 heard

RS: decreased breath sounds in B/ L ISA ,IAA

 CNS: normal


INVESTIGATIONS:

 CHEST X RAY



HEMOGRAM

   


                                                           




SERUM AMYLASE




ABG


SERUM LIPASE



 
HEMOGRAM



ANTI HCV ANTIBODIES-RAPID



HIV 1/2 RAPID TEST



HBsAG-RAPID




T3,T4,TSH


POST LUNCH BLOOD SUGAR




RFT:
serum electrolytes:
   Na :137
   K :3.3
   Cl :98
Serum creatinine:0.9
Blood urea:14

LFT:
Direct bilirubin:0.72
Total bilirubin:2.07
ALT:27
AST:64
ALP:113
Albumin:3.1
Total protein:5.9
A/G ratio:1.11

Endoscopy upper GI:
Shows small hiatus hernia 
Erosive gastritis
 
Psychiatric referral:

Pychogenic vomiting
Adjustment illness due to medical illness
Nicotine dependence syndrome

Provisional diagnosis:
Acute severe erosive gastritis with small hiatus hernia 
 K/c/ o hypertensive since 2 years



TREATMENT:
DAY1:

1.IVF- 2 NS at 100 ml/ hr
         1 RL
          DNS
2.Inj. ZOFER 4 mg/ iv/ tid
3.Inj. METROGYL 500 mg / iv/ tid
4.Inj. CIPROFLOXACIN 500 mg / iv/ bd
5.inj.PANTOP INFUSION at 1 ml/ hr continuously for 24hrs
6. Tab.DOLO 650 mg  po/ SOS
7. Sup. SUCRALFATE 15 mg / PO before meal

Day2:

1.IVF- 2 NS at 100 ml/ hr
         1 RL
          DNS
2.Inj. ZOFER 4 mg/ iv/ tid
3.Inj. METROGYL 500 mg / iv/ tid
4.Inj. CIPROFLOXACIN 500 mg / iv/ bd
5.inj.PANTOP INFUSION at 1 ml/ hr continuously for 24hrs
6. Tab.DOLO 650 mg  po/ SOS
7. Sup. SUCRALFATE 15 mg / PO before meal

Day 3:

1.IVF- 2 NS at 100 ml/ hr
         1 RL
          DNS
2.Inj. ZOFER 4 mg/ iv/ tid
3.Inj. METROGYL 500 mg / iv/ tid
4.Inj. CIPROFLOXACIN 500 mg / iv/ bd
5.inj.PANTOP INFUSION at 1 ml/ hr continuously for 24hrs
6. Tab.DOLO 650 mg  po/ SOS
7. Sup. SUCRALFATE 15 mg / PO before meal

Day 4:
1.IVF- 2 NS at 100 ml/ hr
         1 RL
          DNS
2.Inj. ZOFER 4 mg/ iv/ tid
3.Inj. METROGYL 500 mg / iv/ tid
4.Inj. CIPROFLOXACIN 500 mg / iv/ bd
5.inj.PANTOP INFUSION at 1 ml/ hr continuously for 24hrs
6. Tab.DOLO 650 mg  po/ SOS
7. Sup. SUCRALFATE 15 mg / PO before meal

Day5:

1.IVF- 2 NS at 100 ml/ hr
         1 RL
          DNS
2.Inj. ZOFER 4 mg/ iv/ tid
3.Inj. CIPROFLOXACIN 500 mg / iv/ bd
4.inj.PANTOP INFUSION at 1 ml/ hr continuously for 24hrs
5. Tab.DOLO 650 mg  po/ SOS
6. Sup. SUCRALFATE 15 mg / PO before meal

Day 6:
 1.IVF- 2 NS at 100 ml/ hr
         1 RL
          DNS
2.Inj. ZOFER 4 mg/ iv/ tid
3.Inj. CIPROFLOXACIN 500 mg / iv/ bd
4.inj.PANTOP INFUSION at 1 ml/ hr continuously for 24hrs
5. Sup. SUCRALFATE 15 mg / PO before meal

Day 7: 
 1.IVF- 2 NS at 100 ml/ hr
         1 RL
          DNS
2.Inj. ZOFER 4 mg/ iv/ tid
3.Inj. CIPROFLOXACIN 500 mg / iv/ bd
4.inj.PANTOP INFUSION at 1 ml/ hr continuously for 24hrs
5. Sup. SUCRALFATE 15 mg / PO before meal

Day 8: 
 1.IVF- 2 NS at 100 ml/ hr
         1 RL
          DNS
2.Inj. ZOFER 4 mg/ iv/ tid
3.Inj. CIPROFLOXACIN 500 mg / iv/ bd
4.inj.PANTOP INFUSION at 1 ml/ hr continuously for 24hrs
5. Sup. SUCRALFATE 15 mg / PO before meal

Day 9: 
 1.IVF- 2 NS at 100 ml/ hr
         1 RL
          DNS
2.Inj. ZOFER 4 mg/ iv/ tid
3.Inj. CIPROFLOXACIN 500 mg / iv/ bd
4.inj.PANTOP INFUSION at 1 ml/ hr continuously for 24hrs
5. Sup. SUCRALFATE 15 mg / PO before meal
6. Tab DOLO 650 mg PO/ sos
8.Tab parozep  x - x - 1 for 2 weeks
9. Tab. Lonazep 0.25 mg 1 - x - x  for 1 week

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