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General Data
A.R.
11 years old
Male
Roman Catholic
born on March 16, 2005
Dasmarias City
admitted for the 2nd time at DLSHSI UMC
March 2, 2016 at around 10:00PM
Chief Complaint
Generalized body weakness
Review of Systems
General
(-) poor activity (-) weight loss
Integument
(-) wound (-) pallor (-) hyperpigmentation
(-) hypopigmentation (-) erythema (-) nail
clubbing
Eyes
Ears
(-) discharge
Respiratory
(-) dyspnea (-) hemoptysis (-) tachypnea
Cardiovascular
(-) dyspnea
(-) palpitation
GIT
(-) vomiting (-) diarrhea (-) abdominal distention
(-) constipation (-) hematemesis (-)
hematochezia
GUT
(-) frequency (-) polyuria (-) oliguria (-) palpable
mass
Hematologic
(-) easy bruising (-) easy bleeding (-) pallor
(-) received blood transfusion
Endocrine
(-) polyuria (-) polydipsia (-) diaphoresis
MSS/Extremities
(-) fractures (-) joint pains
Nervous System
(-) seizures (-) syncope (-) tremors
Autonomic Deficiency
(-) fecal incontinence (-) urinary incontinence
Family History
(+) DM Type II- Maternal side
(+) Hypertension- Maternal side
(+) Colon Ca- Maternal side
No family history of asthma,
tuberculosis, liver disease, lung
disease, kidney disease, epilepsy,
and congenital anomalies.
Developmental History
Patients development is at par with age
Specific timing of developmental
milestones cannot be recalled by
grandmother
Nutritional History
The patient was exclusively breastfed
Milk formula, ratio, amount and frequency
cannot be recalled by grandmother
Solid food: 7 months
Table food: 15 months
Immunization History
Vaccine
Given
BCG1
Yes
DPT
1st dose
2nd dose
3rd dose
Yes
Yes
Yes
OPV
Yes
Hepa B
1st dose
2nd dose
3rd dose
Yes
Yes
Yes
MMR
1st dose
No
Gynecologic History
Menarche: 11 years old (February
2016)
Interval: Presently irregular
PHYSICAL EXAMINATION
Physical Examination
General Survey
The patient is well developed, well
nourished, conscious, not in cardiorespiratory distress and looks his
chronological age. IV line is inserted
on his left dorsal hand.
Vital Signs
BP: 90/60 mmHg, right arm, lying
position
HR: 121 bpm
RR: 24 cpm
Temperature: 36.5 degrees Celsius
Weight: 33 kg
Regional Examination
Integumentary
The skin is moist, smooth, and fair. There
was no pallor, jaundice, or any
discoloration. Patient is afebrile and not
cold to touch. There is prompt return of
skin after finger pressure is applied. No
excessive moisture nor sclerosis was
noted. No peripheral cyanosis was noted.
Maculopapular rashes were noted in the
trunk and extremities. Polumorphous
exanthem in the groin area.
Nose
Nose is symmetrical with no masses
and lesions. Nasal septum is
midline.
Ears
No obvious mass or lesion was
noted at the external ear.
Chest is symmetrical, no
deformity, mass or retraction
noted.
Palpation
Not done
Auscultation
Cardiovascular
Inspection
No bulging was noted
Palpation
No heaves or thrills.
Auscultation
The patient has regular rhythm.
Apex beat at 5th ICS LMCL. No
murmur was appreciated.
Abdomen
Inspection
Auscultation
12 bowel sounds per minute was
noted. No bruit.
Percussion
Not done
Palpation
No tenderness and organomegaly were
elicited.
EXTREMITIES
There were no masses, lesions, gross
deformities
Full and Equal peripheral pulses
There were no tenderness, crepitus or
limitation in ROM
Neurologic Examination
Mental Status Examination
COMPONENT
REMARKS
Level of Consciousness
Cognitive Function
Grapho-motor/visuomotor
skills
Neurologic Examination
CN
I
II
FINDINGS
not done
(+) Directand Consensuallight reflex
Visual acuity:not done
Visual fields: able to respond or turn toa non-audible
stimulifrom the side
Fundoscopy:not done
Ciliospinalreflex:not done
III, IV, VI
Neurologic Examination
VII
VIII
IX, X
XI
XII
Neurologic Examination
Motor
System
b. Palpation
o Normal muscle bulk
o Body is symmetrical
a. Inspection
o General activity: active
o (-) tremor
o (-) involuntary movement
o (-) jointmalalignment
o (-)fasciculations
o Normal muscle tone, (-) spastic,
(-)flaccid
Meningeals
Discussion
DIABETES MELLITUS
common, chronic, metabolic syndrome
characterized by hyperglycemia (cardinal
biochemical feature)
Type 1 DM( T1DM) deficiency of insulin
secretion due to pancreatic -cell damage
Type 2 DM( T2DM) consequence of insulin
resistance occurring at the level of skeletal
muscle, liver, and adipose tissue, with various
degrees of -cell impairment
PATHOPHYSIOLOGY of T1DM
INSULIN
permit controlled disposition of ingested
food as energy for immediate or future use
Released by the pancreatic islet cells
PATHOPHYSIOLOGY of T1DM
FOOD INTAKE with low insulin Hyperglycemia
Producing an osmotic diuresis (glycosuria)
Diabetic Ketoacidosis
leading cause of morbidity and
mortality in children with type 1
diabetes mellitus (T1DM),
case fatality rate 0.15 % to 0.31 %
Diagnosis :
International Society for Pediatric and
Adolescent Diabetes (ISPAD) in 2014 biochemical criteria
Hyperglycemia, defined as a blood glucose
of >200 mg/dL (11 mmol/L) AND
Metabolic acidosis, defined as a venous pH
<7.3 or a plasma bicarbonate <15 mEq/L
(15 mmol/L) AND
Ketosis, ideally determined by serum betahydroxybutyrate as measured in the
laboratory or by a point-of-care testing
device.
