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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.
This is a case of a 14 year old girl who came with chief complaints of:
Shortness of breath since 2 days
Fever since 1 day
Abdominal pain since 1 day
Vomiting 1 episode
HOPI:
The patient was apparently asymptomatic 4 years ago, then she had a fever with generalised body weakness and polyuria and was diagnosed having type 1 DM and started on insulin.
2 years ago patient had similar complaints after an episode of fever and was admitted at our hospital and was treated here.
2 days ago then she developed sudden onset shortness of breath since 2 days, gradually progressive and progressed to stage 4. Shortness of breath started after patient missed taking 2 doses of insulin. No orthopnea, no PND.
Fever since 1 day, high grade associated with chills and rigors, relieved on taking medication, no diurnal variation.
Abdominal pain since 1 day epigastric region alter progressed to diffuse abdominal pain.
No h/o vomiting, loose stools, giddiness.
Headache present, vomiting 1 episode- non bilious, non projectile, not blood stained, content- food material.
Past history
k/c/o type 1 DM since 4 years in biphasic insulin 30/70(17U-12U)
h/o 2 previous admissions for fever in last 4 years
Family history
h/o diabetes in younger sister from 6 years of age
Personal history
She's a 9th class student
Diet mixed
Appetite normal
Sleep adequate
Bowel and bladder regular
Menarche not attained
GENERAL EXAMINATION
Patient is conscious coherent and cooperative. Well oriented to time place and person.
No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema
Vitals:
Pulse - 98 bpm
BP - 120/80 mm Hg
RR - 28 count
Temp- 99.1F
SpO2- 98%
GRBS- 526mg%
CVS:
Inspection:
There are no chest wall abnormalities
The position of the trachea is central.
Apical impulse is not observed.
There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses.
Palpation:
Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line
Position of trachea was central
There we no parasternal heave , thrills, tender points.
Auscultation:
S1 and S2 were heard
There were no added sounds / murmurs.
Respiratory system:
Bilateral air entry is present
Normal vesicular breath sounds are heard.
Per Abdomen:
Shape is scaphoid
Abdomen is soft and non tender with no signs of organomegaly
Bowel sounds are heard
CNS:
HIGHER MENTAL FUNCTIONS-
Normal
Memory intact
CRANIAL NERVES :Normal
SENSORY EXAMINATION
Normal sensations felt in all dermatomes
MOTOR EXAMINATION
Normal tone in upper and lower limb
Normal power in upper and lower limb
Normal gait
REFLEXES
Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited
CEREBELLAR FUNCTION
Normal function
No meningeal signs were elicited
PROVISIONAL DIAGNOSIS
Diabetic ketoacidosis secondary to non compliance
k/c/o DM1 since 4 years
Investigations
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