16 yr old girl with complaints of loose stools and fever

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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 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.


CHIEF COMPLAINTS

  • Loose stools since 3 days
  • Fever (two episodes)

HISTORY OF PRESENTING ILLNESS

  • Patient was asymptomatic 3 days back later she had manchuria outside.
  • Later on same afternoon she had loose stools without blood.
  • Later on same night she had developed fever with out associated chills and rashes.
  • There was second episode of fever on next day morning.
  • Fever was relieved after taking medication 
  • But loose stools were not controlled so she came to our hostipal.
  • No c/o abdomen pain and vomiting
  • H/O of recurrent upper respiratory tract infection since  age 4.
  • H/O of jaundice with severe anemia 2 years back.

HISTORY OF PAST ILLNESS 

  • No k/c/o HTN,diabetes,asthma,epilepsy,TB
  • k/c/o common variable immunodeficiency with Autoimmune hemolytic anemia.

DRUG HISTORY 

  1. Immunoglobulin injection since 2 years(2020)
  2. Blood transfusion one year back.


PERSONAL HISTORY


Diet - Mixed

Appetite - Normal

Bowel movements - irregular 

bladder movements - Normal

Allergies - No

Menarche at 15yrs


FAMILY HISTORY 

Not significant 


GENERAL EXAMINATION


➤Pallor : Not seen

➤Icterus :  Not seen

➤Cyanosis :  Not seen

➤Clubbing :  Not seen

➤Lymphadenopathy :  Not seen

➤Edema :  Not seen


VITALS

1.Temperature : 98.3℉

2.PR : 120 beats per minute

3.BP : systolic 80mm hg by palpatory method

4.RR : 24 cycles per minute

5.SpO2 : 97% in room air

6.Blood Sugar (random) : 112mg/dl


SYSTEMIC EXAMINATION :

CVS :

No thrills

No murmurs

S1 and S2 heard


RESPIRATORY SYSTEM :

Position of trachea - Central

No Dyspnoea , Wheeze

Breath Sounds - vesicular


ABDOMEN EXAMINATION 


1.Shape - Scaphoid

2.Equal movements in all the quadrants.

3.No visible pulsation, dilated veins and localized swellings.

4.No palpable mass

5.tenderness present in right iliac fossa


CNS : Normal

- Patient is Conscious, Coherent well oriented to surroundings.


PROVISIONAL DIAGNOSIS : 

Acute gastroenteritis 

K/c/o primary immunodeficiency disorder


INVESTIGATIONS
































STOOL CULTURE




ECG






TREATMENT

1) IV FLUIDS NS AND RL 75ML/HR

2) TAB. ZOFER 4MG PO/OD

3) TAB PANTOP 40MG PO/OD

4) TAB PARACETAMOL 650MG PO/SOS

5) TAB SPOROLAC DS PO/TID

DAY 2

➤Loose stools decreased

➤No fever spikes

TREATMENT

1)IV FLUIDS NS AND RL 75ML/HR

2) TAB PANTOP 40MG PO/OD

3) TAB PARACETAMOL 500MG PO/SOS

4) TAB SPOROLAC  2tab PO/TID

5) PLENTY OF ORAL FLUIDS

6) ORS ONE SACHET IN 1LTR WATER PO/TID

7) BP/PR/TEMP 4th HOURLY


DAY 3

➤Loose stools decreased

➤No fever spikes

TREATMENT

1) IV FLUIDS NS AND RL 50ML/HR

2) TAB PANTOP 40MG PO/OD

3) TAB PARACETAMOL 500MG PO/SOS

4) TAB SPOROLAC  2tab PO/TID

5) PLENTY OF ORAL FLUIDS

6) ORS ONE SACHET IN 1LTR WATER PO/TID

7) BP/PR/TEMP 4th HOURLY

DAY 4

➤Loose stools decreased

➤No fever spikes

TREATMENT

1) IV FLUIDS NS AND RL 50ML/HR

2) TAB PANTOP 40MG PO/OD

3) TAB PARACETAMOL 500MG PO/SOS

4) TAB SPOROLAC  2tab PO/TID

5) PLENTY OF ORAL FLUIDS

6) ORS ONE SACHET IN 1LTR WATER PO/TID

7) BP/PR/TEMP 4th HOURLY

DAY 5

➤Loose stools decreased

➤No fever spikes

TREATMENT

1) IV FLUIDS NS AND RL 50ML/HR

2) TAB PANTOP 40MG PO/OD

3) TAB PARACETAMOL 500MG PO/SOS

4) TAB SPOROLAC  1tab PO/TID

5) PLENTY OF ORAL FLUIDS

6) ORS ONE SACHET IN 1LTR WATER PO/TID

7) BP/PR/TEMP 4th HOURLY

8) TAB OFLOX-OZ PO/BD

9) SYP. POTKLOR 10ML ONE GLASS OF WATER PO/BD













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