A 16 year oldgirl with loose stools

 A 16 year old girl 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 in stools

She also had fever which was high grade associated with chills and subsided after taking there were 2 episodes of fever one on Thursday night and other on Friday morning

No history of pain abdomen vomiting 

PAST HISTORY 

No similar complaints in the past 

No history of DM HTN Asthma TB Epilepsy Thyroid disease

PERSONAL HISTORY

Diet mixed

Appetite Decreased

Sleep  adequate

Bowel (loos stools)and bladder (regular)

Addictions No addictions

Menstrual history

Age of menarche 15 years 

Cycles are regular

DRUG HISTORY

No history of allergy to any kind of drugs

FAMILY HISTORY No significant family history

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


Ascultation:


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 absent


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 

On 6/08/2022 











On 7/08/2022





On 8/08/2022






 
On 9/08/2022






10/08/2022



PROVISIONAL DIAGNOSIS

Acute Gastritis with Autoimmune haemolytic Anemia 
TREATMENT
IV normal saline
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 

Tab sporolac TID





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