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TRANSCRIPT
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Case Presentation 7
1. Khiddir bin Nasruddin
2. Maisarah binti Ismail
3. Nur Adibah binti Shaharul
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Demographic Profile
Name : KHY Age: 14 years old RN: SB00188556 Gender: Female Ethnicity: Indian Date of Admission: 2/12/2010 Date of Clerking: 9/12/2010 Date of Discharge: 18/12/2010 Accompanied by: Sister (STH 16 years old)
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History taking
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Chief Complain
KHY, 14 years old, Indian, female a known case of Diabetes Mellitus Type 1 since 3 years old, admitted to Sungai Buloh Hospital 1 week ago by referred case from paediatric clinic due to uncontrolled blood sugar level and having pus discharge at her right inguinal area three month prior to admission.
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History of presenting complains
Pus Discharge (3 month prior to admission)
Uncontrolled Blood Glucose on regular follow-up (2/12/2010) Admitted to hospital
Vaginal Discharge (1 week prior to admission)
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History of presenting complains
Uncontrolled blood sugar level; Started when she monitored her blood
glucose level at home, >20 mmol/L. Came to clinic for regular follow up,
confirmed for high blood glucose level, admitted to ward 8c.
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History of presenting complains
Pus Discharge; She was well until 3 month ago when her right
inguinal area started to have pus discharge, it associated with swelling and pain. The pus colour was yellowish, thick and have foul smelling. The pus come intermittently, every day in small amount. She said walking will aggravate the pain and lying down will relieve the pain. It does not radiate to other area. She receive antibiotic tablets and cream from her visits at paediatric clinic, Sungai Buloh Hospital but it does not resolves.
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History of presenting complains
Vaginal discharge; She started to have vaginal discharge 1
week prior to admission. The discharge is whitish, thick, no foul smelling, no pain. Associated with vaginal itchiness. It comes everyday with amount of approximately 1 tea spoon. No aggravating factor and relieving factor.
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Systemic ReviewBODY SYSTEMS COMPLAINTS
General Lethargic, Fever with chills and rigor. No increase in sweating,
Cardiovascular No palpitation, no orthopnea, no paroxysmal nocturnal dyspnoea, no bilateral edema.
Respiratory She had cough, and runny nose. No difficulties in breathing, no chest pain.
Gastrointestinal She had vomitted once. No decrease in appetite. no change in bowel habits,
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Body Systems Complains
CNS Headache, no photophobia, no phonophobia, no abnormal movement.
MSK No joint pain, no joint swelling
Endocrine No neck enlargement, no increase in sweating,
Genitourinary No polyuria, no polydipsia, no dysuria, no haematuria, no proteinuria.
Hematology & lymphatic
No easy bruising, no gum swelling, no lymph node enlargement.
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Past Medical History
She had been diagnosed with Diabetes Mellitus Type 1 since 3 years old at HKL.
She started to take insulin injection on her own since she was 10 years old. She also has home blood sugar monitoring device and constantly controlling her blood sugar level.
She is on regular follow-up every month in Specialist Clinic in Sungai Buloh hospital or Putrajaya hospital.
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She claimed to multiple hospital admission because of Diabetic Ketoacidosis and hypoglycemic attack. Last admission was on August 2010 in Hospital Sungai Buloh.
The attack usually come at school. Her teacher already know about her conditions.
She had an eye assessment at Putrajaya Hospital in September 2010, normal.
She never undergo any surgery before.
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Drug History
She been taking insulin on 4 regimes;
Time Type of Insulin Unit
Before Breakfast NovoRapid 8
Pre Lunch NovoRapid 8
Pre Dinner NovoRapid 8
Before Bed Lantus 16
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Diet HistoryTime Food Drinks
Breakfast Bihun goreng Plain water
Lunch Nasi Plain water
Dinner 2 slice of bread
Plain water
Snack - Milk
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Birth & Neonatal History
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Allergies No known allergies to food, medication
or weather.
