18 year female with Type1 DM and perianal abscess

 18 Year female Perianal abscesses with DKA

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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 :

 A 18 Years Old Female who is a Student Presented with C/o

• Pain & Swelling in Perianal Region Since 11 days
• Fever with Chills Since 11 Days 

• Shortness of Breath Since 3 Days

History of Present Illness : 

Patient Was Apparently Asymptomatic 8 Years ago then She Suddenly Developed Pain Abdomen ; Shortness of Breath (grade 4) & Lethargy for Which she went to Hospital in Hyderabad & Was Diagnosed with Type 1 DM ( RBS was around 600mg/dL ) Since then She was on Inj.MIXTARD BD.

4 Years Ago She Developed Pain Abdomen Which was Sudden Onset , Diffuse , Squeezing Type ; Non Radiating & Not Relieved With Medication & Went to Hospital Where she was told it is Due to Uncontrolled Sugars & Pain Got Subsided after Treatment & Was Prescribed with Inj.MIXTARD ( 20U - Morning ; 15U - Night )

11 Days Back She Developed Swelling Around the Perianal Region Which is Initially Around 1x1cm & Gradually Progressed to Present Size Around 4x4cm,Associated with Pus Discharge with reddish skin discoloration around the swelling , Pain, Fever with Chills 6 days back which is Low Grade & Intermittent for Which She Went to Hospital 6 Days Back & Was Started on Antibiotics. After Taking These antibiotics She Started Having Nausea & Decreased Food Intake. So They Decreased the Insulin Dose to 5U Morning & 5U Night Since 4 Days. 3 Days Back She Started Having Shortness of Breath which Was  Grade 2 & GRBS Was 480mg/dl for Which She Went to Local Hospital & Took Some Injections. Then after 1 Days SOB Progressed to Grade 4 & Referred to Our Hospital.

Past History : 

• H/O Swelling over inner Thighs associated with Pus Discharge 1 Year Ago Following 2nd Dose of COVID vaccination & Took Medication in local Hospital & Got Relived

• K/C/O Type 1 DM Since 8 Years

• N/K/C/O HTN ; TB ; Asthama ; Epilepsy 

Personal History : 

Diet : Mixed 

Appetite : Decreased since 6 days

Sleep : Inadequate since 6 days

Bowel : not passed stools since 6 days

Bladder : regular

Addictions : Nil 

Family History : 

Her Father -  T 2 DM Since 10 Years 

GENERAL PHYSICAL EXAMINATION  

 Patient is conscious, coherent, coperative and well oriented to Time place and person.

She is moderately built and nourished.

No h/ o pallor, Cyanosis, clubbing, generalized lymphadenopathy - absent.

Vitals 

Temperature - 99.5F

Pulse rate - 86bpm

Respiratory rate - 24cpm

Blood pressure - 120/70mm hg

SYSTEMIC EXAMINATION 

•Cardiovascular system- 

 S1 and S2 are heard ,no murmurs are heard.

•Respiratory system:

  Trachea central, all quadrants of chest moves equally with respiration. No adventitious sounds.

 Breath sounds- bilateral normal

 Vesicular breath sounds are heard.

•Central nervous system- 

   No focal neurological deficits

  •Abdominal system:

Inspection:

  On inspection abdomen is flat, symmetrical.

Umbilicus is centre and inverted. 

All 9 regions of abdomen are equally moving with respiration.

Palpation:

     On palpation abdomen is soft and mild tender. 

 All inspectory findings are confirmed.

Auscultation: decreased  bowel sounds. 

Investigations:

 

Provisional diagnosis: .... 

Diabetics ketoacidosis with type 1 diabetes with perianal abcess

Treatment... 

1) IVF - NS @100ml/HR 

 2) Inj HAI(0.1u/kg/hr) IV infusion

3) inj Piptaz 4.5g/IV/BD

4) inj amikacin 500mg/IV/BD 

5) Inj metrogyl 100ml/iv /tid

6) GRBS monitoring hourly

7)Diabetic protein powder in glass of water TID

8)Tab. Vit C PO OD

9)Tab MVT PO OD

10)Diabetic diet

11)Tab. Chymoral forte PO TID