A CASE OF PRIMARY IMMUNODEFICIENCY DISORDER

  


NOTE:

  • The following E-log aims at discussing our patient de-identified health data shared after taking the guardian's signed consent.
  • Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
  • This E-log also reflects my patient's centered online learning portfolio.
I have been given this case to solve 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 a diagnosis and providing treatment best to our skills and wisdom.


A 16 years old girl presented in the casualty with complaints of loose stools and fever.

CHIEF COMPLAINTs

➤Loose stools for 3 days
➤Two episodes of fever 

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 3 days back after then she ate outside food(manchuria) and had loose stools from the afternoon of the same day which was non bilious and not associated with blood .Patient had one episode of fever on the same day at night which was not associated with chills and rashes. One more episode of fever on next day morning which got relieved on medication which she took from local medical store but loose stools wasn't controlled so she came to our hospital.
He is not having any complain of abdominal pain and vomiting.

She had history of recurrent upper respiratory tract infection since the age of 4years.
She had jaundice in 2020 associated with severe anemia which was resolved.


HISTORY OF PAST ILLNESS 

➤Not a known case of hypertension , diabetes ,bronchial asthma ,epilepsy, tuberculosis

➤k/c/o common variable immunodeficiency with Autoimmune hemolytic anemia.

DRUG HISTORY

➤Immunoglobulin injection since 2020

➤Blood transfusion 1year back (3 units)

PERSONAL HISTORY

➤Student

➤Patient is unmarried

➤Patient takes mixed diet but has a normal appetite.

➤Bowel and bladder movement is normal and regular.

➤Menarche at  15yrs

FAMILY HISTORY 

➤No significant family history.

GENERAL EXAMINATION 

➤Pallor : Not seen

➤Icterus :  Not seen

➤Cyanosis :  Not seen

➤Clubbing :  Not seen

➤Lymphadenopathy :  Not seen

➤Edema :  Not seen

➤Weight : 28

➤Height: 4'5''

VITALS

➤Temperature : 98.3℉

➤PR : 120 beats per minute

➤BP : systolic 80mm hg by palpatory method

➤RR : 24 cycles per minute

➤SpO2 : 97% in room air

➤Blood Sugar (random) : 112mg/dl

SYSTEMIC EXAMINATION


CARDIOVASCULAR SYSTEM EXAMINATION

➤s1 and s2 heard

➤Thrills absent.,

➤No cardiac   murmurs

 RESPIRATORY SYSTEM

➤Normal vesicular breath sounds heard.

 ➤Bilateral air entry present

 ➤Trachea is in midline


ABDOMINAL EXAMINATION


INSPECTION

➤Shape - Scaphoid

➤Equal movements in all the quadrants.

➤No visible pulsation, dilated veins and localized swellings.

PALPATION

➤Tenderness in right iliac fossa

➤No palpable mass

CENTRAL NERVOUS SYSTEM EXAMINATION

➤Conscious and coherent

PROVISIONAL DIAGNOSIS : ACUTE GASTROENTRITIS K/C/O PRIMARY IMMUNODEFICIENCY DISORDER

INVESTIGATIONS : 

DAY 1

1) COMPLETE BLOOD PICTURE
LYMPHOCYTES 11%

2) COMPLETE URINE EXAMINAION
NORMAL

3) ESR
ELEVATED 42mm/hour

4) STOOL 
BLOOD IS SEEN

5) CRP
POSITIVE 1.2mg/dl

6) RFT
CREATININE 1.1mg/dl
CALCIUM 7.3mg/dl

7) LFT
TOTAL BILIRUBIN:4.41mg/dl
DIRECT BILIRUBIN:0.89mg/dl

8) USG
BOWEL WALL EDEMA
SPLENOMEGALY

9) 2D ECHO


10) STOOL CULTURE
PLENTY OF PUS CELLS
NO OVA/CYSTS SEEN

11) 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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