20 years female with abdominal pain and vomiting

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Name-E.RishithaReddy 

Roll no -30

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:

20 year old female student by occupation has come to OPD on 22/3/22

chief complaints: 

abdominal pain since morning 7:00 am (22/3/22) 

vomiting since morning 7:00am (22nd march)

History of presenting illness:

Patient was asymptomatic 5 days back then she developed abdominal pain in epigastric region sudden in onset gradually progressive burning type of pain since morning there are no aggravating and relieving factors . For relieving the abdominal pain she has taken omi d and digene after which she had 3 episodes of vomiting (bilious ,non projectile)non foul smelling and was releived by taking medication (zofer) she also have a history of constipation from 2 days.

Past history

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 a history of similar complaint of abdominal pain 6 months back in the epigastric region which was sudden is onset, gradually progressive radiating to left flank and was diagnosed as acute pancreatitis and was treated with conservative management. On further investigations, her blood glucose levels were high and was prescribed subcutaneous Mixtard Insulin (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 the doctor several times but they did not resolve. 

She had an irregular lifestyle since the past 2 months and on the night before she complained epigastric pain, she took her Insulin but did not have her meals.

Patient is not a known case of Hypertension, Thyroid disorders, Seizures, Tuberculosis, Asthma.

No history of any blood transfusion, previous surgeries

Personal history :

Diet - mixed 

Appetite - decreased 

Sleep - adequate

Bowel and bladder movements - regular

Addictions - no

No history of food or drug allergy

Menstrual history :

Menarche -  13 years

Regular cycles 5/30 not associated with pain clots and foul smelling 

But since one month she complaints of spotting pv 

Family history :

History of diabetes Mellitus in paternal grand mother .

General Examination:

Pt was conscious cooperative coherent well oriented to time place and person moderately built and nourished .

NO Pallor , Icterus , Cyanosis , Clubbing, generalised ,lymphadenopathy.

Vitals-

Temp - afebrile

BP      - 120/100 mm hg 

PR      -  120 bpm. 

RR      - 19 cpm 

spo2  100 @RA 

GRBS  - 215mg/dl 

SYSTEMIC EXAMINATION :

Per abdomen - 

Inspection-

Abdomen appears to be distended

Umbilicus inverted

Multiple scars and Hyperpigmentation around the umbilicus is seen  (Cullen sign)

No sinuses and engorged veins are seen 

No visible peristalsis and pulsations 

Palpitation:

No raise of temperature no tenderness 

No guarding and rigidity 

No hepatomegaly and splenomegaly

Percussion :

Tympanic note is heard 

Auscultation: 

Bowel sounds are decreased and no Bruits 

CVS - S1, S2 heard and no murmurs 

RS     : bae present 

CNS  : No neural focological defects 

INVESTIGATIONS :

1. Lipid Profile :

Elevated Total Cholesterol - 261 mg/dl

Triglycerides - 932 mg/dl

HDL Cholesterol - 81 mg/dl

LDL Cholesterol - 150 mg/dl

2. Glycated Hemoglobin :

HbA1c - 6.9%

3. Random Blood Sugar : 292 mg/dl

4. Urine for Ketone Bodies : Positive

5. Complete Urine Examination : 

Albumin : positive

Sugar : positive 

6. Urine Protein/Creatinine Ratio :

Spot urine protein : 45.7 mg/dl

Spot urine creatinine : 83mg/dl

Ratio : 0.55

7. Hemogram :

Haemoglobin : 13 g/dl

Total WBC Count : 13,200 cells/cumm

Neutrophils : 79%

Lymphocytes : 15% (decreased)

Eosinophils : 3%

Monocytes : 3%

Basophils : 0

PCV : 39

MCV : 71.4 fl (decreased)

MCH : 23.8 pg (decreased)

MCHC : 33.3%

RDW- CV : 14.2%

RBC Count : 5.46 millions/cumm

Platelet Count : 3.36 lakhs/cumm

8. RFT :

Uric acid - 8.8 mg/dl (2.6-6 mg/dl)

Serum Urea - 29 mg/dl

Serum Creatinine - 0.7 mg/dl

Serum Calcium - 10.2 mg/dl

Na - 137 mEq/L

K - 4.5 mEq/L

Cl - 98 mEq/L               

Complete Urine Examination :

Serum Lipase      -  135

Serum Amylase   -  261

9. LFT

Total Bilirubin    - 1.52

Direct Bilirubin   - 0.62

AST                      - 17

ALT                    - 9

ALP                   - 181

Total Protein     - 6.8

Albumin             - 3.37

A/G                    - 0.98

10. Serum Lipase - 135

11. Serum Amylase - 261

ECG- 

2D Echo

Chest Xray PA View

USG Abdomen

CECT ABDOMEN

DIAGNOSIS 

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

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