GASTEROENTRITIS

 A 51 year old female who is a labourer by occupation  presented to the opd with chief c/o of loose stools , bloating , stomach pain and dry mouth since 10 days . 


CHIEF C/O : 

1) loose stools 

2 ) vomitings 

3).stomach pain since 10 days 


H/O PAST ILLNESS :

 1) N/k/C/o of HTN, DM , TB , CAD , epilepsy 

H/O of PRESENT ILLNESS : 

  No complaints of burning micturition

  No complaints of blood in stools 

  No complaints of fever 

TREATMENT HISTORY : 

    Saline was infused 

     Tablets for motions and stomach pain were given 

PERSONAL HISTORY : 

    Loss of appetite 

     Alc consumption- no 

      Smoking - no 

       Toddy - drank toddy in summer for 20 days 

 FAMILY HISTORY : 

      Nothing significant 

 

PHYSICAL EXAMINATION : 

> GENERAL EXAMINATION 

   No pallor , no cyanosis , no icterus , no lymphadenopathy, no clubbing , dehydration present, no oedema 

1) VITALS : 

     Temp - 98.8 F 

      Pulse rate - 114/min 

      Respiratory rate - 20 / min 

      Bp - 130/100 mm/Hg

       Spo2 - 98%

> SYSTEMIC EXAMINATION 

1) CVS  

Thrills - no 

S1 S2 - positive 

2) RESPIRATORY 

Dysnea - no 

Wheeze - no 

Position of trachea - central 

Breath sounds - vesicular 

3) ABDOMEN 

Shape - scaphoid 

Tenderness - no 

Bowel sounds - yes 

4) CNS 

Conscious - yes 

Speech - normal 

Neck stiffness - no 


INVESTIGATIONS ORDERED : 

Hemogram 

Serology 

Stool for ova and parasites 









PROVISIONAL DIAGNOSIS:

GASTROENTERITIS 


TREATMENT : 

IV fluids  - 10 Ns , 10 RL 

Inj zofer

Tab sporlac 

Cap . Redoteril 

Inj . Pan 40 


   






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