14 yr old female with shortness of breath


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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.


This is a case of a 14 year old girl who came with chief complaints of:


Shortness of breath since 2 days

Fever since 1 day

Abdominal pain since 1 day

Vomiting 1 episode


HOPI: 

The patient was apparently asymptomatic 4 years ago, then she had a fever with generalised body weakness and polyuria and was diagnosed having type 1 DM and started on insulin.

2 years ago patient had similar complaints after an episode of fever and was admitted at our hospital and was treated here. 

 2 days ago then she developed sudden onset shortness of breath since 2 days, gradually progressive and progressed to stage 4. Shortness of breath started after patient missed taking 2 doses of insulin. No orthopnea, no PND. 

Fever since 1 day, high grade associated with chills and rigors, relieved on taking medication, no diurnal variation.

Abdominal pain since 1 day epigastric region alter progressed to diffuse abdominal pain.

No h/o vomiting, loose stools, giddiness.

Headache present, vomiting 1 episode- non bilious, non projectile, not blood stained, content- food material.


Past history 

k/c/o type 1 DM since 4 years in biphasic insulin 30/70(17U-12U)

h/o 2 previous admissions for fever in last 4 years


Family history

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


Personal history

She's a 9th class student

Diet mixed

Appetite normal

Sleep adequate

Bowel and bladder regular

Menarche not attained


GENERAL EXAMINATION


Patient is conscious coherent and cooperative. Well oriented to time place and person. 


No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema





Vitals:

Pulse - 98 bpm

BP - 120/80 mm Hg

RR - 28 count

Temp- 99.1F

SpO2- 98%

GRBS- 526mg%







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. 




Per Abdomen:


Shape is scaphoid

Abdomen is soft and non tender with no signs of organomegaly

Bowel 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 ketoacidosis secondary to non compliance

k/c/o DM1 since 4 years


Investigations 


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