A 40YR OLD MALE WITH ACUTE GASTROENTERITIS.

VASANTHI REDDY.L

This is an 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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.

July 7,2023.

A 40year old male, security guard by occupation  from narketpally was brought to casualty by his wife

CHEIF COMPLAINTS:-
1)cold since 3days
2)fever since morning
3)loose stools since morning
4)pain abdomen since morning 

HISTORY OF PRESENT ILLNESS -

Patient was apparently asymptomatic 3days ago then he developed cold following which he developed fever since morning,high grade associated with chills and rigors,no aggravating and relieving factors.
-c/o loose stools (10-12episodes) since morning.
-c/o nausea and pain abdomen (umbilical region), diffuse,pricking type of pain.
-No other c/o sob,orthopnea,pnd,chestpain, palpatations.
-No c/o giddiness / lightheadness

PAST HISTORY:

No similar complaints in the past.

No H/o Type II DM , Hypertension, TB, CAD , Epilepsy and Thyroid disorders.

PERSONAL HISTORY:-

Diet: Mixed

Appetite: Normal

Sleep: Adequate

Bowel & bladder: Regular

Patient was a occasionally alcoholic for about 15 years.Usually he consumes beer(1 bottle per one time).
Last intake - 7 days ago 

No allergies

DAILY ROUTINE AND LIFESTYLE:

He work as security guard, his routine is active lifestyle 
He wakes up at 6am in the morning, eat breakfast (rice and curry).
Do his duty upto 1pm and have lunch(rice and curry).
Have tea at time of 5pm.
Finishes his duty by 7pm and goes to house by 7:30pm and have dinner(rice and some curry).

FAMILY HISTORY:

No significant family history 

GENERAL EXAMINATION:

Patient is conscious,coherent, co-operative to time,place and person.

Moderately built, well nourished.

No pallor/icterus/cyanosis/clubbing/Generalized lymphadenopathy/pedal edema.
-Mild Dehydration is present.

VITALS:

Temp: 104°F

PR: 96 bpm

RR: 20cpm

BP: 130/80mmHg

Spo2: 98%@RA

GRBS: 111mg/dl

SYSTEMIC EXAMINATION:

CVS: S1 S2 heard, No murmurs

RS: BAE+

P/A: soft, non tender 

No organometally.

CNS examination: 

GCS- E4V5M6

Pupils -B/L NSRL

Deep tendon reflexes:
             Right.       Left
Biceps:  +2             +2

Triceps: +1             +1

Supinator:. +1        +1

Knee:      +2             +2

Ankle:    +1              +1

Plantar: - -

PROVISIONAL DIAGNOSIS -
?ACUTE GASTROENTERITIS.

INVESTIGATIONS:-(7/7/2023)

BGT: B-POSITIVE

RBS - 85mg/dl

HEMOGRAM:
Hb: 15.4 gm/dl

TLC: 1100

Platelets :2.30

PBS:NC/NC with WBC leukocytosis

Urea: 18mg/dl

Serum Creatinine: 1.0mg/dl

SERUM ELECTROLYTES:

Na: 136

K:3.4

Cl:99

Ca:1.11

LFT:-

Total bilirubin-2.72

Direct bilirubin-0.50

AST-30

ALT-12

ALP- 159

Total protein-5.8

Albumin-3.67

A/G: 1.72

CUE: Albumin-nil

          Sugar- nil

          Ep cells - 2-4

          Pus cells -2-3

          Bile pigments-nil
    
          Bile salts-nil

SEROLOGY:

HBsAG - negative 

HCV- negative 

HIV 1/2 -negative

ECG:-

USG ABDOMEN -   No sonlogical abnormalities detected.



TREATMENT -
1)1SACHET ORS IN 1LIT OF WATER 200ML AFTER EACH LOOSE STOOLS EPISODE.
2)INJ.NEOMOL 1GM IV/STAT.
3)I.V FLUIDS 2*NS , 1*RL @100ML/HR.
4)INJ.PAN 40MG IV/BD(AT 8AM AND 8PM).
5)TAB.SPOROLAC DS PO/TID.







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