18 y/o female with DKA

January 05, 2023

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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 Complaints :

An 18 Year old Female who is a student by occupation Presented with C/O
Pain & Swelling in Perianal Region Since 11 days

Fever with Chills Since 11 Days
Shortness of Breath Since 4 Days

Constipation since 5 days

History of Present Illness :

The patient was apparently asymptomatic 6 years ago and then suddenly developed pain in the abdomen; shortness of Breath (grade 4) & lethargy for which she went to a hospital in Hyderabad & was diagnosed with Type 1 DM ( RBS was around 600mg/dL ) Since then she has been on Inj.MIXTARD BD.

4 years ago she developed pain abdomen which was sudden onset , diffuse, squeezing type ; Non radiating & not relieved with medication and she went to the hospital & Pain Got Subsided after Treatment & Was Prescribed with Inj.MIXTARD ( 20U - Morning ; 15U - Night )

11 days ago she developed a swelling in the anal region which was initially 1x1cm & Gradually Progressed to Present Size Around 4x4cm,Associated with Pus, discharge with reddish discolouration of the skin around the swelling.
Pain, high grade fever with Chills 6 days ago, for she went to the hospital and was started on antibiotics. After Taking These antibiotics She Started Having nausea & decreased food intake. So they decreased the Insulin Dose to 5U Morning & 5U Night Since 4 Days.

3 Days ago, she developed Shortness of breath which was Grade 2 & GRBS Was 480mg/dl for which she was treated using some injections at the local hospital. Then after 1 Day SOB Progressed to Grade 4.

Past History :

H/O Swelling over inner Thighs associated with pus and discharge 1 Year Ago following 2nd Dose of COVID vaccination -relieved on receiving medication at the local Hospital .

K/C/O Type 1 DM Since 8 Years

N/K/C/O HTN ; TB ; Asthma ; Epilepsy

Personal History :

Diet : Mixed
Appetite : Decreased since 5 days
Sleep : Inadequate since 4
Bowel : not passed stools since 5 days
Bladder : regular
Addictions : Nil

Family History :
Her Father - T2 DM Since 10 Years

GENERAL PHYSICAL EXAMINATION

Patient is conscious, coherent, cooperative
She is moderately built and nourished.
No h/ o pallor, Cyanosis, clubbing, generalized lymphadenopathy
Vitals on admission -
Temperature - 98.5F
Pulse rate - 105 bpm
Respiratory rate - 28cpm
Blood pressure - 120/70mm hg

SYSTEMIC EXAMINATION

•Cardiovascular system-
S1 and S2 are heard ,no murmurs are heard.

•Respiratory system:
Trachea central, all quadrants of chest moves equally with respiration. No adventitious sounds.
Breath sounds- bilateral normal
Vesicular breath sounds are heard.

•Central nervous system-
No focal neurological deficits

•Gastrointestinal System

-Inspection:
On inspection abdomen is flat, symmetrical.
Umbilicus is centre and inverted.
All 9 regions of abdomen are equally moving with respiration.

-Palpation:

On palpation abdomen is soft and mildly tender.
Auscultation:decreased bowel sounds