A 16yr old girl with loose stools
A 16 year old female resident of gouraram who is a student came with complaints of loose stools since 2 days 6/08/2022
HOPI
Patient was apparently asymptomatic 1 yr back .Then she developed yellowish discoloration of eyes and fever for which she came to our hospital and diagnosed with jaundice.
During that time itself she was told that her haemoglobin was low and need blood transfusion 5 packets of blood was transfused.After transfusion her haemoglobin increased and again decreased and she was diagnosed with autoimmune haemolytic Anemia and common variable immune disorder .
Then now on Thursday (4/08/2022) she consumed some outside food (Manchuria) and started developing loose stools
There were 10 episodes per day and the stools were watery and bilious and not associated with blood
She also had fever which was high grade associated with chills and subsided after taking paracetamol.
No history of pain abdomen vomiting
PAST HISTORY
No similar complaints in the past
No history of DM, TB, Asthma, Epilepsy, Thyroid disease.
PERSONAL HISTORY
Diet mixed
Appetite Decreased
Sleep adequate
Bowel (loos stools)and bladder (regular)
Addictions :No
DRUG HISTORY
No history of allergy to any kind of drugs
FAMILY HISTORY No significant family history
MENSTRUAL HISTORY
Age of menarche 15 years
Cycles are regular
GENERAL EXAMINATION
Patient was conscious coherent and cooperative .Moderately bulit and nourished
Pallor - present
No Icterus , Clubbing, Cyanosis, Generalised lymphadenopathy, edema
Vitals:
Temp:Febrile
Pulse rate: 90 bpm
Blood pressure:110/70
Respiratory rate: 20 cpm
GRBS:98mg/dl
SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM EXAMINATION
Inspection:
Symmetrical chest seen
No scars and sinuses
Trachea central
Palpation:
Inspectory findings are confirmed
Percussion:
Resonant note present in all lung areas
Auscultation:
Breath sounds heard.
PER ABDOMEN
Inspection:
No Abdominal distension
No scars, sinuses, mass visible
Palpation:
Inspectory findings are confirmed
No local rise of temperature
Tenderness present in right iliac fossa
Percussion:
Auscultation:
Normal bowel sounds heard
No bruit heard
CARDIOVASCULAR SYSTEM EXAMINATION
Inspection : Bilaterally symmetrical chest present
No scars, sinuses
Palpation:
Inspectory findings are confirmed
Apex beat normal
On Auscultation :
S1 S2 heard
No murmurs or additional heart sounds
CENTRAL NERVOUS SYSTEM EXAMINATION
Higher mental functions intact
Cranial nerves intact
No focal neurological defecits
INVESTIGATIONS:
6/8/22
8/8/22
9/8/22
10/8/22
PROVISIONAL DIAGNOSIS
Acute Gastritis with Autoimmune haemolytic Anemia
TREATMENT
IV NormalSaline
Tab.PAN 40 mg PO OD
Tab.DOLO 650 mg PO SOS
ORS 1 sachet in one litre of water
Tab.OFLOX O2 PO BD
Syrup POTKLOR 10 ml in one glass of water PO BD
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