1801006141 SHORT CASE
13 YR OLD GIRL WITH PAIN ABDOMEN
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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 diagnosis and treatment plan.
CHIEF COMPLAINT
A 13 yr female brought to causality at with h/o 5-6 episodes of vomitings , pain abdomen and in a drowsy state.
HOPI
Patient was apparently normal, one day ago, patient did not take take any insulin in the morning and had food and went to school. By evening pt reached home with complaint of abdominal pain and 3 episodes of vomiting.
Abdominal pain was sudden onset, progressive and no aggrevating and relieving factors.
Vomitings were non projectile , with food particles as content, non bilious , 6 episodes.
No history of fever, burning micturition, headache, cough.
Past history:
3 months back, then pt had fever and weakness for which she was admitted in hospital (miryalaguda) and was diagnosed as diabetes mellitus.
Patient was on insulin 16 units morning,12 units evening for 10 days,dose was increased to 18 units morning and 16 units evening.
PAST HISTORY
K/c/o type 1 diabetes mellitus since 3 months,
on insulin( HAI ) 18 units,16 units
No history of hypertension, cyanosis,CAD ,epilepsy, TB , asthma .
TREATMENT HISTORY
Insulin (HAI)since 3 months
PERSONAL HISTORY
She wakes up at 7am.
8am she takes her insulin
9am goes to school
6pm returns home does her homework
Diet : mixed
Appetite: increased ,and she refused to follow diet and consumes rice 3 times a day
Sleep adequate
Bowel movements regular
Bladder movements : increased frequency of micturition
No known allergies
No addictions
Family history -- No relevant history
GENERAL EXAMINATION
Pt was drowsy
GCS : E3V4M6
No pallor, icterus, cyanosis, clubbing, generalized lymphadenopathy and Edema
VITALS at admission
Bp 100/55mmhg
Pulse 120bpm
RR 55 cpm
Temperature 98.7
SpO2 99
Grbs 650 mg/dl
SYSTEMIC EXAMINATION
CNS
She is in a confused state,
CRANIAL NERVE EXAMINATION: INTACT
SENSORY EXAMINATION : NORMAL
MOTOR EXAMINATION
Upper limb lower limb Rt lt Rt lt
Tone
N N N N
Power
5/5 5/5 5/5 5/5
Reflexes right left
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee ++ ++
Ankle ++ ++
Cerebellar signs : normal
Absent meningeal signs
Abdominal examination
INSPECTION
Normal in shape
Umbilicus is normal
No scars or engorged veins are present
PALPATION:
No local rise of temperature
Tenderness in epigastric region and around umbilicus
No Hepatomegaly
No Splenomegaly
PERCUSSION:
Normal liver span
No shifting dullness
AUSCULTATION:
Bowel sounds heard
Inspection -
Supra clavicular:
Infra clavicular:
Mammary:
Axillary:
Infra axillary:
Suprascapular:
Infra scapular:
Inter scapular:
Supra clavicular NVBS NVBS
Infra clavicular: NVBS NVBS
Mammary:
Axillary:
Infra axillary:
Supra scapular:
Infra scapular:
Inter scapular:
Cardiovascular system
S1 S2 heard ,no murmurs
PROVISIONAL DIAGNOSIS
Diabetic ketoacidosis due to missed insulin dose
Investigations
CUE
Sugars+
(Benedicts )
urine ketone bodies
Positive ( Rothera test )
USG abdomen
was normal
Management
IV FLUIDS
Normal saline
INJ HAI
GRBS CHARTING
The actual management of this patient lies in understanding the reason for her skipping the dose and EDUCATING the patient regarding the need to take the insulin and meals on time.
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