A 28/F WITH VOMITINGS AND 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. 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.

A 28 year old female resident of Nalgonda presented to hospital with 

CHIEF COMPLAINTS:

-Vomitings since 10 days.

-Burning micturition since 10 days.

-shortness of breath since 2 days.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 10 days ago when she developed vomitings,6-8 episodes per day,non projectile,non bilious,non blood stained,yellowish to green in colour.There is history of burning micturition since 10 days which got relieved on medication.There is history of pedal edema 10 days ago which had no postural variation and was pitting in type and got relieved spontaneously.There is history of shortness of breath since 2 days,sudden in onset,gradually progressive. 

No history of orthopnea,peripheral neuropathy,palpitation,chest pain,loose motions.

PAST HISTORY:

Known case of Type 2 diabetes mellitus since 2 years.

No history of tuberculosis,hypertension,epilepsy,asthma,coronary artery disease.

PERSONAL HISTORY:

-Patient wakes up at 6 am and starts the day with doing her daily chores.

-She eats breakfast like idli,dosa or Upma everyday at 8 am.

-She takes insulin 30 minutes prior to both lunch and dinner and eats rice and curries everyday as meals.

-She is a homemaker and doesn’t have any other physical activity apart from doing daily chores.

-She goes to sleep at 10 pm and doesn’t have disturbed sleep.

-She takes mixed diet,non veg twice weekly and has good appetite.

-Patient has normal bowel and bladder movements,No addictions.

TREATMENT HISTORY:

Insulin 15 units twice daily (30 minutes prior lunch and dinner)

FAMILY HISTORY-

GENERAL PHYSICAL EXAMINATION:

-Patient is conscious, coherent and non cooperative,he is well oriented to time, place, person.

-examined in a well lit area

-moderately built and moderately nourished.

-Pallor-absent

-Icterus- absent

-cyanosis-absent

-clubbing- absent

-lymphadenopathy- absent

-pedal edema- absent

VITALS

Temperature- 98.7 F

Pulse rate- 72 beats per min

Respiratory rate- 29 breaths per minute 

Blood pressure -130/80 mm of Hg

SYSTEMIC EXAMINATION 

RESPIRATORY SYSTEM 

INSPECTION : 

-shape of chest normal

- central trachea

-abdomino thoracic type

PALPATION: -

-all inspectory findings are confirmed

PERCUSSION:

 -resonant in all areas

AUSCULATION:

-bilateral air entry present 

CARDIO VASCULAR SYSTEM :

S1,S2 heard no murmurs heard

PER ABDOMEN 

INSPECTION  

-all quadrants are moving equally with respiration

-abdominal distention is present,

-umbilicus is inverted, central, 

-no scars or sinuses are seen,

- no engorged veins are seen 

PALPATION

- all inspectory findings are confirmed

-  abdomen is soft

-  non tender

- no local rise in temperature,

- no organomegaly is noticed. 

PERCUSSION-normal liver span

AUSCULTATION-bowel sounds heard

 

CNS:

no focal Neurological deficits found

Higher mental functions-normal

Sensory examination-

                                                               Right.                                       Left.

Spinothalamic-                                       

Crude touch-                                           normal                                     normal

Pain-                                                        normal                                     normal

Temperature-                                           normal                                    normal

 

Dorsal column

Fine touch                                              Normal.                                    Normal 

Vibration.           

Medial malleolus                                    3.5.                                           4.7 

Shaft of tibia                                           3.6.                                           5.1

Tibial tuborisity                                      5.7.                                           6.0

Cortical 

Graphesthesis.                                       Normal                                      normal

Stereognosis.                                         Normal.                                     normal

INVESTIGATIONS:

 

   

ECG

                                          

Ultrasound

Provisional diagnosis-DKA