18F with DKA with Perianal Abscess

Cheif Complaints : 

A 18 Years Old Female who is a Student Presented with C/O
Pain & Swelling in Perianal Region Since 10days
Fever with Chills Since 10 Days 
Shortness of Breath Since 2 Days

History of Present Illness : 

Patient Was Apparently Asymptomatic 8 Years ago then She Suddenly Developed Pain Abdomen ; Shortness of Breath & Lethargy for Which she went to Hospital in Hyderabad & Was Diagnosed with Type 1 DM ( RBS was around 600mg/dL ) Since then She was on Inj.MIXTARD BD.

4 Years Ago She Developed Pain Abdomen Which was Sudden Onset , Diffuse , Squeezing Type ; Non Radiating & Not Relieved With Medication & Went to Hospital Where she was told it is Due to Uncontrolled Sugars & Pain Got Subsided after Treatment & Was Prescribed with Inj.MIXTARD ( 20U - Morning ; 15U - Night )

10 Days Back She Developed Swelling Around the Perianal Region Which is Intially Around 1x1cm & Gradually Progressed to Present Size Around 4x4cm,
Associated with Pus Discharge, Pain, Fever with Chills which is Low Grade & Intermittent for Which She Went to Hospital 5 Days Back & Was Started on Antibiotics. After Taking These antibiotics She Started Having Nausea & Decreased Food Intake. So They Decreased the Insulin Dose to 5U Morning & 5U Night Since 3 Days. 2 Days Back She Started Having Shortness of Breath which Was  Grade 2 & GRBS Was 480mg/dl for Which She Went to Local Hospital & Took Some Injections. Then after 1 Days SOB Progressed to Grade 4 & Reffered to Our Hospital.


Past History : 

H/O Swelling over inner Thighs associated with Pus Discharge 1 Year Ago Following 2nd Dose of COVID vaccination & Took Medication in local Hospital & Got Relived

K/C/O T1DM Since 8 Years
N/K/C/O HTN ; TB ; Asthama ; Epilepsy 

Personal History : 

Diet : Mixed 
Appetite : Decreased 
Sleep : Inadequate 
Bowel & Bladder : Irregular
Addictions : Nil 

Family History : 

Her Father - T2DM Since 10 Years 

Surgery Referral for Perianal Abscess :



Discharge Summary : 

DOA : 3/1/2023

Date of Operation : 03/01/2023 PERIANALABSCESS,INCISIONANDDRAINAGEDONEUNDERSOPINAL ANAESTHESIA.
31/01/2023-DEBRIDEMENT AND SPLIT SKIN GRAFTING UNDER SPINAL ANAESTHESIA.

Discharge Date:17/02/2024
Ward:PLASTICSURGERY

Diagnosis

POST OP GLUTEAL ULCER WITH SSG WITH TYPE 1 DIABETES MELLITUS

Case History and Clinical Findings
CHIEF COMPLAINTS:
SHORTNESSOFBREATHSINCE2DAYS FEVER SINCE 1WEEK

HISTORY OF PRESENT ILLNESS:
PATIENT WAS APPARENTLY ASYMPTOMATIC 6 YEARS BACK AND THEN DEVELOPED WEAKNESS FOR WHICH SHE WENT TO LOCAL HOSPITAL AND THE GRBS WAS HIGH AND WAS DIAGNOSED TO BE HAVING DIABETES MELLITUS AND STARTED ON INSULIN INJECTION AND WAS USING SINCE TEHN.?INJ.MIXTARD 20U--X--15U.AND PATIENT WAS ASYMPTOMATIC1WEEKAGOANDTHENDEVELOPEDSWELLINGOVERANALVERGEWITH DISCHARGE (PUS AND BLOOD DISCHARGE) ASSOCIATED WITH HIGH GRADE FEVER,WITH CHILLS AND RIGORS AND FOR WHICH ANTIBIOTICS WERE STARTED SINCE 5 DAYS AND SHE DEVELOPED NAUSEA AND SO SHE WAS ON PROPER DIET AND SO DECREASED THE INSULIN DOSAGE TOO,5U--X--5U SINCE 3 DAYS AND DEVELOPED SOB ON REST SINCE 2 DAYSANDYESTERDAYASSOBINCREASEDGOTHERGRBSCHECKEDATHOMEANDWAS 480 MG/DL AND WAS TAKEN TO LOCAL HOSPITAL WAS GIVEN INJECTIONS(NOT KNOWN) AND TODAY MORNING I/V/O INCREASED SOB ,WENT TO HOSPITAL AND RBS BEING HIGH WAS GIVEN IGU OF ?HAI AND REFERRED HERE FOR FURTHER MANAGEMENT.