Polyuria
Polydypsia
Tachycardia
Fatigue
Decreased energy and activity
Irritability
Physical signs of dehydration
Polyphagia
Anorexia
Nausea
Vomiting
Abdominal pain
Hypervetilation
Kussmauls breathing
Hyperpnea
Tachypnea
Fruity Breath
Complications
Cerebral Edema
Cognitive Impairment
Venous thrombosis
Aspiration
Cardiac Arrhythmia
Prevention
Early detection of risk factors
Glycemic control
EMERGENCY ROOM
S
Known type 1 diabetic for 2 years
maintained on Regular Insulin
20u ODAM; 16u ODPM
2 days history of dizziness, body
weakness with decreasing
appetite
Presenting with vomiting x 2
episodes with no abdominal pain
CBG at home 311 with ketones
#1 Hyperglycemia
O
PE: Stable VS: 110/80, 84, 20,
35.9
Awake, alert and conscious
No cyanosis/ pallor, good skin
turgor, slightly sunken eyeballs
Dry lips, moist oral mucosa
CBS
Normal rhythm, regular rate (-)
murmur
SNABS
Good pulses, good capillary refill
time
No neurologic deficits
EMERGENCY ROOM
A
Type 1 Diabetes Mellitus, uncontrolled
T/C Diabetic Ketoacidosis
For CBG
For Urinalysis with ketones
For ABG, 15L ECG
Hook to cardiac monitor
EMERGENCY ROOM
CBG: 365mg/dL
Urinalysis with Ketones
Glucosuria +2
Ketonuria +3
ABG:
Metabolic acidosis,
partially compensated
15L ECG: normal for age
IVF started
TX:
REGULAR INSULIN 5U SQ
now
Advised ADMISSION
Admitting Diagnosis
DIABETIC KETOACIDOSIS, MILD
TYPE 1 DIABETES MELLITUS,
UNCONTROLLED
Goals of therapy
To correct dehydration
To correct acidosis
To reverse ketosis
To restore blood glucose to near
normal
Identify precipitating event
Emergency Assessment
Additional Measures
Secure Airway
Give oxygen
Hook to cardiac monitor
IV access
Give antibiotics
Catheterization, if needed
S
(+) pain over extraction site
(-) abdominal pain
(-) vomiting
(-) weakness
(-) DOB
(-) tremors
(-) polyuria
(-) changes in sensorium
#1 Hyperglycemia
O
PE: Stable VS: 100/70, 86, 19,
36.1
Awake, alert and conscious
No cyanosis/ pallor, slightly
sunken eyeballs
Dry lips, moist oral mucosa
CBS
Normal rhythm, regular rate (-)
murmur
SNABS
Good pulses
No neurologic deficits
CBG: 114-340mg/dL
P
IVF PNSS IL x 106-107cc/hr, if CBG > 200
IVF D5 0.45 NaCL 1L x 106-107cc/hr, if CBG <200
Regular Insulin 5u SQ q3, if CBG <180 adjust to 4u
For CBCPC
For HbA1C
For blood ketones q6
Monitor VS q1 and NVS
Fluid Replacement
Rationale:
Restore circulating volume
Replaced sodium and fluid deficit
Improved glomerular filtration with
enhanced clearance of glucose and
ketones
Fluid Replacement
Resuscitation fluids
0.9% saline; 10-20mL/kg over 1-2 hours
If in shock, isotonic saline; 20mL/kg
bolus
Insulin therapy
Rationale
Restore normal cellular metabolism
Normalize blood glucose concentration
Suppress lipolysis and ketogenesis
Insulin therapy
IV Insulin infusion 1-2h after fluid
replacement
Dose: 0.05-0.1u/kg/h
May decreased accordingly, to prevent
hypoglycemia
If given for prolonged period of time,
may induce hypokalemia
Insulin therapy
If continuous IV administration is not
possible and for uncomplicated DKA
Hourly/2-hour SC or IM administration of
short or rapid acting insulin
Initial dose: 0.3u/kg SC then reduce to
0.1u/kg every hour or 0.15u-0.2 every 2
hours (Insulin lispro or aspart)
Insulin Preparation
Electrolyte correction
Potassium replacement
Start after initial volume expansion and
concurrent with starting insulin therapy
Initial: 0.5mmol/kg/h (max)
Subsequent potassium replacement
therapy based on serum potassium level
S
(-) pain over extraction site
(-) abdominal pain
(-) vomiting
(-) weakness
(-) DOB
(-) tremors
(-) polyuria
(-) changes in sensorium
Able to tolerate diet
O
PE: Stable VS: 100/70, 86, 19,
36.1
Awake, alert and conscious
No cyanosis/ pallor, nonsunken
eyeballs
Slightly dry lips, moist oral
mucosa
CBS
Normal rhythm, regular rate (-)
murmur
SNABS
Good pulses, good capillary refill
No neurologic deficits, GCS 15
CBG: 80-274mg/dL
IVF to consume
MGH
HM: Scillin M30 24u ODAM, 16u ODPM
Resolution?
When oral fluid is tolerated, reduced
IVF accordingly
If planning to shift insulin to
subcutaneous injection, before
mealtime and 15-30min (rapidacting insulin) or 1-2h (regular
insulin) before stopping insulin
infusion
Algorithm
Algorithm
Patient Education
Nutritional management
Continuous glucose monitoring
Healthy Plate
Timing of MBG
At bedtime, during the night,
overnight fast
During the day prior meals, after
food intake (2hours after meal)
In association with vigorous exercises
During intercurrent Illness
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