27 year old male with pain abdomen and fever since 5 days

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 27 year old male came with complaints of fever for 5 days, abdominal discomfort since 5 days, nausea, vomiting ,loose stools since 5 days, burning micturition since 3 days.

 Patient works as a car driver since 5 years who was occasional Toddy drinker ( 1 glass of intake for any occasional festival ) 

5 days ago he went to function where he consumed 1 litre of Toddy along with red meat , following next day he experienced pain abdomen which was squeezing type predominantly in epigastric region diffuse type associated with nausea & vomiting 10 to 12 episodes/day.  Whenever he consumes water or food  he has vomitings -  nonbilious,  non projectile,  water or food as content for 3 days now the frequency reduced to 4 /day 

LOOSE STOOLS - watery,  small volume,  no blood or mucus in stools

 FEVER low-grade,  intermittent , associated with burning micturition not associated with chills& rigors cold , cough,  weakness ,joint pains

O/E : 

Pt is c/c/c 

Vitals : 

Temp: 99.4 f

HR: 100 bpm

RR : 14cpm

BP : 100/70 mm hg

Spo2: 99 @ RA

GRBS :  106 mg/dl 

 

 

 

 

SYSTEMIC EXAMINATION : 

CVS : S1 S2  + . 

RS : BAE + NVBS + 

PA: mild tenderness in epigastric region 

CNS :  NAD 

 

 

 

 

 

 

 

DIAGNOSIS : Acute gastro enteritis 

TREATMENT : 

IVF : NS , RL @ 100ml/hr 

INJ. ZOFER 4mg IV /BD

INJ.PANTOP 40mg IV/BD

INJ.PCM 650mg po/TID 

INJ.NEOMOL 1g sos(if temp >101 f ) 

INJ. OPTINEURON 1amp in 100ml NS IV/BD

INJ. TRAMADOL 1amp in 100ml NS IV/BD