A 18 y/o female with c/o of shortness of breath since 2 days,fever since 1 week and pain & swelling in perianal region since 10 days

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Chief Complaints:

A 18 year old female who is a student, came to the casuality on 03.01.23 with chief complaints of shortness of breath since 2days,fever since 1 week and pain and swelling in the perianal region since 10 days

History of present illness:

The patient was apparently asymptomatic 6 years ago.She went to a nearby hospital because of her weakness, polyuria, polydipsia, polyphagia, and weight loss; while there, her GRBS was high and she was diagnosed with diabetes; she then started using insulin injections(mixtard)

Patient had swelling in perianal region that started as 1x 1cms and increased to the current size of 4x 4 cms along with discharge of pus and mixed with blood.

Along with it she had high grade fever associated with chills and rigors,therfore she consulted a local doctor and received antibiotics

Due to the effects of the antibiotics,she later developed nausea as her diet was improper.

Therefore she decreased her insulin dosage since 3 days and developed shortness of breath on rest since 2 days.

Past history:

History of similar complaints of swelling in inner thighs and in gluteal region 1 year back.

At that time she consulted local doctor and recieved antibiotics ( amoxiclav 625mg/po/bd for 5 days and also herbal medicine for swelling.

Not a k/c/o hypertension, Tb, asthma, epilepsy, thyroid disorders.

Menstrual history: 

Age of menarche: 13 years 

Personal history:

Daily routine:- she used to wake up around 7 am in the morning,take insulin injection and then have breakfast and go to college.she used to come back around 5pm.Then at night before dinner she used to take an injection again (mixard)

Diet: mixed

Appetite: decreased 

Bowel and bladder: regular

Sleep: adequate

Addictions: none

Family History: 

Her father is a known case of diabetes since 16 years and he was using insulin mixtard 2 times daily

General Examination :

Patient was conscious, coherent, cooperative and well oriented to time, place and person.

Pallor: present

Icterus: absent. 

No cyanosis, clubbing, lymphadenopathy and edema.

Vitals:

Temperature: 101° F

Bp: 120/70mmhg

PR: 92 BPM

RR: Tachyponeic at the time of admission

21cpm

Spo2: 98%

Grbs: 348mg 

Surgerical examination:-

On local examination:

Swelling was in perianal region which was initially 1x1 cms and progressed to present size of 4x4 cms

Pus discharge present

Skin over swelling: reddish colour

Palpation:

Tenderness- positive 

Local rise of temperature

Induration of skin over the swelling- Positive

   

Systemic examination:

Respiratory system:

Inspection :

Position of trachea: midline

Position of Apex beat: left 5ics 1cm medial to mid clavicular line

Symmetry of chest : symmetrical and elliptical

Movement of chest : normal

Palpation :Position of trachea, apical pulse is confirmed

No tenderness over chest wall, no crepitations.

Percussion:

Resonant note heard.

Auscultation :

vesicular breath sounds

  abdomen:

Shape: scaphoid

Umbilicus: central

Movements: normal

Skin over abdomen :normal

Palpation: 

soft non tender

Percussion :

Liver: resonant note heared

No fluid thrills and shifting dullness

Auscultation:

Bowel sounds are heard

CVS:

S1 and  S2 heart sounds are heard

CNS:

Higher mental functions normal 

Gait- normal

Investigations

             

Pus culture

Urine examination:-

Appearance:

Albumin:++

Sugars:++

Pus cells:4-5

Epithelial cells:3-4

Urine for ketone bodies: positive

ABG:

Day1:

Day2:

Day3: 

Day4: 

Chest X Ray:

Diagnosis:

Diabetic ketoacidosis with Type 1 DM since 6 years with perianal abscess

S/P : incision and drainage of abscess done under spinal anaesthesia on 03/1/23.

Treatment:

Iv fluids Ns@100ml/hr

Inj Human Actrapid insulin Sc/TID 

Inj NPH sc/BD

15u- × -15u

Inj meropenam 1gm/iv/Bd d2

Inj Amikacin 500 mg/iv/Bd d2

Inj metrogyl 500 mg/iv/Tid d3

Inj pantop 40 mg/ iv/ bd

Inj neomol 1 gm/iv/bd

Inj Tramadol 2ampoules in 100ml Ns/iv/bd

Inj Zofer 4 mg/ iv/bd

Inj kcl 20 meq in 100 ml Ns/iv /stat

Tab orofer xt/ po/ od

Tab Dolo 650mg/po/Tid