14 yr old female with SOB,Vomiting,Abdominal pain

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P.Manogna

CASE REPORT

A 14 year old female, Student by occupation came to the OPD with 

Chief complaints of :

Shortness of breath since 1day

Vomiting since 1day

Abdominal pain since 1 day

Fever since 1day

HOPI:

Patient was apparently asymptomatic 4years back then she developed fever for which she was taken to local hospital and was treated, later 2days after she developed epigastric pain for which she was brought to our hospital where she was diagnosed with Type-1 Diabetes Mellitus And was started on Insulin therapy.

On 15th of April- she missed 2doses(i.e morning and evening), she was taken to near by RMP on 16th where her blood glucose was-500mg/dl,following which she developed shortness of breath(3Am) which was sudden in onset, progressed from grade 2 to 4 according to MMRC, No Orthopnea, No PND

Vomiting-1 episode, food particle as content, non-bilious, non-blood stained, non-projectile 

Abdominal pain- Initially in the epigastric region and then all over the abdomen 

Fever- which was high grade, associated with chills and rigor, relieved on medication, no diurnal variation 

Past history:

K/C/O Type-1 Diabetes Mellitus 

Similar complaints-2yrs back for which she was admitted in hospital 

Not a K/C/O HTN,Asthma, TB,Epilepsy 

Family History:

H/o diabetes in younger sister from 6years of age

Personal history:

She wakes up at 6Am gets ready and takes her Insulin shot(17units) before breakfast(8Am) and goes to school, she has lunch in the school(12pm) and returns to home by afternoon, she takes another Insulin dose in the evening before dinner(8pm)(12units)

She takes rice(2times) and non compliant to the diet given by the doctor 

Diet: mixed 

Appetite: increased 

Sleep: disturbed 

Bladder habits: increased

Bowel habits:regular 

No Addictions 

GENERAL EXAMINATION:

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

Moderately built and nourished 

No Pallor,Icterus,Cyanosis,Clubbing,

lymphadenopathy,Edema

Vitals:

Pulse:98bpm

BP:110/70 mm hg

RR:28cycles/min

Temperature: 99.1F

Spo2: 98%

GRBS:526gm%

SYSTEMIC EXAMINATION:

Abdomen:

Inspection: 

Normal in shape

Umbilicus central in position 

No scars, sinuses or engorged veins

Palpation: 

Inspectory findings are confirmed

No local rise of temperature 

Tenderness elicited in left hypochondrium region 

No hepatomegaly, No spleenomegaly 

Percussion:

Normal liver span

Auscultation: normal bowel sounds heard 

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. 

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 keto acidosis secondary to non- compliance of medication 

Type-1 diabetes mellitus 

Investigations:

Final diagnosis:

Diabetic keto acidosis secondary to non- compliance of medication 

Type-1 diabetes mellitus 

18/4/23

fever spikes present - 9AM (101.4F) 4NPM (99.7F)

abdominal pain subsided

Pt is c/c/c

BP:110/60 mmHg

PR:108 bpm

GRBS:238@ 8AM

I/O 2500/1100 ML

Temp 96.8F

1. NBM TILL FURTHER ORDERS

2. INJ HAI 1 ML+39 ML @2 ML/HOUR to increase/decrease according to GRBS to maintain between 150-250 mg/dl

3. IVF 0.45% NS +5% Dextrose @125 ml/hr

4. Maintain GRBS 150-250 mg/dl

5. Tab PCM 500 MG PO/SOS

19/4/23

fever spike present - 8AM-99.2F

Pt is c/c/c

BP:110/60 mmHg

PR:72bpm

I/O 2000/1100 ML

Temp 99.2F

GRBS:446gm/dl@ 8AM

Inj HAI -12 UNITS

Inj NPH -10 UNITS

1. INJ HAI S/C/TID

2. Inj NPH /BD

3. IVF 0.45% NS @125 ml/hr

4. Tab PCM 500 MG PO/SOS