PAST HISTORY:
K/C/O DM SINCE 6 YEARS (ON INJ.MIXTARD 20U--X--15U--) PERSONALHISTORY:NOTPASSEDSTOOLSSINCE3DAYS. GENERAL EXAMINATION:
PATIENT IS CONSCIOUS,COHERENT AND COOPEREATIVE.
NOSIGNSOFPALLOR,ICTERUS,CYANOSIS,LYMPHADENOPATHY,EDEMA VITAL:-
BP:130/80MMHG PR:102/MIN RR:36/MIN TEMP:98.6F SPO2:100% @ RA GRBS:348 MG%


SYSTEMIC EXAMINATION:
RS:BAEPRESENT,NVBSHEARD. CVS:S1,S2 HEARD.
CNS:INTACT
P/A:SOFT,NONTENDERBS+ P/R:SWELLING PRESENT
Treatment Given(Enter only Generic Name)
COURSE IN THE HOSPITAL:
PATIENT WAS ADMITTED IN THE GENERAL MEDICINE I/V/O SHORTNESS OF BREATH AND DIAGNOSED TO HAVE DIABETIC KETOACIDOSIS AND WAS STARTED ON IV FLUIDS AND INSULIN INFUSION @ 5ML/HR.GENERAL SURGERY OPINION WAS TAKEN I/V/O SWELLING OVER THE PERIANAL REGION AND WAS DIAGNOSED TO HAVE PERIANAL ABSCESS AND INCISIONANDDRAINAGEWASDONEUNDERSPINALANAESTHESIA.PATIENTWASSHIFTED TO ICU I/V/O STRICT GRBS MONITORING AND WAS STARTED ON ANTIBIOTICS(MEROPENEM,AMIKACIN,METROGYL).REGULAR BEDSIDE DEBRIDEMENT AND DRESSINGSWEREDONE.CASEWASTRANSFERREDTOGENERALSURGERYDEPARTMENT I/V/O GLUTEAL ULCER.ENDOCRINOLOGIST OPINION WAS TAKEN I/V/O UNCONTROLLED SUGARS AND ADVISE FOLLOWED.PLASTIC SURGERY OPINION WAS TAKEN ON 24/01/2023 AND SPLIT SKIN GRAFTING WAS PLANNED.
SSGWASDONEON31/01/2023ANDCASEWASTRANSFERREDTOPLASTICSURGERY DEPARTMENT.
IMMEDIATE POST OP PERIOD-GENERAL MEDICINE OPINION WAS TAKEN I/V/O UNCONTROLLED SUGARS AND PATIENT WAS DAIGNOSED TO HAVE DIABETIC KETOAACIDOSISANDPATIENTWASSTARTEDONINSULININFUSION@3ML/HR.
ONFURTHERFOLLOWUPPATIENTWASSHIFEDTOSUBCUTANEOUSINSULINACCORDING TO SLIDING SCALE.
ENDOCRINOLOGIST OPINION WAS TAKEN I/V/O HYPOGLYCEMIC EPISODES @ 2AM AND ADVISEFOLLOWEDANDPATIENTWASSHIFTEDTOICUI/V/OSTRICTGRBSMONITORING ON POD 9.
REGULAR DRESSINGS WERE DONE.

Advice at Discharge
STRICT DIABETIC DIET
REGULAR DRESSINGS.
OINT.MEGAHEAL FOR LOCAL APPLICATION OVER THE DONOR SITE.
STRICT HYGEINE OVER THE PERIANAL REGION.
INJ.HAI S/C 14U-10U-6U
INJ.NPH 14U--X--4U
GRBS MONITORING @ 8AM,10AM,1PM,3PM,7PM,9PM,2AM


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