A 16 YEAR OLD GIRL WITH LOOSE STOOLS AND FEVER

 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- afebrile

PR-73bpm

RR- 18cycles /min

BP-120/70

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






Comments

Post a Comment

Popular posts from this blog

19 year old male with fever and lower back pain

Image
19 Year old male with fever and lower backache December 01,2022  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 This is a case of 19 year old male from mirylaguda who is intermediate second year student came to general medicine OPD with chief complaints of :
Read more

A 45 YEAR OLD FEMALE WITH PARAPARESIS SECONDARY TO TRAUMA ASSOCIATED WITH DYSPHAGIA

Image
C/O Generalized weakness of lower limbs since 10 years Difficulty in swallowing since 15 days  HOPI: Pt was apparently asymptomatic till 1999  then she delivered a baby(by c-section due to cord entanglement)  she also stated that she started  developed Generalized weakness ( due to low haemoglobin levels ) not associated with pain and was able to perform her daily activities Her husband also left as she couldn't perform her daily activities.Her son currently stays in the hostel   She previously used to work as mandal officer. And in 2012 she stopped going to work because she started developing weakness  insidious in onset , gradually progressive , associated with pain , Aggrevated with walking and relieved with rest. she could not walk for long distances and she managed to  to perform  daily activities In 2023 Jan she alleged had h/o slippage in bathroom following which she was normal for 5 days  Next day she couldn't get up from bed which is sudden in onset and non progressive
Read more

A 25 YEAR OLD MALE PATIENT WITH YELLOWISH DISCOLORATION OF EYES AND URINE, ABDOMINAL DISTENSION AND SOB

Image
 A 25 year old male who is a resident of yadagirigutta Mason by occupation came to casualty with chief complaints of :  *DISTENSION OF ABDOMEN SINCE 6 DAYS  *SHORTNESS OF BREATH SINCE 6  DAYS   *YELLOWISH DISCOLORATION OF EYES AND URINE SINCE 6 DAYS  •HISTORY OF PRESENTING ILLNESS  : Patient is apparently asymptomatic 3 months ago he then developed abdominal distension which is insidious in onset and gradually progressive associated with shortness of breath 3 months back which is of grade 2 and it progressed to grade 3 over 3 months .He also has yellowish discoloration of eyes and urine 6 days back .He also has similar complaint 4 months ago for which he took herbal medication for a week and the symptoms subsided and  he also  stopped drinking for 7 days after that he continued drinking .He also complaints of fever 3 months back which is intermittent which is not associated with chills and rigors for 2- 3 days  And cough which is non productive 10 days back .  Vomiting 2to 3 episodes p
Read more