16 yr old girl with gastroenteritis

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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