22 yr old male with vomitings and loose stools
22 yr old male resident of lingotum,works in agarbathi factory came with c/o vomiting since morning 10 am,loose stools since morning 10 am.
HOPI: pt was apparently asymptomatic till today morning,he had h/o packed food consumption followed by c/o loose stools assc with ?pus 4-6 episodes since today morning.
c/o vomiting 3-5 episodes assc with food particles,non bilious.
no c/o fever,cold,cough.
c/o abdominal pain-diffuse,tenderness in epigastrium,Right hypochondrium,umbilicus.
no c/o SOB,orthopnoea,PND.
PAST H/O:
no similar complaints in the past
no h/o HTN,DM,CVA,CAD,TB,EPILEPSY.
PERSONAL H/O:
occasional alcoholic weekly once since 6-7 years
occasional smoker.
VITALS:
BP-90/60mmhg
PR:110/m
RR:20/m
TEMP:97.7 F
GENERAL EXAMINATION:
CVS:S1S2 +
RS:BAE +
CNS: NAD.
DIAGNOSIS:ACUTE GASTROENTERITIS
1.INJ.PAN 40mg/stat
2.INJ.ZOFER 4mg/stat
3.IVF.RL in 1 hr and NS in another hr i/v/o BP:80/60mmhg after 3 hours BP:100/70.than IVF.NS 100ml/hr was continued.
4.INJ.METROZYL 500mg IV/TID
notes 20/5/22 ICU BED 3
s-vomiyings 2-3 episodes
losse stools 2 episodes
diffuse abdominal pain
O-o/e pt is c/c/c
no pallor, icterus, cyanosis, clubbing, lymphadenopathy.
dehydration +
BP-100/70
PR-120
RR-20
TEMP-97.8
A-ACUTE GASTRO ENTERITIS
p-
1.IVF.NS AND RL 100ml/hr
2.INJ.ZOFER 4mg/IV/TID
3.ORS SACHETS IN 1LITRE OF WATER PO
4.INJ METROGYL 500mg IV/TID
5.BP/PR/RR/TEMP CHARTING
soap notes 23/5/22 AMC BED 1
s-no vomiting episodes
no c/o loose stools
O-
o/e pt is c/c/c
no pallor, icterus, cyanosis, clubbing, lymphadenopathy.
BP-110/70
PR-84
RR-18
TEMP-98.4
A-ACUTE GASTRO ENTERITIS
p-
1.IVF.NS AND RL 100ml/hr
2.Tab.zinc sulphate 10 mg/PO/BD
3.BP/PR/RR/TEMP CHARTING
