A 18 YEAR OLD FEMALE WITH PAIN IN THE ABDOMEN ALONG WITH VOMITINGS AND LOOSE STOOLS

       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 SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT

A 18 year old girl came to OPD  with C/o diffuse pain the abdomen  since 2 weeks , fever ( on and off ) from last 1 week, vomitings since 1 week ,loose stools from last 2 days .

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 .

Family history: no similar complaints in the family members.

Personal History :

DIET: MIXED

 APPETITE : decreased 

BOWEL AND BLADDER :REGULAR 

SLEEP :INADEQUATE

General Examination: 

O/E: pt is c/c/c 

No signs Of dehydration.

Temp: AFEBRILE 

Bp: 120/80 mmhg 

PR : 87 bpm 

Systemic Examination: 

CVS : S1S2  

RS : BAE  

CNS : NAD 

abdomen : soft, diffuse tenderness present, normal bowel sounds heard

sphincter tone normal ,rectum collapsed, gloved finger stained with faecal matter

X - ray erect abdomen  shows Dilateod 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 . 

Hb: 6.9 GM/dl 

RFT:

Blood urea:39

serum creatinine:0.6

Na:137

K:3.5

Cl :99

LFT:

Total bilirubin:1.o4

Direct bilirubin:0.24

AST:21

ALT:22

TP:6.3

Albumin:4

A/G:1.73

IMAGES: 

USG :

provisional diagnosis: ACUTE GASTROENTERITIS ALONG  WITH ANAEMIA?

Treatment:

 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