General medicine ELOG : 45 yr old female presented with vomiting,epigastric pain

 GM : ELOG  45 year old female 

NOTE

This is an ongoing case and will be updated .
This e log is made under the guidance of Dr. TEJASWINI 
The reference link (if any) will be mentioned at the bottom.

Date of admission: 30/08/21

HISTORY OF PRESENT ILLNESS- 

  • 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
  • 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, on blood tinged vomiting containing food particles.
  • Loose stools - green colour ,watery, small stools, no tenesmus

PAST HISTORY:

  • Known case of HYPERTENSION since 2 years. On irregular medication. Tab.Atenolol 25 mg.

  • History of hysterectomy 25 years back.

  •  No History of DIABETES MELLITUS, EPILEPSY, TUBERCULOSIS,CORONARY ARTERY DISEASE.

PERSONAL HISTORY:
  • Diet: mixed.
  • Appetite:  decreased
  • Sleep: Adequate
  • Bowel :  loose stools.
  • Micturition: Regular
FAMILY HISTORY:
Not significant

GENERAL EXAMINATION:

  • Patient is conscious, coherent, co-operative.
  • She is well oriented to time, place and person. She is moderately nourished.
  • Pallor - present
  • No icterus
  • No cyanosis
  • No clubbing
  • No lymphadenopathy
  • No Edema.

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

 CARDIO VASCULAR SYSTEM:

• S1 and S2 are heard, no murmurs  heard.

RESPIRATORY SYSTEM:

• Bilateral air entry present

ABDOMINAL EXAMINATION:

• Soft and tender in Epigastric region.

  Bowel sounds are heard.

  No organomegaly.




CENTRAL NERVOUS SYSTEM:

• Reflexes are elicited.

INVESTIGATIONS

HEMOGRAM 30/08/21

   


                                                         
SERUM AMYLASE




ABG


SERUM LIPASE




HEMOGRAM 31/08/21



ANTI HCV ANTIBODIES-RAPID



HIV 1/2 RAPID TEST



HBsAG-RAPID




T3,T4,TSH


POST LUNCH BLOOD SUGAR


PROVISIONAL DIAGNOSIS: ACUTE GASTROENTERITIS

TREATMENT

DAY 1

1.Injections of two bottles of NS and one bottle of RL @100ml/hr.

2.Inj.pan 40mg IV/OD

3..Inj.Zofer IV 4mg TID.

4.Tab.Dolo650mg PO/sos

5.inj.metrogyl500mg i.v. TID

6.Inj.ciprofloxacin 500mg iv/od

7.Monitor vitals.

 DAY 2

 1.Injections of two bottles of NS and one bottle of RL @100ml/hr.

2.Inj.pan 40mg IV/OD

3..Inj.Zofer IV 4mg TID.

4.Tab.Dolo650mg PO/sos

5.inj.metrogyl500mg i.v. TID

6.Inj.ciprofloxacin 500mg iv/od

7.Monitor vitals.

   DAY 3

1.Injections of two bottles of NS and one bottle of RL @100ml/hr.

2.Inj.pan 40mg IV/OD

3..Inj.Zofer IV 4mg TID.

4.Tab.Dolo650mg PO/sos

5.inj.metrogyl500mg i.v. TID

6.Inj.ciprofloxacin 500mg iv/od

7.Monitor vitals.

8.Allow water till tolerated orally.

9.Inj. Phenergan 25mg/IM/OD

10. Syrup Sucralfate 15ml/PO/ before mea

 DAY 4

1.Injections of two bottles of NS and one bottle of RL @100ml/hr.

2.Inj.pan 40mg IV/OD

3..Inj.Zofer IV 4mg SOS.

4.Tab.Dolo650mg PO/sos

5.inj.metrogyl500mg i.v. TID

6.Inj.ciprofloxacin 500mg iv/od

7.Monitor vitals.

8.Allow water till tolerated orally.

9.Inj. Phenergan 25mg/IM/OD

10. Syrup Sucralfate 15ml/PO/ before meal

11. Inj PANTOP infusion 8ml/hour.

           .  Day 4  9:15 am

One episode of vomiting after allowing oral sips of fluid

1.max dose 240mg/ day

   1 vial (5 ml) dilution---40 mg

Add 10 vials is 50 ml syringe

 50 ml --- 400mg

   1 ml --- 8 mg

1 ml/hour infusion continuosly for 24 hours

2. GRBS 6 th hourly.

3.Inj.Zofer IV 4mg TID.

4.Tab. Promethazine TID

5.inj.metrogyl500mg i.v. TID

6.Inj.ciprofloxacin 500mg iv/od

7.Monitor vitals.




DAY 5

  • Temperature: Febrile
  • Pulse rate: 82bpm
  • Respiratory rate: 15/min
  • Blood pressure: 120/80 mm Hg 
  • P/A soft and not tender

TREATMENT 

1.Injections of two bottles of NS and one bottle of RL @100ml/hr.
2.Inj.pan 40mg IV/OD
3..Inj.Zofer IV 4mg SOS.
4.Tab.Dolo650mg PO/sos
5.inj.metrogyl500mg i.v. TID
6.Inj.ciprofloxacin 500mg iv/od
7.Monitor vitals.
8.Allow water till tolerated orally.
9.Tab Promethazine TID
10. Syrup Sucralfate 15ml/PO/ before meal
11. Inj PANTOP infusion 1ml/hour



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