20 Year old Female with ABDOMINAL PAIN AND VOMITING

Introduction: This is an online E-log Entry Blog to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs. 

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.

 20 year old female patient, nursing student presented 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 PRESENTING ILLNESS:

Patient was apparently asymptomatic 5 days back, when 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, 5 minutes 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.




DAILY ROUTINE





PAST HISTORY:


  • Patient is not a known case of Hypertension, Thyroid disorders, Seizures, Tuberculosis, Asthma or any cardiac disorder.
  • No history of any blood transfusion or previous surgeries.
DISEASE PROGRESSION





PERSONAL HISTORY:

  • Her appetite has decreased, she consumes a mixed diet, sleep is adequate, bladder movements normal. She is constipated. 
  • No addictions

MENSTRUAL HISTORY:

  • Menarche at 13 years
  • Regular cycles, 5/30, changes 2 pads per day and not associated with pains, clots, foul smell.
  • But she complains of menorrhagia (spotting) since last 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.
  • No signs of Pallor, Icterus, Cyanosis, Clubbing, Generalized Lymphadenopathy, Edema.

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. Discoloration 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.







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