A 50 year old male with acute Gastroenteritis

UNIT 4 ADMISSION:-

A 50 year old male came to casuality with complaints of
Vomiting since 2 hours
Loose stools since 2 hours
HOPI:
Pt was apparently asymptomatic 2 hours back then he had vomitings 4-5 episodes, nonbilious in nature,non projectile, food particles as content and h/o loose stools since 2 hours,watery in consistency, 
No h/o fever,cold,cough, burning micturition 
No h/o pain abdomen
Past history:
No similar complaints in the past
He is a a k/c/o HTN since 3 years and on Tab.telma 20 mg Po/od and 
Depression and on tab.sizdon 25mg Po/od
Not a k/c/o DM type 2/ASTHMA/EPILEPSY/TB
He is a non alcoholic and non smoker

O/E: 
Pt is conscious , oriented to time , place , person
 
No pallor , Icterus, cyanosis , clubbing, lymphadenopathy , edema. 

Vitals: 
Temp - 98.7
BP - 90/60mm of hg
PR - 112 bpm 
Spo2 - 96%at RA 
RR- 18cpm
GRBS - 149 mg/dl 

Systemic examination: 

Cvs: s1 s2 present , no murmurs

Rs: BAE present, normal vesicular breath sounds present. 

P/A: soft, non tender 

cns-intact 
Investigations:


Hemogram: HB:13.3
TLC: 4000 
N: 92
L: 05
PLT- 1.10 lakhs/cu.mm

RBS -142

RFT:-
Blood urea- 59
Serum creatinine - 1.4 mg/dl 
Na- 140
K- 4.2
Cl- 102

ALP-157
 
 
Provisional diagnosis: Acute Gastroenteritis

Treatment:
 Plenty of oral fluids
Inj.pan 40mg iv od
Inj.zofer 4mg iv od
Inj.ceftrioxone 1gm iv bd

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