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Abstract: A 25-year-old man who was previously in good health had nausea and vomiting several times after improper diet 1 day ago, ranging from 50-150g each time, diarrhea, resolution of yellow mucus stool 20 times/day, with urgency, fever, temperature up to 40.5℃, with malaise, chills, loss of appetite, daily intake of staple food decreased by 4/5 compared to normal, routine blood tests with elevated leukocytes and C-reactive protein, confirmed the diagnosis of infectious gastroenteritis After anti-infection and nutritional support treatment, the patient’s symptoms gradually improved and he was discharged successfully.
Basic information】Male, 25 years old
Disease Type】Infectious gastroenteritis
Hospital】The 988th Hospital of the PLA Joint Logistics and Security Forces
Time of consultation】April 2022
Treatment plan】Medication (levofloxacin hydrochloride injection + sodium chloride glucose injection + potassium chloride injection + vitamin C injection + ibuprofen injection + montelukast + meropenem for injection)
[Treatment Period] 10 days of inpatient treatment, 1 month of outpatient follow up
Treatment effect】The disease has been controlled and all indicators are back to normal
I. Initial consultation
A 25-year-old boy came to the hospital with diarrhea. He had a painful expression, slightly curled up, extremely weak, lazy speech, blood pressure of 100/65 mmHg, body temperature of 40.5℃, pulse of 118 beats/min. 220×10^9/L, C-reactive protein 28.57mg/L, the first impression is that the disease is relatively obvious dehydration, and the patient has high fever, nausea, vomiting, diarrhea symptoms, previous physical health, before the onset of this trip to the field physical and mental fatigue, and unclean diet, resulting in the body’s immunity, the preliminary diagnosis: infectious gastroenteritis.
II. Treatment history
Immediately after admission, the patient was given empirical anti-infection with levofloxacin hydrochloride injection, rehydration with sodium chloride glucose injection, potassium chloride injection and vitamin C injection, antipyretic with ibuprofen injection and antidiarrheal with montelukast, etc. At the same time, blood culture and drug sensitivity, stool culture and drug sensitivity, liver and kidney function and electrolyte examination were performed. mg/L, interleukin-6: 257 pg/ml. 2 days later, the patient’s nausea, vomiting and diarrhea symptoms were relieved, but the patient’s body temperature still fluctuated at 40.0℃, abdominal discomfort, poor diet, and the blood culture on the 3rd day of admission suggested Escherichia coli, a multi-drug resistant bacteria, which was immediately changed from levofloxacin hydrochloride injection to meropenem for injection and continued anti-infection for 7 days.
III. Treatment effect
Through active anti-infection, anti-diarrheal, rehydration, nutritional support and other drug combination therapy, and symptomatic comprehensive treatment, the patient’s body temperature returned to normal after 10 days, no more symptoms of nausea and vomiting, appetite and energy returned to normal, and diarrhea and abdominal discomfort symptoms were effectively relieved. The follow-up examination of calcitoninogen, C-reactive protein and interleukin-6 showed normal, no red blood cells or white blood cells were found in the stool routine, the face was flushed, the mental status was good and the recovery of the body was considerable. 1 month later, the patient recovered from the disease in the outpatient follow-up.
IV. Notes
The patient’s recovery was very good, and as a doctor, I was also very pleased. The patient was instructed to pay attention to the following conditions after discharge.
1. pay attention to rest, avoid overexertion, regular rest and rest, appropriate exercise, enhance physical fitness, and combine work and rest.
2, pay attention to dietary hygiene, avoid eating raw, cold, hard and spicy foods, eat mainly cooked food, and consume more high-quality protein and well-digested food to reduce the burden on the gastrointestinal tract.
3, develop the habit of washing hands diligently, especially before and after meals, to avoid the entrance of viruses through the hands.
4, maintain good personal and environmental hygiene, do not give the virus the opportunity to take advantage of the situation.
5.If there are uncomfortable symptoms, seek medical attention in time to avoid delaying the disease.
V. Personal insight
The common symptoms of infectious gastroenteritis are fever, nausea, vomiting, diarrhea, etc. Light infectious gastroenteritis can be effectively treated by routine rehydration and anti-infection, but moderate to heavy gastroenteritis can progress to sepsis, shock, and even life-threatening if not treated in time. Like this case, the patient recovered well after timely medical attention, symptomatic treatment and care. So do not be too nervous, usually pay attention to diet and hygiene, relaxation, can be very good to prevent this disease. The majority of patients can be completely cured after conventional treatment, the development of heavy for very few. As long as timely consultation, reasonable treatment, generally can be cured.