16 yr old girl with gastroenteritis

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This e-log also reflects patients centered learning portfolio.

Case in brief:

A16yr old  girl r/o gourala came to OPD with 

Chief complaints of loose stools since 3 days and fever since 3days.

HOPI:

Patient was apparently asymptomatic 3days back and she had consumed outside food  and had loose stools since 3 days which is watery,green in colour and foul smelling.
H/o 2episodes of high grade fever, associated with chills which relieved on medication .
H/o vomitings and abdominal pain.

Past History:

No h/o DM/HTN/CAD.

Personal history:

Diet:mixed 

Appetite: decreased

Sleep: adequate 

Bowel (loose stools)and bladder(regular)

Addictions: none

FAMILY HISTORY:

No significant family history


GENERAL EXAMINATION:

Patient was conscious coherent and cooperative

 Moderately built and nourished  

No pallor,icterus,clubbing,generalised lymphadenopathy.





Vitals:
Temp-
PR- 120 bpm
HR-
BP-100/60 mmHg
Spo2- 98%on RA

Systemic examination:

Abdomen:soft and tender in right iliac fossa.
RS:Bilateral air entry present.
CNS:No focal neurological deficit.
CVS: S1,S2 heard.

Investigations-












Provisional diagnosis:

Acute gastroenteritis with primary immunodefeciency

Treatment:

IV fluids -NS}75 ml/hr
               -RL}
Tab.PAN-40 mg  |PO|OD     
Tab.SPOROLAC-2 tabs PO|TID
Tab.DOLO -500 mg PO| SOS
Plenty of oral fluids
ORS 1sachetin 1 lit water PO|TID
BP/RR/Temp -4th hrly






Comments

Popular posts from this blog

25 yrs old female with dengue fever

OSCE- pre final practical examination