Medical Case Details:
BACKGROUND - Why do you think this case is important? Why did you write it up? The incidence of gastroenteritis is higher in the summertime, so patient with loose motion and abdominal pain should be assessed of having acute gastroenteritis or other acute abdomen conditions.
SUMMARY - 25 years old lady came to the emergency department with complaints of vomiting and loose motions 5 times since morning. The patient took outside food last night. Patient has a history of Iron-deficiency anemia. Examination showed mild dehydration with normal blood pressure and heart rate. The abdomen was soft, lax with mild epigastric and left iliac fossa tenderness. Stool routine examination showed a few red blood cells with bacteria. Urine examination showed pus cell 5-8, RBS-8-10, with nitrate positive. Complete blood count showed no leukocytosis but hemoglobin is 9.12g/dl. Biochemistry was normal. The patient was given intravenous fluid Ringer’s lactate 1 litter, Inj. Metoclopramide HCL 20mg intravenous drip, inj. Ranitidine 50 mg intravenous bolus, and inj. Hyoscine N butyl bromide 20 mg intravenous bolus. The patient was feeling better after medication. The patient was advised to take soft regular food with increase fluid intake. The patient was given a follow-up in Medical OPD for iron-deficiency anemia.