13 yr old girl with vomiting and stomach pain

This is an 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.

CHIEF COMPLAINT

A 13 yr female brought to causality at around 3:00am with h/o 5-6 episodes of vomiting and in a drowsy and arousal state, obeying commands 

HOPI

Patient was apparently asymptomatic 3 months back, then pt had developed fever and weakness for which she was admitted in hospital (miryalaguda) and was diagnosed diabetes. Patient was on insulin 16 units morning, 12 units evening for 10 days, dose was increased  to18 units morning and 16 units evening.

One day back(10/10/22) pt did not take take any insulin in the morning and had food and went to school. By evening pt reached home with complaint of abdominal pain and 3 episodes of vomiting. Pt was taken to hospital(in miryalaguda) at around 1:00 am in Altered sensorium state and was administered iv fluids and 10 units ......... and 20 ml of bicarbonates

PAST HISTORY 

K/c/o DM1 since 3 months,on insulin 18 units,16 units

Not a k/c/o htn,cyanosis,cad,epilepsy, tb,asthma 

TREATMENT HISTORY

Insulin since 3 months 

PERSONAL HISTORY

(She wakes up at 7am.8am she takes insulin, 9am goes to school  6pm returns home do homework)

Diet mixed

Apatite: increased ,and she refused to follow diet and consumes rice 3 times a day 

Sleep adequate 

Bowel movements regular,bladder movt: increased frequency of micturition 

No known allergies 

No addictions 

Family history --

GENERAL EXAMINATION

Pt was drowsy E3V4M6

No pallor, icterus, cyanosis, clubbing, generalized lymphadenopathy and oedema 

VITALS

Bp 100/55mmhg

Pulse 120bpm

RR

Temperature 98.7

SpO2 99

Grbs 88 mg/dl

SYSTEMIC EXAMINATION

CNS 

                         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

Abdominal examination

INSPECTION

Normal in shape 

Umbilicus is central in position 

No scars or engorged veins are present 

PALPATION:

No local rise of temperature 

Tenderness in epigastric region and around umbilicus 

No Hepatomegaly 

No Splenomegaly 

PERCUSSION:

Normal liver span

AUSCULTATION: Bowel sounds were heard

RS

Shape of the chest normal, 

-Trachea appears to be in central

-Normal vesicular breath sounds heard

Cvs

S1 S2 + no murmurs

Investigations 

Ecg,hemogram, CUE, urine ketone bodies,ogt,chest x-ray pa view, usg abdomen , rft,lft

Provisional diagnosis 

Diabetic ketoacidosis because of skipped medication 2° to type 1 DM 

Treatment 

At around 5 :30 am

IVF 20 NS BOLUS given,@125ml/hr

Inj HAI @4ML/hr ( 39ml NS+ 1ml insulin)

Grbs charting  1 hrly

IVF NS 100 ml/hr iv infusion 

Tab PCM 500mg tid

Inj MONOCEF 1gm iv bd

Inj INSULIN  2ml/hr iv infusion 

Grbs monitoring 

Ivf 5 % dextrose @ 30ml/hr