A 14 yr old female came with c/o shortness of breath since 2 days

 This is an online E-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient centered online learning portfolio and your valuable comments on comment box is welcome.

I've 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 prognosis

A 14 year old female  resident of Narketpally studying 9 th class  came to the OPD with the chief complaints of 

CHIEF COMPLAINTS:

Shortness of breath since 2 days 

Fever since 1 day.

Abdominal pain since 1 day.

One episode of vomiting 1 day back.

History of present illness : patient was apparently asymptomatic 2 days back then she developed sudden onset of shortness of breath since 2 days gradually progressive grade 4 .Shortness of breath started after patient missed taking insuline dose.

Fever since 1 day high grade associated with chills and rigor relieved on taking medication and no diurinal variation.

Abdominal pain since 1 day in the epigastric region later Progressive to diffuse abdominal pain.

One episode of vomiting non projectile non bilious.

No history of PND,orthopnea,giddiness,loose stools.

History of past illness : 

History of 2 previous admissions in the hospital for fever in last 4 years

Known case of diabetes mellitus type 1  since 4 years.N

No H/o HTN TB,asthma,CHD,CVD,eplipsy

No drug allergies.

Family history : History of diabetes mellitus type 1 in the younger sister from 6 years of age.

Personal history : 

Sleep : adequate

Diet : mixed 

Appetite : normal

Bowel and bladder movements : regular

No history of alcohol consumption, tobacco smoking, tobacco chewing.

General examination : 

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

Moderately built and nourished.

Pallor : absent

Icterus : absent

Cyanosis : absent 

Pedal edema : absent

Lymphadenopathy : absent

Vitals :

BP : 110/70 mm of Hg

Pulse : 120/min

RR :28/min

Temperature : 99 F 

Spo2 : 98% 

GRBS :126 mg%

System examination :

On abdominal examination:

Inspection:

Shape of abdomen is scaphoid 

Flanks are free

Umblicus is in position, inverted

Skin over abdomen normal shiny, no scars, no sinuses, no nodules, no puncture marks.

No visible veins.

No engorged veins.

Movements of abdominal wall are normal, no visible gastric peristalsis.

Palpation: 

Liver examination:

On superficial palpation

no tenderness , no raised temperature

On deep palpation

 No tenderness in liver

Non pulsatile

Spleen examination: 

No tenderness and pain

Percussion :

 No fluid thrill 

On shifting dullness: tympanic note

Percussion of Liver for Liver Span : 14cm

 

Auscultation 

Normal bowel sounds heard.

2. Bruit - no renal artery bruit heard.

                no iliac artery bruit heard.

Respiratory system examination :

Inspection : 

Position of trachea central

No dropping of right shoulder

No intercostal indrawing

No supraclavicular hallowness

Shape and symmetry of the chest normal.

No dilated veins. 

No visible scars.

accessory muscles of respiration not prominent.

Palpation : 

On three finger test : position of the trachea central.

Respiratory movements are normal

On Vocal framitus vibrations are normal.

Ascultation :

Vocal resonence normal

Normal  vesicular  breath sounds.

 

Bilateral air entry positive.

No crackles heard.

CVS Examination :

Inspection :

No abnormal palsations

No visible scars.

No chest deformities.

Mediastinum normal

Trachea central in position.

Palpation :

Mediastinal position : apex beat normal

                                       Position of trachea central.

Percussion :

On percussion No cardiomegaly.

Ascultation : S1 and S2 heard. No murmurs heard.

CNS : NAD

INVESTIGATIONS

Complete blood picture 

Liver function test

Blood grouping

Random blood sugar

 

Complete urine examination

ECG

USG abdomen

Serology

Provisional diagnosis : 

Diabetic ketoacidosis with type 1 diabetes mellitus since 4 years.

Treatment :

Injection HAT 5U  iv or stat

Iv fluids : 10 NS in first one hour

                  20 NS  500 ml/h for 3 hours

Maintain GRBS : 150  - 250 mg/ dl

Inform if GRBS greater than or equal to 250 mg/dl and less than or equal to 75 mg /dl

Hourly GRBS monitoring

Monitor vitals hourly and temperature 4 th hourly.