20 YR OLD FEMALE WITH ABDOMINAL PAIN AND VOMITINGS

DATE :- 28 March 2022

" This is an online E-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient centered online learning portfolio and your valuable comments on comment box are welcome." 

Name :- G Meghana

Roll.no : 161 

9 th semester 

" 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 year old female patient, student by occupation has come to the OPD on 22nd March with 

CHIEF COMPLAINTS :

1. Abdominal pain since morning 7:00 am (22nd March)

2. Vomiting since morning 7:00 am (22nd March)

HISTORY OF PRESENT ILLNESS :

-- Patient was apparently asymptomatic 7 days back, then she developed abdominal pain in the epigastric region which was sudden in onset, gradually progressive, squeezing type of pain since morning with no aggravating and relieving factors.

                                                                                     🠋

--   For the relief of abdominal pain, she took Omedine and Digene after which she had 3 episodes of vomiting which was  bilious, non projectile, non foul smelling and was relieved by taking medication(zofer). 

                                                                                       🠋

--She also has a history of constipation since 2 days.

PAST HISTORY :

Patient had a history of RTA(fracture to right leg) 3 years back, at the timeof 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.

                                                                             🠋                        🠋

--She 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 complaints 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. ( Not associated with itching ) 

                                                                                                         🠋

--She had an irregular lifestyle since the past 2 months and on the night before she complained of 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 - normal
• No addictions
• Allergies - no known allergies

FAMILY HISTORY :

-- History of Diabetes mellitus in paternal grandmother.

--No similar complaints in the family members.

GENERAL PHYSICAL EXAMINATION :

-- Patient was observed in a well lit room after having taken her informed consent .

- Patient was conscious, coherent, co-operative and well oriented to time, place and person.

- Moderately built and nourished 

-- Pallor, Icterus, Cyanosis, Clubbing, Generalized Lymphadenopathy, Edema are absent.

Vitals : 

• Temperature - Afebrile
• Respiratory Rate - 17 cpm
• Pulse Rate : 80 bpm
• Blood Pressure - 110/80 mm Hg
• SpO2 - 100 % at RA
• GRBS - 215 mg/dl 

SYSTEMIC EXAMINATION :

Per Abdomen :

On Inspection :

Abdomen is scaphoid not distended and the umbilicus is inverted.  

Multiple scars are seen around the umbilicus.

No sinuses, engorged veins, visible peristalsis, pulsations are seen.

On Palpation :

There is no local rise of temperature.

No tenderness.

No signs of   hepatomegaly and splenomegaly.

No guarding and rigidity.

Percussion :

Tympanic note is heard.

Auscultation :

Bowel sounds are decreased.

CVS : S1, S2 heard. No murmurs.

Respiratory System : Bilateral air entry is present.

 Normal vesicular breath sounds are heard.

Central Nervous System : Motor and sensory system examination is normal

Reflexes :-        right                   left 

Biceps                 ++.                     ++

Triceps                 ++.                    ++

Supinator             ++.                     ++

Knee                      ++.                     ++

Ankle                    ++.                      ++

-- multiple polysized scaly annular plaques noted all over buttocks ,  groin and legs , face  since 6 months 

-- not associated with itching 

 

INVESTIGATIONS:-

Hemogram 

CUE 

ABG 

RBS 

Glyclated hb 

sedum amylase 

Serum lipase 

lipid profile 

LFT 

RFT

ECG

2D Echo -

USG

CT Scan 

Chest X Ray 

Provisional diagnosis:

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

TREATMENT

 Day 1:- 

• 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

Day 2 

No Fresh Complaints 

 Patient is conscious,coherent,cooperative

vitals :

• Temp - afebrile
• BP - 110/80 mm hg 
• PR - 99 bpm. 
• RR - 18 cpm 
• spo2 - 100 @RA 
• GRBS - 222 mg/dl @ 8 am
• CVS - S1, S2 heard 
• RS - bae present 
• P/A - Soft , Non tender
• bowel Sounds - Present
• Stools - Not Passed
• CNS - NAD

I/O - 2000/1800 ml

Rx

• NBM 
• IVF- NS & RL @ 100 ml/hr.
• Inj Pantop 40mg/IV/OD.
• Inj. Zofer 4mg/IV/SOS.
• Inj. Tramadol 1amp in 100 ml/NS/IV/ SOS
• Inj. THIAMINE 2amp in 1 NS/IV/TID.
• Monitor vitals.

Day 3 

No Fresh Complaints  

 Patient is conscious,coherent,cooperative

vitals :

• Temp - afebrile
• BP - 110/80 mm hg 
• PR - 75 bpm. 
• RR - 18 cpm 
• spo2 - 100 @RA 
• GRBS - 215 mg/dl @ 8 am
• CVS - S1, S2 heard 
• RS - bae present 
• P/A - Soft , Non tender
• bowel Sounds - Present
• Stools - Not Passed
• CNS - NAD

Rx:-

• I/O - 1500/1300 ml
• Oral Sips Of water Given
• IVF- NS & RL @ 100 ml/hr.
• Inj Pantop 40mg/IV/OD.
• Inj. Zofer 4mg/IV/SOS.
• Inj. Tramadol 1amp in 100 ml/NS/IV / SOS
• Inj. Optineuron 1amp in 100ml NS/IV/OD
• Monitor vitals.

  Day 4:-

No Fresh Complaints 

 - Patient is conscious,coherent,cooperative

vitals :

• Temp - afebrile
• BP - 110/80 mm hg 
• PR - 72 bpm. 
• RR - 18 cpm 
• spo2 - 100 @RA 
• GRBS - 243 mg/dl @ 7 am
• CVS - S1, S2 heard 
• RS - bae present 
• P/A - Soft , Non tender
• bowel Sounds - Present
• Stools - Passed
• CNS - NAD

Rx

• Oral feeds allowed
• IVF- NS & RL @ 100 ml/hr.
• Inj Pantop 40mg/IV/OD.
• Inj. Zofer 4mg/IV/SOS.
• Inj HAI acc to GRBS TID / SC
• Inj. Tramadol 1amp in 100 ml/NS/IV / SOS
• Inj. Optineuron 1amp in 100ml NS/IV/OD
• Monitor vitals.

Link reference :- 

http://medicineelogcasesturpusharathchandra.blogspot.com/2022/03/20yr-old-female-came-to-opd-with-pain.html