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

B.Aishwarya Laxmi 

Roll no:152

12/3/22

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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 . 

Hb: 6.9 GM/dl 

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