40 yr old male with acute diarrhea 2° to ?Food poisoning
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A 40 year old male businessman came to the hospital with the complaints of :
Generalised weakness since 3 to 4 days
Loose stools associated with blood since 3 to 4 days .
HOPI:
Patient was apparently asymptomatic 4 days back.patient went to cousins marriage there he had H/O food consumption followed by complaints of loose stools for two days 15 to 20 times/day . Two days ago he was admitted in the local hospital for two days where symptoms hasn't been resolved from presentation . He complained of blood in stools yesterday morning for 10 to 12 episodes .
No C/O nausea/ vomiting
No c/o fever, cold, cough
No c/o chest pain , palpitations , syncopal attack
No c/o sob, orthopnea, PND
Past history:
No H/o Diabetes, HTN, CAD, Asthma , TB
No H/o surgeries
Personal history:
Diet: mixed
Appetite: normal
Sleep: adequate
B&B: regular
Addictions: Alchohol since 5 years , 2 to 3 times a week /90 ml/day ; non smoker
On examination:
Vitals:
Temp: 101°F
PR: 110 bpm
RR: 22 cpm
BP: 130/80 mm Hg
Spo2 : 98% at RA
Grbs: 138 mg%
Systemic examination:
Cvs: S1 S2 heard
RS: position of trachea is central, BAE present
Normal vesicular breath sounds heard .
Abdomen:
Shape of abdomen: scaphoid
No tenderness
No palpable masses
CNS: NAD
Provisional diagnosis:
Acute diarrhoea secondary to ? Food poisoning with mixed hyperbilirubinemia
c/o abd.pain during passing stools
Investigations:-
Hemogram
HB- 10.7
TLC- 2600 cells/cu mm
PLT- 1.5
Neutrophills-60
Lymphocytes-27
Eosinophils-03
Monocytes-10
Basophills-0
CUE-
Albumin- +
Pus cells- 3-6
Epithelial cells- 2-4
RBC - 2-3
Serology for HIV,HCV,HbsAg- Non reactive
SARS COVID 19- Negative
LFT
TB-3.24
DB-1.10
AST-40
ALT-36
ALP-124
TP-4.9
ALBUMIN-2.5
RFT
Blood urea-26
Serum creatinine-0.9
Serum Na-130
Serum k-3.5
Serum cl-99
Chest x ray-
USG-
Treatment given:-
Day 1:
IV FLUIDS -2NS, 2RL
1) Inj.Pan 40 mg IV OD
2) Inj.Zofer 4mg IV SOS
3) Inj.Metrogyl 500 mg IV TID
4) TAB.SPOROLAC-DS PO/TID
5) Inj.Neomol 1g IV SOS
6) TAB.PCM 650 mg PO SOS
Day 2:
IV FLUIDS - 2NS, 2RL
1) INJ.CEFTRIAXONE 1g IV BD
2) INJ.METROGYL 500 mg IV TID
3) INJ.PAN 40 mg IV OD
4) TAB.SPOROLAC-DS PO/TID
5) INJ.ZOFER 4mg IV/SOS
6) ORS SACHETS IN 1LT OF WATER
100 ml AFTER PASSING STOOLS
7) TAB.PCM 650 mg PO/SOS
8) BP/PR/RR/SPO2 CHARTING 4TH HRLY
9) STRICT I/O CHARTING
DAY 3:
IV FLUIDS - 2NS, 2RL
1) INJ.CEFTRIAXONE 1g IV BD
2) INJ.METROGYL 500 mg IV TID
3) INJ.PAN 40 mg IV OD
4) TAB.SPOROLAC-DS PO/TID
5) INJ.ZOFER 4mg IV/SOS
6) ORS SACHETS IN 1LT OF WATER
100 ml AFTER PASSING STOOLS
7) TAB.PCM 650 mg PO/SOS
8) BP/PR/RR/SPO2 CHARTING 4TH HRLY
9) STRICT I/O CHARTING
10) TAB.REDODRIL 100 mg PO/BD
11) TAB.UDILIV 300 mg PO/BD
12) GRBS CHARTING
13) INJ.METHYL COBOLAMIN 1000 mcg IV OD
Day 4-
IV FLUIDS - 2NS, 2RL
1) INJ.CEFTRIAXONE 1g IV BD
2) INJ.METROGYL 500 mg IV TID
3) INJ.PAN 40 mg IV OD
4) TAB.SPOROLAC-DS PO/TID
5) INJ.ZOFER 4mg IV/SOS
6) ORS SACHETS IN 1LT OF WATER
100 ml AFTER PASSING STOOLS
7) TAB.PCM 650 mg PO/SOS
8) BP/PR/RR/SPO2 CHARTING 4TH HRLY
9) STRICT I/O CHARTING
10) TAB.REDODRIL 100 mg PO/BD
11) TAB.UDILIV 300 mg PO/BD
12) GRBS CHARTING
13) INJ.METHYL COBOLAMIN 1000 mcg IV OD
