20 year old female with abdominal pain and vomiting

 

GENERAL MEDICINE Case Discussion

20 YEAR OLD FEMALE WITH ABDOMINAL PAIN AND VOMITING

- March 29, 2022

 A 20 YEAR OLD WITH ABDOMINAL PAIN AND VOMITING

-29th March '2022

This is an online E log book to discuss our patient's de-identified health data shared after taking 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 also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box are welcome.

MADHU KUMAR 

ROLL NO. : 11

9th 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:

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

CHIEF COMPLAINTS :

1. Abdominal pain 

2. Vomiting on 22/03/22

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 5 days back, then she developed abdominal pain in the epigastric region which was sudden in onset, gradually progressive, burning type of pain since morning with no aggravating and relieving factors. For the relief of abdominal pain, she took Omedy and Digene after which she had 3 episodes of vomiting and was relieved by taking medication (zofer). She also has a history of constipation since 2 days.

DAILY ROUTINE 

PAST HISTORY 

Patient is not a known case of Hypertension, Thyroid disorders, Seizures, Tuberculosis, Asthma.

No history of any blood transfusion, previous surgeries.

DISEASE PROGRESSION 

PERSONAL HISTORY :

Diet -mixed

Appetite -decreased

Sleep -adequate

Bowel and bladder movements - Constipated 

No addictions

MENSTRUAL HISTORY :

Menarche at 13 years

Regular cycles, 5/30, Not associated with pains, clots, foul smell.

But she complains of menorrhagia since 1 month.

FAMILY HISTORY :

History of Diabetes mellitus in paternal grandmother.

No similar complaints in the family members.

HISTORY OF ALLERGIES :

No history of any drug or food allergy.

GENERAL PHYSICAL EXAMINATION :

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 appears to be distended and the umbilicus is inverted. Discolouration around umbilicus is seen (Cullen's sign positive) 

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 hepatomegaly. No 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.

INVESTIGATIONS :

1. Lipid Profile :

Elevated Total Cholesterol - 261 mg/dl

Triglycerides - 932 mg/dl

HDL Cholesterol - 81 mg/dl

LDL Cholesterol - 150 mg/dl

2. Glycated Hemoglobin :

HbA1c - 6.9%

3. GRBS :

On day 1 : 265 mg/dl

On day 2 : 222 mg/dl @ 8 am

On day 3 : 215 mg/dl @ 8 am

On day 4 : 243 mg/dl @ 7 am

26.3.22 : 216 mg/dl

4. Urine for Ketone Bodies : Positive

5. Complete Urine Examination : 

Albumin : positive

Sugar : positive 

6. Urine Protein/Creatinine Ratio :

Spot urine protein : 45.7 mg/dl

Spot urine creatinine : 83mg/dl

Ratio : 0.55

7. Hemogram :

Haemoglobin : 13 g/dl

Total WBC Count : 13,200 cells/cumm

Neutrophils : 79%

Lymphocytes : 15% (decreased)

Eosinophils : 3%

Monocytes : 3%

Basophils : 0

PCV : 39

MCV : 71.4 fl (decreased)

MCH : 23.8 pg (decreased)

MCHC : 33.3%

RDW- CV : 14.2%

RBC Count : 5.46 millions/cumm

Platelet Count : 3.36 lakhs/cumm

8. RFT :

Uric acid - 8.8 mg/dl (2.6-6 mg/dl)

Serum Urea - 29 mg/dl

Serum Creatinine - 0.7 mg/dl

Serum Calcium - 10.2 mg/dl

Na - 137 mEq/L

K - 4.5 mEq/L

Cl - 98 mEq/L               

Complete Urine Examination :

Serum Lipase - 135

Serum Amylase - 261

9. LFT

Total Bilirubin - 1.52

Direct Bilirubin - 0.62

AST - 17

ALT - 9

ALP - 181

Total Protein - 6.8

Albumin - 3.37

A/G - 0.98

10. Serum Lipase - 135 IU/L (Elevated)

11. Serum Amylase - 261 IU/L (Elevated)

12. ECG

13. 2D Echo

14. Chest X-ray PA View

15. USG Abdomen

16. CECT ABDOMEN

17. Sickling test - negative

18. Dengue test - negative

PROVISIONAL DIAGNOSIS :

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

TREATMENT :

1. NBM till further orders.

2. Ryle's tube insertion.

3. IVF- NS & RL @ 150ml/hr.

4. Inj HAI ( 39ml Normal Saline + 40 IU HAI ) @ 4 ml / hr according to Algorithm

5. Inj. Tramadol 1amp in 100 ml/NS/IV/BD.

6. Inj. Pantop 40mg/IV/OD.

7. Inj. Zofer 4mg/IV/OD.

8. Strict I/O charting

9. Inj. THIAMINE 2amp in 100 ml NS/IV/TID.

10. Monitor vitals.

11. Measure abdominal girth daily.

12. GRBS charting hourly.