A 55yr old female complains of fever,decreased appetite since 1 month, Breathlessness since 1 week,vomitings and loose stools since 3 days.
Diet- mixed
Appetite-decreased
Bowel and Bladder movements- regular.
Addictions-
Allergies- none
General examination:
Patient is conscious, coherent and cooperative. Well oriented to time, place and person.
Moderately built and moderately nourished.
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.
Vitals:
Temp- 98°F
BP-110/80MMHG
RR-18CPM
PR- 74BPM.
GRBS-92mg/dl on the day of admission.
Spo2 - 100%
Systemic Examination:
CVS: S1,S2 Heard
No Murmurs
RS: B/L Normal Vesicular Breath Sounds Heard.
CNS:NAD
P/A: On Inspection:
Shape - scaphoid
Umbilicus inverted
No scars and sinuses present.
No visible pulsatios , no engorged veins
On palpation:
No rebound tenderness, no gaurding, no rigidity
No organonegaly
On percussion:
No fluid thrill
No shifting dullness
On Auscultation:
Bowel sounds heard.
1) IV FLUIDS(2units NS, 1unit RL) @100ml/hr.
2) INJ. NEOMOL 1GM/IV/SOS(IF temp>101°F).
3) INJ. METROGYL 100Ml/IV/TID.
4)INJ PAN 40MG/IV/BEFORE BF.
5) INJ.ZOFER 4MG/IV/OD.
6) CAP. RETODRIL 100MG/PO/TID.
7) TAB. SPORLAC-DS ,2TAB/PO/TID.
8) ORS SACHETS IN 1LITRE OF WATER, 200ML TO BE TAKEN AFTER PASSAGE OF EACH STOOL.
9)T.DOLO 650MG/PO/BD.
10) MONITOR VITALS.
11) INFORM SOS.
DIAGNOSIS:
ACUTE VIRAL GASTROENTERITIS.
K/C/O HTN SINCE 7YRS.
HIV POSITIVE (DENOVO DETECTED).
