20 yr female with abdominal pain and vomiting

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Name: G Sai Manogna

Roll no: 33

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 treatment plan.

CASE PRESENTATION:

A 20 yr old female, student by occupation has come to the OPD on 22nd march 2022 with the chief complaints of

• Abdominal pain since 7 am in the morning (22/3/2022)
• Vomiting since morning

History of presenting illness:

Patient was apparently asymptomatic 5 days back when she developed pain in the epigastric region. It was sudden in onset, gradually progressive and is of burning type. There were no aggrevating and relieving factors.

She took omidine and digiene for the relief of abdominal pain after which she had 3 episodes of vomiting which was bilious, non projectile, and non foul smelling and was relieved after taking medication(Zofer). She also has a history of constipation since 2 days

Patient had a history of RTA(fracture to right leg) 3 years back, at the of which she was diagnosed with Diabetes mellitus Type 1 and was prescribed Subcutaneous insulin injection. She took Insulin for 1 year and then discontinued it for 1 month at the end of which her blood glucose levels remained high. So, she continued Insulin. The used oral diabetic medication for a month but as the blood glucose levels remained abnormal, she went back to using Insulin again.

Then she had an history of similar complaint 6 months back in the epigastric region which was sudden in onset, gradually progressive radiating  to right flank and was diagnosed with acute pancreatitis and was treated conservatively with iv fluids.

On further investigations her blood glucose levels were high and she was prescribed with mixtard insulin sub cutaneous(12 units- 2 times a day)

After 10 days she developed hyperpigmented spots and patches on her lower back and lower limbs for which she consulted a doctor several times but they did not resolve

She had irregular life styles since the past two months and on the night before epigastric pain, she took the insulin but did not have her dinner

Patient was not a known case of hypertension, asthma, thyroid, TB and epilepsy

No history of previous surgeries and blood transfusions

Personal history:

Diet- Mixed

Appetite- decreased

Sleep- Adequate

Bowel and bladder- Regular

Addictions- None

Menstrual history:

Menarche-13 yrs

Regular cycles - 5/30

Not associated with pains, clots and foul smelling

Since 1 month she complaints of spotting PV

Family history:

Her paternal grand mother was diagnosed with diabetes

No other significanf family history

Allergic history:

No history of any allergies to drugs or any food

General physical examination:

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

Moderately nourished and built

No pallor, icterus, cyanosis, clubbing, generalized lymphadenopathy, edema

Vitals:

Temperature- Afebrile

Blood pressure- 110/80mm of Hg

Pulse rate- 94 bpm

Respiratory rate- 18/min

SPO2- 99%

GRBS- 215 mg%

 

Systemic examination:

Per abdomen examination:

Inspection:

On inspection, abdomen appears to be  distended and umbilicus is inverted.

Discolouration around the umbilicus is seen(Cullen's sign positive)

Multiple scars are seen around the umbilicus

No sinuses, engorged veins, visible peristalsis and pulsations 

Palpation:

Inspectory findings were confirmed

No local raise of temperature

No tenderness 

No guarding and rigidity

No hepato and splenomegaly

Percussion:

Tympanic note is heard

Auscultation:

Bowel sounds are decreased and no bruits

CVS:

S1 and S2 were heard and no murmers

Respiratory system:

Bilateral air entry is present.

Normal vesicular breath sounds were heard

CNS:

No neurol focalogical deficits

Investigations:

Serum Lipase      -  135

Serum Amylase   -  261

RBS             -  292 mg/dl

HAEMOGRAM  23/03/2022

Haemoglobin  -  13 gm/dl

Total Count     -   13,200

RBC                  -  5.46

Platelet Count -  3.36 lakh

RFT

S Urea            - 29

S Creatinine  - 0.7

Uric acid       -  8.8

S Calcium     -  10.2

Na                  - 137

K                    - 4.5

Cl                   - 98

LFT

Total Bilirubin    - 1.52

Direct Bilirubin   - 0.62

Ast                      - 17

Alt                       - 9

Alk P                   - 181

Total Protein     - 6.8

Albumin             - 3.37

A/G                    - 0.98

 

CRP                   - 

HbA1c   -  6.9 %

ECG:

2D echo:

USG:

CT:

Chest x-ray:

Provisional diagnosis:

Acute Pancreatitis with DKA with Type 1 Diabetes Mellitus (since 3 years)

Treatment:

1. Nbm till further orders.

2. IVF- NS & RL @ 150ml/hr.

3. Inj HAI ( 39ml Normal Saline + 40 IU HAI ) @ 4 ml / hr according to Algorithm

4. Inj. Pantop 40mg/IV/OD.

5. Inj. Zofer 4mg/IV/OD.

6. Inj. Tramadol 1amp in 100 ml/NS/IV/BD.

7. Inj. THIAMINE 2amp in 1 NS/IV/TID.

8. Monitor vitals.

9. Measure abdominal girth.