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

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