16yr old girl with gastroenteritis

A 16yr 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-
HR-
BP-


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 ,known case of primary immuno deficiency.

Treatment:
IV fluids
Tab zofer
Tab pantop 40mg bd
Tab PCM 650mg
Tab sporolac

Comments

Post a Comment

Popular posts from this blog

Diabetic foot ulcer with CKD

Image
July 31,2022  This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. A 49yr old male contacter by occupation r/o nalgonda came to OPD with chief complaint of swelling in the right leg since 20days and fever since 1 week. History of presenting illness  Patient was a...
Read more

64yr old male with obstructive uropathy

Image
A 64 yr old male with obstructive uropathy July 24,2022 A 64 yr old male resident of chotuppal came with chief complaints of pain in the right loin, vomiting and burning micturition since one month HOPI                                                                      Patient was apparently asymptomatic 15 yrs back.Then he developed pain in the right loin and was diagnosed with renal calculi and was operated and then 3 yrs later again he developed bilateral loin pain and was diagnosed with bilateral renal calculi and was operated with a gap of one month . Then 3 yrs later he developed a midline swelling approx 3 cm below umbilicus and diagnosed with ventral hernia and a mesh was placed. Then 1 yr later he developed abdominal pain and endoscopy was done and diagnosed with intestinal ulcer and was managed conserva...
Read more

Acute Cerebrovascular Accident;left hemiplegia

Image
This is an 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 global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan .  A 50yrs old  who is a resident of cheruvugattu came with c/o weakness in  left UL and LL since today morning(05/05/23)At 8:00AM HOPI- patient was apparently asymptomatic till today mornin...
Read more