A 14year old female with shortness of breath and headache

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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 COMPLAINTS:

Shortness of breath 7days back

Fever and headache 5days back 

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 7days back then she developed shortness of breath which was sudden in onset,gradually progressed from grade 1 to grade 4,not associated with orthopnoea and pnd. She complained of headache since 5 days and two episodes of vomiting 5 days back which was non projectile,non bilious,not blood stained, contents were food material.She also had fever 5days back which was insidious in onset,low grade, intermittent,not associated with chills and rigor,no diurnal variation.She also complained of abdominal pain in the upper abdomen and later it was diffuse.                                                                   H/O polydipsia,polyuria since 5days.H/O missed insulin injections for two days before the development of above mentioned symptoms.         No h/o diarrhoea,recent infections, dizziness, burning micturition,decreased urine output,numbness,tingling sensation in the limbs, decreased vision.

PAST HISTORY:

 K/C/O diabetes mellitus since 4 years and takes biphasic insulin.History of similar complaints twice in the past 4years.Not a K/C/O hypertension,epilepsy,chronic kidney disease,thyroid disease,coronary heart disease, tuberculosis.

FAMILY HISTORY:

Younger sister is the k/c/o DM type2.

PERSONAL HISTORY:

Diet: Mixed
Sleep: adequate
Appetite:normal
Bowel movements: regular
Bladder movements:increased                                   No addictions.

GENERAL EXAMINATION:

Patient is conscious, coherent, and comfortable
Pallor is present, No icterus, No clubbing, No lymphadenopathy, No pedal edema, No cyanosis.

VITALS:-

Temperature:94.8F

PR-95bpm

RR-18cpm

BP-110/70mm Hg

SpO2-98%

GRBS-236mg/dl

SYSTEMIC EXAMINATION:

CVS:-

S1,S2 heard and no murmurs

P/A :-

- shape of abdomen is scaphoid 

  No flank fullness is seen 

  Umbilicus is inverted and skin is normal 

  No engorged/dilated veins 

  Hernial surfaces are normal

-On palpation

 No tenderness

 No other organomegaly.

-No fluid thrill

 Liver span-15cm

-bowel sounds were reduced (7/min )

RS :- BAE+ , NVBS heard, tracheal position is 

central 

CNS :- HMF present and no focal  neurological deficits are noticed.

PROVISIONAL DIAGNOSIS:

Diabetic ketoacidosis

INVESTIGATIONS:

Urine for ketone bodies: Positive

ELECTROLYTES:

19/04/23-

Sodium-138mEq/L

Potassium-4mEq/L

Chloride-104mEq/L

Calcium ionised- 1.20mmol/L

20/04/23-

Sodium-139mEq/L

Potassium-3.2mEq/L

Chloride-101mEq/L

GRBS:

20/04/23-236mg/do

FINAL DIAGNOSIS:

Diabetic ketoacidosis 2° to non compliance

TREATMENT:

IV fluids 0.44% 100ml/hr

Inj HAI S/C TID

Inj NPH S/C BD