general medicine

16 yr old girl with gastroenteritis 

This is an online eblog book to discuss our patients deidentified health data shared after taking his or her guardian signed inform consent is required .
Here we discuss our individual patients problems thorugh series of inputs from avaliable global online commity of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs 

16yr old  girl came tk causality with 
Chief complaints of loose stools  and fever since 3 days

History of present illness 
Patient was asymptomatic 3days back ,as she consumed outside food she  had loose stools since that is watery,green in colour and foul smelling.
History of high grade fever, associated with chills which relieved on medication .
H/o vomitings and abdominal pain.

Past history
No diabetes 
No surgery done
No hypertension 
No tuberculosis 
No thyroid 

Personal history
Diet:mixed 
Appetite: decreased
Sleep: adequate 
Bowel,, loose stools 
Regular bladder
Addictions: none

FAMILY HISTORY:
No significant family history

GENERAL EXAMINATION

Patient was conscious coherent and cooperative 
Moderately built
No pallor,icterus,clubbing,generalised lymphadenopathy.

Vitals 
Temperature  99.8
Spo2 98%
Pulse rate 75beats per min
Respiratory rate 17cycles per min 
Bp 100/70mmhg

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

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


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