27 yr old male patient with Acute gastro enteritis


 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 a series of inputs available global online community of experts with the aim to solve the patient’s clinical problems with the collective current best evidence based inputs. This E log reflects my patient centred online learning portfolio and your valuable inputs in the comments section.




27 year old male came to OPD with complaints of fever for 5 days, abdominal discomfort since 5 days, nausea, vomiting ,loose stools since 5 days, burning micturition since 3 days.




 Patient was apparently asymptomatic 5 days back who works as a car driver since 5 years who was occasional Toddy drinker ( 1 glass of intake for any occasional festival ) 



5 days ago he went to function where he consumed 1 litre of Toddy along with red meat , following next day he experienced pain abdomen which was squeezing type predominantly in epigastric region diffuse type associated with nausea & vomiting 10 to 12 episodes/day. Whenever he consumes water or food he has vomitings - nonbilious, non projectile, water or food as content for 3 days now the frequency reduced to 4 /day 


LOOSE STOOLS - watery, small volume, no blood or mucus in stools


 FEVER low-grade, intermittent , associated with burning micturition not associated with chills& rigors cold , cough, weakness ,joint pains




O/E : 


Pt is c/c/c 


Vitals : 


Temp: 99.4 f


HR: 100 bpm


RR : 14cpm


BP : 100/70 mm hg


Spo2: 99 @ RA


GRBS : 106 mg/dl 











SYSTEMIC EXAMINATION : 




CVS : S1 S2 + . 


RS : BAE + NVBS + 


PA: mild tenderness in epigastric region 


CNS : NAD 













DIAGNOSIS : Acute gastro enteritis 




TREATMENT : 


IVF : NS , RL @ 100ml/hr 


INJ. ZOFER 4mg IV /BD


INJ.PANTOP 40mg IV/BD


INJ.PCM 650mg po/TID 


INJ.NEOMOL 1g sos(if temp >101 f ) 


INJ. OPTINEURON 1amp in 100ml NS IV/BD


INJ. TRAMADOL 1amp in 100ml NS IV/BD






Investigations:




















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