Acute gastroenteritis .Shock 2° to hypovolemia (resolved)

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A 52 yr old male came to the casualty with my c/o vomitings and loose stools since yesterday 

HOPI 

Patient was apparently asymptomatic until yesterday mrng  .He is having c/o vomitings 6-8 times , non projectile , non bilious , food or water as content since yesterday mrng .

C/o loose stools , 6-8 times , watery , no blood in stools , tenesmus -ve .

No c/o pain abdomen, fever , burning micturition.

Not a k/c/o DM, HTN, TB , Asthma , Epilepsy, CAD .

Family history - not significant

Personal history - 

Diet - mixed 

Appetite - increased 

Bowel & bladder movements- regular , decreased urine outpu since yesterday 

Addictions - occasional alcohol consumer 

GENERAL EXAMINATION 

Patient is c/c/c

No pallor , icterus , cyanosis , clubbing lymphadenopathy , edema .

VITALS 

Temp - Afebrile 

BP-90/60 mmHg

PR- 70 bpm 

RR -19cpm 

SpO2 -99% @RA

Systemic examination 

CVS - S1 S2 +ve , No murmurs 

RS - NVBS +ve , BAE +ve 

P/A - soft , non tender , BS +ve 

CNS - NAD 

PROVISIONAL DIAGNOSIS 

Acute gastroenteritis.

INVESTIGATIONS

Soap notes 

Day 1

15/12/21

S -

Vomitings decreased , stools decreased , no fever spikes 

O -

Pt is c/c/c 

Temp -98.8°F

BP -120/70 mmHg

PR -86 bpm , regular ,normal volume

CVS -S1 S2 +ve 

RS - NVBS +ve 

P/A - soft , non tender , BS+

CNS - NAD 

GRBS -116mg% 

SpO2 -99% @RA

I/O - 3100 / 1600 ml

A-

Acute gastroenteritis .Shock 2° to hypovolemia (resolving )

P-

IVF - NS , RL @ 100ml /hr 

Inj pantop 40mg /OD

Inj zofer 4mg IV /SOS 

Inj neomol 100ml IV SOS 

Inj buscopan 2cc/iv/sos

Tab sporolac 2tabs/PO/TID 

Tab zofer 4mg BD 

Day2

S -

Vomitings decreased , stools decreased , no fever spikes 

O -

Pt is c/c/c 

Temp -98.8°F

BP -120/80 mmHg

PR -80 bpm , regular ,normal volume

CVS -S1 S2 +ve 

RS - NVBS +ve 

P/A - soft , non tender , BS+

CNS - NAD

SpO2 -99% @RA

A-

Acute gastroenteritis .Shock 2° to hypovolemia (resolved )

P-

IVF - NS , RL. UO+ @ 30ml /hr 

Inj Metronidazole 500mg IV/BD

Inj ciproflaxacin 500mg IV/OD

Tab pantop 50mg PO /sos 

Tab pcm 500mg po /sos 

Tab sporolac 2tabs/PO/TID 

GRBS -12th hrly