Final long case

 This is an online e-log platform to discuss case scenario of a patient with their guardians permission.

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. 18 y/o female patient came to opd Chief Complaints: A 18 year old female patient , came to opd on 3rd of January with chief complaints of shortness of breath since two days and fever since 1 week along with pain and swelling in the perianal region since 10 days History of present illness: The patient was apparently asymptomatic 6 years back Course of events: 6 years ago: She went to a nearby hospital because of her weakness, polyuria, polydipsia, polyphagia, and weight loss and she was diagnosed with diabetes; she then started using insulin injections as prescribed by a local doctor 

Injecction mixtard 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 preanal that started as small lesion and increased to the current size of 4*4cms 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 

 

As due to use of antibiotics she developed nausea Therefore she decreased her insulin dosage on her own since 3 days and developed shortness of breath As sob was increased, she checked her random glucose leve at home and it was 480mg/dl, was then taken to local hospital and was given injection ( not known)

Since 2days  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 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 Personal history:

Daily routine-

She used to wake up at 5 am and she used to have breakfast at 7am ,before which she used to take an injection of insulin and go to college at 9am and come back at 5pm and she used to have dinner at 9pm before with she used to take another dose of insulin 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-

Pt is conscious coherent and cooperative , and well oriented to time place ,person

Pallor -present

Icterus-absent

No lymphadenopathy , cyanosis,edema

Vitals-

Temperature-101F

Bp-120/70 mm/hg

RR-tachypnice

Spo2-98%

PR-92bpm

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- is present 

Local rise of temperature

Induration present 

Visible pus discharge

Systemic examination:

Respiratory system:

Inspection :

Position of trachea: middle

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,  

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-

No fluid thrills and  shifting dullness

Auscultation:

Bowel sounds are heard

CVS:

Inspection: normal on inspection, apex beat not visible,no visible pulsation ,equal and symmetrical chest movement 

Palpation: all the inspections are confirmed 

Percussion: all the borders of heart normal on percussion 

Auscultation:S1 and  S2 heart sounds are heard

No murmurs heard

CNS:

Higher mental functions intact

Reflexes- present

Power,muscle tone- normal

Gait- normal

No meningeal signs

Cranial nerves - intact

Investigations:

USG(ultrasound)

             

IMPRESSION : Internal Echoes noted in urinary bladder- Cystitis

2D- ECHO:

ECG: 

Pus culture sensitivity:

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06.01.23

07.01.23 

Complete urine examination:

Appearance:

Albumin:++

Sugars:++

Pus cells:4-5

Epithelial cells:3-4

Urine for ketone bodies: positive

Blood grouping and typing: O positive

Chest X Ray:

ABG:

Day1:

Day2:

Day3: 

Day4: 

Diagnosis:

Diabetic ketoacidosis with Type 1 DM since 6 years with perianal abscess

Treatment:

Iv fluids Ns (saline)100ml/hr

Inj Human Actrapid insulin Sc/3*day

12u- 12u- 12u

Inj NPH sc/2*day

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