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Abstract: A 50-year-old male patient complained of abdominal distension and pain for 1 day without nausea, vomiting, and impaired consciousness. After treatment at a local clinic, the efficacy was not good, so he came to our hospital in order to relieve his discomfort as soon as possible, and after systematic testing, he was diagnosed with gastroenteritis, and after immediate drug treatment, the patient’s condition was well controlled and the abdominal distension and pain basically disappeared.
Basic information】Male, 50 years old
Disease Type】Gastroenteritis
Hospital】The First Hospital of China Medical University
Time of consultation】October 2017
【Treatment plan】Medication (cefotaxime sodium for injection, levofloxacin hydrochloride tablets, omeprazole sodium for injection, rabeprazole sodium enteric coated tablets)
[Treatment period] In-hospital treatment for 2 days
Treatment effect】The condition has been well controlled, and the abdominal distension and pain have basically disappeared.
I. Initial consultation
When I first saw the patient in the hospital, the patient complained that he suddenly felt abdominal distension and pain one day ago, and could not be relieved after resting for a period of time, so he went to the local clinic to take antispasmodic drugs, but the discomfort was not relieved after using the drugs, so he sought medical treatment. After listening to the patient’s self-report, I then conducted a physical examination of the patient and found that the patient had a flat abdomen with no abdominal wall veins showing, pressure pain in the left lower abdomen but no rebound pain, and no abdominal mass.
II. Treatment process
Before treatment, I explained to the patient that the reason why he did not improve after taking antispasmodic drugs was because the lesions in the stomach and intestines had not been removed, and that symptomatic treatment alone was usually not effective. I first prescribed two antibacterial drugs, cefotaxime sodium for injection and levofloxacin hydrochloride tablets, to control and eliminate the infected lesions in the stomach and intestines, and supplemented them with omeprazole sodium for injection and rabeprazole sodium enteric-coated tablets to protect the tissues in the stomach and reduce pain by reducing excessive secretion of gastric acid. In addition, I also informed the patient that if any adverse reaction was found during the medication, he/she needed to inform the healthcare provider in time and should not increase the medication dose at will.
III. Treatment effect
After the patient was treated with antibacterial and acid-suppressive drugs, the abdominal distension and pain were reduced, and the vital signs were within the normal range. The results of each examination during hospitalization were better than the previous one, indicating that the patient’s body recovered well. When the symptoms of abdominal pain were relieved, a colonoscopy was performed, and the swelling and congestion of the lesions in the gastrointestinal area were found to have decreased. On the second day of in-hospital treatment, the mental state was good, the condition had been well controlled, and the abdominal distension and pain basically disappeared, so the patient was discharged.
IV. Precautions
1. During treatment, I reassured the patient that the disease of gastroenteritis can be cured after active treatment, so there is no need to worry too much.
2. During the illness, inflammation stimulates the gastrointestinal mucosa and tissues, often causing gastrointestinal dysfunction, so I suggested that the patient should eat a light diet, with less stimulating foods such as sorbet, cold drinks, spicy pot, fried chicken, etc., and can choose to eat millet porridge, egg soup, yam porridge and other good digestive and nutritious diets.
3, during the illness, the patient’s body is weak, I advised him not to work too hard, should combine work and rest, do appropriate activities such as walking, and keep a relaxed mood, which can promote physical improvement.
V. Personal insight
The phenomenon of abdominal distension and pain is more common in normal times, such as cold in the abdomen, overeating, etc., and it is mostly ignored, but when one suffers from gastroenteritis, the symptoms of abdominal distension and pain will also appear, just like the patient in this case, taking antispasmodic drugs on his own can only deal with the symptoms, but cannot remove the cause from the root, which makes the abdominal discomfort persist. It is recommended to seek medical advice when you feel unwell, and we will provide targeted treatment measures through the causes and accompanying symptoms to effectively improve the patient’s adverse reactions.