A 18 y/o female with a complaint of shortness of breath.
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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 treatment plan.
Chief Complaints:
A 18 year old female who is a student, came to the casuality on 03.01.23 with chief complaints of:
- shortness of breath since 2days
- fever since 1 week
- pain and swelling in the perianal region since 10 days
History of present illness:
The patient was apparently asymptomatic 6 years ago.
Course of events:
6 years ago:
She went to a nearby hospital because of her weakness, polyuria, polydipsia, polyphagia, and weight loss; while there, her GRBS was high and she was diagnosed with diabetes; she then started using insulin injections.
Injecction mixtard 20U - x- 15U.
In between due to raised sugar levels she develops abdominal pain and consults a doctor and takes fluids and high dose of insulin
1 week ago:
Patient had swelling over analverge that started as 1x 1cms and increased to the current size of 4x 4 cms along with discharge of pus and mixed with blood.
Along with it she had high grade fever associated with chills and rigors,therfore she consulted a local doctor and received antibiotics
She had used those antibiotics for 5 days, later developed nausea as she was not on a proper diet.
Therefore she decreased her insulin dosage to 5u-5u on her own since 3 days and developed shortness of breath on rest since 2 days.
As sob was increased, she got her Grbs checked at home and it was 480mg/dl, was then taken to local hospital and was given injection ( not known).
Since today morning her sob was increased. She went to hospital and RBS being high, insulin14u HAI given and referred here for further management.
Past history:
History of similar complaints of swelling in inner thighs and in gluteal region 1 year back as she has taken covid vaccine.
At that time she consulted local doctor and recieved antibiotics ( amoxiclav 625mg/po/bd for 5 days and also herbal medicine for swelling, on local application it got relieved.
Not a k/c/o hypertension, Tb, asthma, epilepsy, thyroid disorders.
Menstrual history:
Age of menarche: 13 years
Menses: regular, 28 days cycle
Flow increased associated with clots and pain
Personal history:
Diet: mixed
Appetite: decreased
Bowel and bladder: regular
Sleep: adequate
Addictions: no
Family History:
Her father is a known case of diabetes since 16 years and he was using insulin mixtard 2 times daily
General Examination :
Patient was conscious, coherent, cooperative and well oriented to time, place and person.
Pallor: present
Icterus: absent
No cyanosis, clubbing, lymphadenopathy and edema.
Vitals:
Temperature: 101° F
Bp: 120/70mmhg
PR: 92 BPM
RR: Tachyponeic at the time of admission
21cpm
Spo2: 98% on ra
Grbs: 348mg/dl
Surgery referral notes:
On local examination:
Swelling was in perianal region which was initially 1x1 cms and progressed to present size of 4x4 cms
Pus discharge present
Skin over swelling: reddish colour
Palpation:
Tenderness- positive
Local rise of temperature
Induration of skin over the swelling- Positive
Visible pus discharge
Systemic examination:
Respiratory system:
Inspection :
Position of trachea: midline
Position of Apex beat: left 5ics 1cm medial to mid clavicular line
Symmetry of chest : symmetrical and elliptical
Movement of chest : normal
Palpation :
Position of trachea, apical pulse is confirmed
No tenderness over chest wall, no crepitations, no palpable added sounds, no palpable pleural rub
Percussion:
Resonant note heard.
Auscultation :
vesicular breath sounds
no added sounds.
Per abdomen:
Shape: scaphoid
Umbilicus: central
Movements: normal
No visible pulsations or engorged veins
Skin over abdomen :normal
Palpation:
soft non tender
No tenderness or local rise of temperature
Percussion :
Liver: resonant note heared
No fluid thrills and shifting dullness
Auscultation:
Bowel sounds are heard
CVS:
S1 and S2 heart sounds are heard
No murmurs.
CNS:
Higher mental functions intact
Reflexes- present
Power,muscle tone- normal
Gait- normal
No meningeal signs
Cranial nerves - intact
Investigations:
USG:
Pus culture sensitivity:
05.01.23
CUE:
Appearance:
Albumin:++
Sugars:++
Pus cells:4-5
Epithelial cells:3-4
Urine for ketone bodies: positive
Blood grouping and typing: O positive
ABG:
Day1:
Chest X Ray:
Diagnosis:
Diabetic ketoacidosis with Type 1 DM since 6 years with perianal abscess
S/P : incision and drainage of abscess done under spinal anaesthesia on 03/1/23.
Treatment:
Iv fluids Ns@100ml/hr
Inj Human Actrapid insulin Sc/TID
12u- 12u- 12u
Inj NPH sc/BD
15u- × -15u
Inj meropenam 1gm/iv/Bd d2
Inj Amikacin 500 mg/iv/Bd d2
Inj metrogyl 500 mg/iv/Tid d3
Inj pantop 40 mg/ iv/ bd
Inj neomol 1 gm/iv/bd
Inj Tramadol 2ampoules in 100ml Ns/iv/bd
Inj Zofer 4 mg/ iv/bd
Inj kcl 20 meq in 100 ml Ns/iv /stat
Tab orofer xt/ po/ od @2pm
Tab Dolo 650mg/po/Tid
Sitz bath/ qid
Strict I/O charting
Discussion:
Diabetic ketoacidosis(DKA) or diabetic coma is the most common complication in type 1 diabetes mellitus.
Q.What are precipitating causes in Dka?
It develops under two situations :
A. Undetected or undiagnosed type1 diabetic patient may present in the ketoacidosis for the first time.
B. Patients of type 1 diabetes on treamtment with insulin mmay develop it under any stress or following an infection.
Infection is most common precipitating cause in known diabetes
In this patient the precipitating cause was peri anal abscess and poor glycemic control.
How it is diagnosed?
It is diagnosed as a combination of hyperglycemia, metabolic acidosis and ketonuria
How it is treated?
It was treated by correcting the substantial hypovolemia by giving fluids @ 100ml/hr.
Hyperglycemia was treated by giving insulin (Human Actrapid injection) intravenously.
Electrolyte imbalance like hypokalemia is corrected by inj kcl infusion.
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