14 yr old girl with Shortness of breath,Fever and Abdominal pain

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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

14 year old girl who came to opd with chief complaints of:

Shortness of breath since 2 days

Fever since 1 day

Abdominal pain since 1 day

Vomiting 1 episode

HOPI: 

The patient was apparently asymptomatic 4 years ago, then she had a fever with generalised body weakness and polyuria and was diagnosed having type 1 DM and started on insulin.

2 years ago patient had similar complaints after an episode of fever and was admitted at our hospital and was treated here. 

 2 days ago then she developed sudden onset shortness of breath since 2 days, gradually progressive and progressed to stage 4. Shortness of breath started after patient missed taking 2 doses of insulin. No orthopnea, no PND. 

Fever since 1 day, high grade associated with chills and rigors, relieved on taking medication, no diurnal variation.

Abdominal pain since 1 day epigastric region alter progressed to diffuse abdominal pain.

No h/o vomiting, loose stools, giddiness.

Headache present, vomiting 1 episode- non bilious, non projectile, not blood stained, content- food material.

Past history:

k/c/o type 1 DM since 4 years in biphasic insulin 30/70(17U-12U)

h/o 2 previous admissions for fever in last 4 years

Family history:

h/o diabetes in younger sister from 6 years of age

Personal history:

Diet mixed

Appetite normal

Sleep adequate

Bowel and bladder regular

Menarche not attained

GENERAL EXAMINATION:

Patient is conscious coherent and cooperative. Well oriented to time place and person. 

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema

Vitals:

Pulse - 98 bpm

BP - 120/80 mm Hg

RR - 28 cpm

Temp- 99.1F

GRBS- 526mg%

Systemic examination:

CVS:

Jvp not raised 

Inspection:

Shape of chest - elliptical

No visible pulsations

No engorged veins 

Apical impulse not visible

Palpation:

Apex beat present over the left 5th intercostal space medial to midclavicular line

No parasternal heave

No precordial thrill

No dilated veins

Auscultation:

S1 S2 heard ,No murmurs 

Respiratory system:

Upper respiratory tarct - normal

Lower respiratory tract:

Inspection:

Chest bilaterally symmetrical,

Shape- elliptical

Trachea- central

Palpation:

Trachea is central

Normal chest movements

Vocal fremitus is normal in all areas ( in sitting position)

Percussion: in sitting postion

                                                 Rt. Lt

Supraclavicular. N(resonant). N

Infraclavicular. N. N

Mammary region. N. N

Inframammary region. N N

Axillary region. N. N

Infra axillary region. N. N

Supra scapular region.N N

Interscapular region. N. N.  

Infrascapular region. N. N

Auscultation:

Normal vesicular breath sounds

No added sounds

Vocal resonance is normal in all areas(in sitting position)

Per Abdomen:

Inspection:

Shape - flat

Flanks - free

Umbilicus - inverted

All quadrants moves equally with respiration 

No engorged veins, visible pulsations

Hernial orifice are free

Palpation:

No local rise of temperature

Abdomen is soft and non tender

No palpable spleen and liver

No other palpable masses

Percussion:

Resonant.

Auscultation:

Normal bowel sounds heard

CNS :

Higher motor functions - intact

Cranial nerves - intact

Motor system:

             Rt- UL. LL.                      Lt- UL. LL

Bulk - normal N.                           N. N 

Tone - N. N.                                    N. N

Power - 5/5. 5/5.                         5/5. 5/5

Reflexes:         

                             UL. LL

Biceps. 2+. 2+

Triceps. 2+. 2+

Supinator. 2+. 2+

Knee 2+. 2+

Ankle. 2+. 2+

Sensory system: intact

Co ordination is present 

Gait is normal

No Cerebellar signs 

No signs of meningeal irritation 

PROVISIONAL DIAGNOSIS :

Diabetic ketoacidosis secondary to non compliance

k/c/o DM1 since 4 years

Investigations: