26th
August, 2023.
MEDICAL
REPORT
B.s
/FEMALE
DIAGNOSIS: Acute
Gastroenteritis
BACKGROUND
HISTORY AND PRESENTATION:
The above named patient is a 60 year old
female, who presented with complaints of 10 episodes of loose watery stools,
non bloody and non mucoid. There was associated abdominal pain which was
generalised, sharp. No history of vomiting prior to presentation however had an
episode of vomiting on admission. She noticed symptoms after ingestion of
several meals.
She is a known DM patient who is not
regular on medications.
EXAMINATION:
O/E: afebrile, anicteric, not pale,
acyanotic, moderately dehydrated
Vitals
PR: 142bpm
SPO2:92 % in room air
BP: 130/70 mmhg
INVESTIGATION:
FBC; WBC- 15.42, PCV- 49%, PLT-152
EUCr: Na- 138, K- 4.1 Urea: 35 Cr: 0.51
MALARIA PARASITE- + seen
RBS: 13.1 mmol/l
STOOL M/C/S: Awaiting result
MANAGEMENT
PLAN:
1.
Admit
2.
IVF N/S 1L Stat
3.
IV Rocephin 1g 12hrly x 24hrs
4.
IV Flagyl 500mg 8hrly x24hrs
5.
IV Omeprazole 40mg bd
6.
IV Pcm 600mg 8hrly
7.
Tabs Lomotil 4mg stat, then 2mg
per loose stool
8.
IM Emal 150mg dly x 3/7
9.
IV ciprofloxacin 200mg 12hrly x
24hrs
Discharge
Medications
·
Tabs Ciprofloxacin 500mg bd x
5/7
·
Tab Flagyl 400mg tds x 5/7
·
Tab ACT i BD X 3/7
·
Tab PCM 1g tds x 3/7
·
Tab Glucophage 500mg bd
·
See in 3 days for review of stool mcs result
·
Tab Zinc 50mg dly x 1/52
·
Tab buscophan 20mg bd x 2/7
Please
revert, if need be, for further clarification
Yours Sincerely,
Dr. Ukandu Chinedu
For
Team Wellington Clinics Abuja
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