A 13 year old with Vomiting and Abdominal pain

This is an a 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.This is an a 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.

P.Manogna, Roll no.120

CASE REPORT

A 13 year old  , Student by occupation came to Opd with 

Chief complaint of:

Vomitings since 1 day

Abdominal pain since 1day 

History of presenting illness:

Patient was apparently asymptomatic 3months back then she developed fever and weakness for which she was taken to a hospital in miryalaguda where she was diagnosed with Type-1 diabetes for which she was on Insulin therapy- Insulin doses in morning(16units) and evening (12units) for 7 to 14days inspite of this dose the glucose levels were not controlled after 1 week the dose where increased to morning(18units) and evening( 16units).

Patient was non compliance i.e didnot follow the diet given by the doctor 

She didnot take insulin dose on 10 of October and went to school  following this she was taken to hosiptal in miryalaguda with altered sensorium along with vomitings. 

Then she came to our hospital with complaints of Vomitings 3 to 4 episodes with food particle as content, non bilious, non projectile associated with Abdominal pain.

Past history:

K/c/o Diabetes since 3months for which given Insulin(18units and 16units) 

Not a K/c/o Hypertension,Asthma,TB,epilepsy

Family history:  

No significant family history 

Personal history:

She wakes up at 7:00Am Gets ready for school

At 8:00Am she takes insulin dose and goes to School by 9:00Am,Returns from school by 6:00Pm

She will complete the given homework and does household chores like cleaning which is now stopped due to illness

She takes another dose of insulin at 8:00Pm

Diet: Mixed 

Appetite: Increased 

Bladder movements: increased urine output 

Bowel movements: regular 

Sleep: Disturbed due to increased frequency of urine

No Addictions

General examination:

Patient is conscious,coherent,co-operative and well oriented with time,place,person.

No signs of pallor,icterus,clubbing,cyanosis and generalised lymphadenopathy. 

Vitals: 

Pulse Rate:120bpm

Blood Pressure: 100/50mmHg

Temperature:98.7degree F

Spo2:99%

Systemic examination

ABDOMEN:

Inspection: 

Normal in shape 

Umbilicus is central in prosition 

No scars or engorged veins are present 

Palpation:

No local rise of temperature 

Tenderness in epigastric region and around umbilicus 

No Hepatomegaly 

No Spleenomegaly 

Percussion:

Normal liver span

Auscultation: Bowel sounds were heard

CNS: 

CNS: 

Patient was drowsy E3V4M6

                         Upper limb                               lower limb

                       Rt                    left               Rt            left

Tone     normal       normal      increased increased

Power           5/5                   5/5             5/5              5/5

Reflexes         right                left

Biceps              ++                   ++

Triceps            ++                   ++

Supinator       ++                   ++

Knee                ++                   ++

Ankle   

Plantar         flexon        Flexon

CVS: 

S1,S2 heard 

No murmurs heard

RESPIRATORY:

Shape of the chest normal, 

-Trachea appears to be in centre 

-Normal vesicular breath sounds heard

Investigations:

ECG:

USG:

GRBS:

Provisional Diagnosis: 

Diabteic keto acidosis with Type-1 Diabetes Mellitus

Treatment:

1. Inf.NS-100ml/hr IV

2.Tab.PARACETAMOL 500mg/TID

3.Inj.MONOCEF 1gm/IV/BD

4.Inj.INSULIN 2ml/hr,IV infusion-1ml in 39ml NS@1ml=1unit

5. GRBS monitoring hourly 

6.IVF-5% DEXTROSE @30ml/hr(increase or decrease according to GRBS)