E log August - 2
16 year old female patients with loose motions.
CHIEF COMPLAINTS
A 16 year old female came to the OPD with chief complaints of loose motions since 3 days.
History of 2 episodes of fever .1 St episode on Thursday night and 2 nd episode on Friday morning. Which relieved with medication
HISTORY OF PRESENT ILLNESS
The patient was apparently normal 3 days back ,and consumed outside food ( Manchuria) on Thursday afternoon (2pm) and has loose motions since 3 days.
The motions are bilious in nature and no blood in the stools.
The patient has 2 episodes of fever. 1st episode on Thursday night and 2 nd episode on Friday morning.
No abdominal pain, vomitings.
PAST HISTORY
No similar complaints in the past are seen.
Not a k/c/o Tuberculosis, Diabetes mellitus, epilepsy, cardiovascular disease, coronary artery disease.
History of anaemia 1 year back. Blood transfusion done (3bags).
History of asthma since age of 3 years and using medication.
TREATMENT HISTORY
Using asthma medication since the age of 3 years.
Blood transfusion done 1 year back(3bags).
PERSONAL HISTORY
Appetite is normal.
Mixed diet .
Bowel movements irregular.
No burning micturition.
Sleep normal.
No allergies.
No addictions.
FAMILY HISTORY
No history of Diabetes mellitus, Tuberculosis, epilepsy, coronary artery disease, cardiovascular disease , asthma.
GENERAL EXAMINATION
The patient is conscious, coherent, cooperative,well oriented to time and place.
Height:
Weight: 28kgs
No pallor.
No icterus.
No cyanosis.
No lymphadenopathy.
No pedal edema .
Malnutrition is seen .
Mild dehydration is seen.
VITALS
Temperature: 98.3C/F.
Pulse rate :120 beats per min.
Blood pressure: systole 80mm HG
SPO2:97 percentage
Respiratory rate : 25 cycles per minute
GRBS :112 mg.
SYSTEMIC EXAMINATION
Cardiovascular system
No thrills.
S1,S2 heard.km
No murmurs heard.
RESPIRATORY SYSTEM
No dyspnoea.
No wheeze.
Position of trachea: central
Breathe sounds vesicular
ABDOMINAL EXAMINATION
Shape of abdomen: scaphoid.
Tenderness: present in right iliac fossa.
No palpable mass
No hepatomegaly.
No spleenomegaly.
Hernial orifices normal
CENTRAL NERVOUS SYSTEM
Conscious
Speech normal
Cranial nerves : normal
Motor system: normal
Sensory system: normal.
PROVISIONAL DIAGNOSIS
Acute gastroenteritis
INVESTIGATIONS.
Complete blood picture
Complete urine examination
Erthryocyte sedimentation rate.
TFR graph sheet
Stool for occult culture
C reactive protein
Renal function test
Liver function test
Ultrasonography
Bacterial culture and sensitivity
Colour Doppler 2D Echo
ECG
DIFFRENTIAL DIAGNOSIS : ACUTE GASTROENTERITIS
TREATMENT
6/8/22
I.V fluids: NS and RL 75ml /hr.
Tab ZOFER 4 mg po/sos.
Tab PANTOP 40mg po/od
Tab PARACETAMOL 650mg po/sos
Tab SPOROLAC DS po/tid.
7/8/22
I.V fluids: NS and RL 75ml /hr.
Tab ZOFER 4 mg po/sos.
Tab PANTOP 40mg po/od
Tab PARACETAMOL 650mg po/sos
Tab SPOROLAC DS po/tid.
Plenty of water
1 ORS sachet in 1 litre of water
8/8/22
I.V fluids: NS and RL 75ml /hr.
Tab ZOFER 4 mg po/sos.
Tab PANTOP 40mg po/od
Tab PARACETAMOL 650mg po/sos
Tab SPOROLAC DS po/tid.
Plenty of water
1 ORS sachet in 1 litre of
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