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Abstract: 70-year-old Master Li presented with abdominal distension and pain with loose stools for half a day and symptoms of pressure on abdominal examination, which is often a manifestation of acute gastroenteritis, usually caused by bacterial, viral, parasitic and other factors of infection, or may be caused by factors such as eating cold food or toxic substances. The disease started relatively quickly and the abdominal pain and loose stool symptoms disappeared after giving Master Li medication.
Basic information】Male, 70 years old
Disease Type】Acute gastroenteritis
Hospital】The First Hospital of China Medical University
Date of consultation】June 2020
Treatment plan】Medication (Ceftriaxone sodium for injection)
Treatment Period】Hospitalization for 3 days, follow-up in 2 weeks
Effectiveness】The condition was basically controlled and the abdominal pain and loose stool symptoms disappeared.
I. Initial consultation
When we first saw the patient, he reported that he had abdominal distension and pain with no obvious cause half a day ago, and the abdominal pain was persistent, accompanied by two bowel movements. Physical examination of the patient showed a flat abdomen with active bowel sounds, a surgical scar of about 15 cm in length in the right lower middle abdomen, soft abdominal muscles with pressure pain, and a mass of about 5 cm x 4 cm in size at the right middle abdominal incision, which could be returned to the abdominal cavity with pressure. It is one of the milder types of such diseases and is easier to heal.
II. Treatment history
Firstly, the patient was given a standing abdominal radiograph, which showed multiple planes of liquid and gas of different sizes and lengths in the abdomen, and the surrounding intestinal cavity showed inflatable dilatation, and the right subdiaphragm showed a limited hypodensity area, which, combined with the patient’s clinical symptoms and physical examination, could be diagnosed as acute gastroenteritis and incisional hernia. The patient was given anti-inflammatory drug treatment, i.e. ceftriaxone sodium for injection, while the patient’s abdomen was closely observed and abdominal examination was given daily, and abdominal pressure pain was still present during the first two days of hospitalization. After 3 days of hospitalization, the patient’s abdominal pain and loose stool symptoms were controlled and he was discharged from the hospital. After discharge, the patient also needed to pay attention to a reasonable diet in daily life and avoid eating colder or more stimulating foods.
III. Treatment effect
The patient’s symptoms such as abdominal distension, pressure pain and loose stools gradually disappeared after medication and general treatment. The patient was taking anti-inflammatory drugs and the abdominal pain disappeared on the same day, but there were still symptoms of pressure pain in the right side of the abdomen as well as passing loose stools. On the 2nd day of hospitalization, the patient still had symptoms of right abdominal pressure pain and loose stools, and her overall spirit and diet were fine. On the third day of hospitalization, the patient’s sleep and bowel movements were normal and the symptoms of abdominal pain disappeared after the combination of medication and general treatment. After discharge, the patient still needed to pay attention to diet, and he visited the hospital for follow-up after 2 weeks without any other abnormalities.
IV. Precautions
1. After the patient develops acute gastroenteritis, due to congestion and edema of the mucosa of the gastrointestinal tract, he needs to avoid eating more irritating and hard food, and try to choose light and easily digestible food, such as porridge and noodles, etc. At the same time, he needs to pay attention to dietary hygiene and avoid eating unclean food.
2, patients should pay attention to ensure rest during the disease, avoid overexertion, so as not to aggravate the disease.
3, patients also need to pay attention to the stool situation in daily life, if there are abnormal stool symptoms, actively go to the hospital and give appropriate treatment.
V. Personal insight
Acute gastroenteritis is one of the more common diseases in daily life, such as the 70-year-old Master Li in this case, the course of the disease is relatively short and rapid, but according to the specific causes of acute gastroenteritis given the appropriate treatment, generally can be cured more quickly, and will not leave sequelae. For the elderly, their resistance is relatively weak, so they need to pay extra attention to dietary hygiene in daily life, and if any uncomfortable symptoms appear, they need to actively go to the hospital and give appropriate treatment.