CBBLE UDHC SIMILAR CASE STUDY

​ 

 18 yr 

old female patient came with c/o diffuse pain abdomen since 2 weeks 

C/o  vomitings since 5 days 

C/o  loose stools since 2 days 

C/o Fever on and off since 1 week 


HOPI: patient was apparently asymptomatic 2 weeks back then she had diffuse abdominal pain after eating hostel food (5 other people also had similar complaints ) treated conservatively 

From 5 days pt had increased intensity of pain in the lower abdomen- colicky type , intermittent , not radiating to back, sudden in onset  pain not relieving on taking medication and associated with vomitings 

Vomitings - since 5 days (15-20 episodes )

Non bilious , non projectile , food as content . 

Loose stools from 2 days - watery in consistency , no blood in stools 

Fever on and off since 1 week not associated with chills and rigors 

Past history : not a k/c/o DM , HTN, Asthama , Epilepsy , TB , Thyroid .

 O/E: pt is c/c/c 

No signs Of dehydration.

Temp: AFEBRILE 

Bp: 120/80 mmhg 

PR : 87 bpm 

CVS : S1S2  

RS : BAE  

CNS : NAD 

P/A: soft , no guarding , no rigidity , non tender , Bs .

P/R: No external skin changes 

Sphincter tone normal . Rectum collapsed

Gloved finger stained with faecal matter 

X - ray erect abdomen  shows Dilated bowel loops with air fluid levels 

Usg abdomen and pelvis : Dilated  small and large bowel loops with sluggish peristalsis suggestive of paralytic ileus and minimal inter bowel fluid . 

Dx: ACUTE GASTROENTERITIS WITH PARALYTIC ILEUS SECONDARY TO ELECTROLYTE IMBALANCE ?

Rx: 1) NBM till further orders 

      2 ) IVF 2 RL , 1 Ns @ 60 ml/ hr

      3) Inj . PAN. 40 mg IV /od 

      4) Inj. Zofer 4 mg IV /od 

      5) Inj tramodol in 100 ml ns 

      6)Inj ciproflox 200 mg IV BD 

      7) Inj metrogyl 100 ml Tid 


13/33/22

AMC 

S: 

Complaints of vomittings since 5 days loose stools since 2 days And Fever on and off since 1 week 


O: 

Temp: AFEBRILE 

Bp: 120/80 mmhg 

PR : 84

RBS: 117 mg/dl

CVS : S1S2  

RS : BAE  

CNS : NAD 

P/A: soft , diffuse tenderness present, Bowel sounds heard. 

P/R: No external skin changes 

Sphincter tone normal . Rectum collapsed

Gloved finger stained with faecal matter 

X - ray erect abdomen  shows Dilated bowel loops with air fluid levels 


 Review Usg abdomen and pelvis : Dilated  small and large bowel loops with good peristalsisand minimal ascites . 


Hb: 6.5mg/dl 

Sr . Iron :38 ug/dl

Reticulocyte count :0.6%


RFT

Se creatinine: 0.6

B urea: 39

Na 137

K 3.5

Cl 99


A: 

ACUTE GASTROENTERITIS with NUTRITIONAL ANAEMIA MICROCYTIC HYPOCHROMIC

ANEMIA 


P:

1) NBM till further orders 

2 ) IVF 2 RL , 1 Ns @ 60 ml/hr

3) Inj . PAN. 40 mg IV /od 

      4) Inj. Zofer 4 mg IV /od 

      5) Inj buscopan IM /sos 

      6)Inj OFLOX  200 mg IV BD 

      7) Inj metrogyl 100 ml Tid

      8. Inj Iron sucrose 200mg in 100ml ns over 40 min 


14/3/22


AMC 

S: 

Complaints of nausea and vomitting reduced 


O: 

Temp: AFEBRILE 

Bp: 110/70 mmhg 

PR : 90 bpm 

CVS : S1S2  

RS : BAE  

CNS : NAD 

P/A: soft , diffuse tenderness present, Bowel sounds heard. 


Usg abdomen and pelvis : Dilated  small and large bowel loops with good peristalsis and minimal ascites.


Hb: 6.5gm/dl


Na 139

K 3.4

Cl 98


A: 

ACUTE GASTROENTERITIS 

WITH NUTRITIONAL ANEMIA


P:

1) NBM till further orders 

2 ) IVF 2 RL , 1 Ns @ 60 ml/hr

3) Inj. Iron sucrose 200mg in 100ml NS over 40 min

      4) Inj. Oflox 200mg IV BD

      5) Inj Buscopan IM SOS

      6) Inj Pan 40mg IV/OD

      7) Inj metrogyl 400 mg IV/TID

8) Inj. Zofer 4mg IV/OD


15/3/22


AMC 

S: 

Complaints of nausea and vomitting reduced 


O: 

Temp: AFEBRILE 

Bp: 110/80 mmhg 

PR : 90 bpm 

CVS : S1S2  

RS : BAE  

CNS : NAD 

P/A: soft , diffuse tenderness present, Bowel sounds heard. 


Usg abdomen and pelvis : Dilated  small and large bowel loops with good peristalsis and minimal ascites.


Hb: 6.5gm/dl


Na 139

K 3.4

Cl 98


A: 

ACUTE GASTROENTERITIS 

WITH NUTRITIONAL ANEMIA


P:

1) Liquid diet 

2 ) IVF 2 RL , 1 Ns @ 60 ml/hr

3) Inj. Iron sucrose 200mg in 100ml NS over 40 min

      4) Inj. Oflox 200mg IV BD

      5) Inj Buscopan IM SOS

      6) Inj Pan 40mg IV/OD

      7) Inj metrogyl 400 mg IV/TID

8) Inj. Zofer 4mg IV/OD


16/3/22


Ward


S: 

Complaints of nausea and vomitting reduced 


O: 

Temp: AFEBRILE 

Bp: 120/70 mm hg

PR : 74bpm 

CVS : S1S2  

RS : BAE  

CNS : NAD 

P/A: soft , diffuse tenderness present, Bowel sounds heard. 


Usg abdomen and pelvis : Dilated  small and large bowel loops with good peristalsis and minimal ascites.


Hb: 6.5gm/dl


Na 139

K 3.4

Cl 98


A: 

ACUTE GASTROENTERITIS 

WITH NUTRITIONAL ANEMIA


P:

1) Soft diet 


3) Inj. Iron sucrose 200mg in 100ml NS over 40 min

      4) Inj. Oflox 200mg IV BD

      5) Inj Buscopan IM SOS

      6) Inj Pan 40mg IV/OD

      7) Inj metrogyl 400 mg IV/TID

8) Inj. Zofer 4mg IV/sos 

  1. Tab . Orofer Xt Po/ BD

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