SHORT CASE: A 18yr old female of Diabeticketoacidosis with perianal abscess

January18,2023

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A 18 y/o female with a chief complaint of diabetic ketoacidosis with perianal abscess

Cheifcomplaint:

A 18 year old female came to Opd on 03.01.23 with chief complaints of:

-pain and swelling in the perianal region since 10 days

-fever since 1 week

-shortness of breath since 2days

History of present illness:

The patient was apparently asymptomatic 6 years ago.

1 week ago: 

Patient had swelling over anal that increased to the present size of 4x 4 cms along with discharge of pus and mixed with blood,

 And also  she had high grade fever associated with chills and rigors,she took antibiotics prescribed by a local doctor.

She had used those antibiotics for 5 days , later developed nausea  

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

As sob was increased ,she got her Grbs checked at home and it was 480mg/dl, was taken to local hospital and was given injection ( not known).

Since today morning her sob was increased went to hospital and RBS being high, insulin14u HAI given and further management is prescribed.

Past history:

History of similar complaints of swelling in inner thighs and in gluteal region 1 year back as she has taken covid vaccine. 

On that time and she consulted local doctor and recieved antibiotics ( amoxiclav 625mg/bd for 5 days and also herbal medicine for swelling, local application it got relieved.

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

Menstrual history:

Age of menarche: 13 years

Menses: regular,28 days cycle 

 associated with pain and clots

Personal history:

Diet: mixed

Appetite: decreased 

Bowel and bladder: regular

Sleep: adequate

Addictions: no

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,edema

Vitals:

Temperature: 101 F

Bp: 120/70mmhg

PR: 92 BPM

RR: Tachyponeic at the time of admission

21cpm

Spo2: 98% 

Grbs:

Surgery referral notes:

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

Visible pus discharge

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

Movement of chest : normal

Palpation :

Position of trachea, apical pulse is confirmed

No tenderness over chest wall, no crepitations, no palpable added sounds,  no palpable pleural rub

Percussion:

Resonant note heard.

Auscultation :

BLAE-PRESENT

Abdomen:

Shape: scaphoid

Umbilicus: central

Movements: normal

No visible pulsations or engorged veins,no visible peristalsis

Skin over abdomen :normal

Palpation: soft non tender

No tenderness or local rise of temperature

Percussion :

Liver: resonant note heared

No fluid thrills and  shifting dullness

Auscultation:

Bowel sounds are heard

CVS:

S1 and  S2 heart sounds are heared 

No murmurs.

CNS:

Higher mental functions intact

Reflexes- present

Power,muscle tone- normal

Gait- normal

Investigations:

USG:

2D- ECHO:

ECG: 

Pus culture sensitivity:

05/1/23:

06/1/23:

O7/1/23:

Urine for ketone bodies: positive

Blood grouping and typing: O positive

Diagnosis:

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

S/P : incision and drainage of abscess done under spinal anaesthesia ( 3/1/23)

Treatment:

Iv fluids Ns@100ml/hr

Inj Human Actrapid insulin Sc/TID

12u- 12u- 12u

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 @2pm

Tab Dolo 650mg/po/Tid

6/1/23

: No fever spikes

    Stools passed