Immunisation HistoryType of Immunisation Age of receiving Notes
Bacile Calmitte Guerin 0,
Hepatitis B 0,1 month, 6 month
Diptheria, Tetenus acelluar pertusis vaccine
2 month, 3 month, 5 month
Inactiveated Polio Vaccine 2 month, 3 month, 5 month
Haemophillius influenza b vaccine 2 month, 3 month, 5 month
Measles 12 month, 6 years old.
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Menstrual History
Menarche: 12 years old Regular 7 days of menses 30 days of cycle First 3 days was heavy, she use 4 pads
fully soaked No dysmenorrhia, no menorrhagia no
intramenstrual bleeding.
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Developmental History
At school, her academic performance is moderate
She does not have many friends She does not talk about her illness to
her friends She did not actively taking part in any
sport activities She does not have problem to go to
school
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Family History
3rd child out of 4 siblings Two older sisters and one younger
brother was normal and healthy. Grand mother from maternal side has
Diabetes Mellitus Type 2 His father have type 2 Diabetes Mellitus.
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Social History Live in Kuala Selangor, terrace house with
basic amenities. Father work as bus monitor with monthly
income of RM1,000.00. Mother recently got a job as school cleaner
with monthly income of RM1,500.00. Total income of the family is RM2,500.00 No one in the family smokes, drinks
alcohol nor take illicit drugs
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Effects of illness to the patient and family Does not talk about her illness to her school
friends. She accept her illness well, trained to take
insulin by her self and do blood sugar monitoring at home.
Her siblings has no problem with her illness, go to school as usual. Her father go to work as usual.
Her mother can not find a decent job, as she had to take care of her if she was admitted to hospital and for regular follow-up.
Mother is able to get a job on school holiday as her sister is taking care of her in hospital
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Physical examination
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General Examination Status: Patient is lying in supine position supported by
one pillow. She is alert, conscious of time, place and person. She look lethargic, not in respiratory distress.
Vital signs;Pulse rate: 103 beats/minRespiratory Rate: 22 breath/minBlood Pressure: 115/70 mm/HgTemperature: 37.6 ˚C
BMI; 22.8 kg/m² (between 75th and 85th centile)Height: 1.48 m (below 5th centile, stature for age 2-20 years
old girls)Weight: 50 kg
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Head, Neck and Limbs Examination Scalp is normal, Hair has normal distribution. Her oral hygiene is adequate, tongue is moist. Hand is warm to touch, not pale, dry. Nail – no clubbing, no koloinechia, no
leukonichia, capillary refill time is less than 2 seconds.
Lower limb – No scar, no lesion, no bilateral pedal edema, no redness, no warmth.
abnormalities detected.
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Cardiovascular Examination Inspection, Palpation, Percussion &
Auscultation were normal.
Respiratory Examination
• Inspection, Palpation, Percussion & Auscultation were normal.
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Abdominal Examination
Inspection: Abdomen moves with respiration. Swelling at right inguinal region, 2cm x 3cm. No redness, no puss discharge seen, no sinuses.
Palpation: Tender on touch, not warm, Percussion: Normal Auscultation: Normal
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Musculoskeletal Examination
Muscle : No muscle wasting or hypertrophy, muscle bulk was adequate
Bones : No bony deformities Movement of joints : No limitation in joint
movement, no athralgia Skin: no skin infection, no signs of
necrobiosis lipoidica.
No Abnormalities Detected
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Central Nervous System Examination
Conscious, movement and gait, speech and cortical function are normal.
No abnormalities in all 12 cranial nerve. Muscle bulk normal Tone normal Power normal Reflex normal Co-ordination normal
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Sensory Modalities; Light touch: normal Superficial pain: normal Deep pain: normal Temperature: normal Vibration: normal Peripheral Nerve: normal
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Summary KHY 14 years old, Indian, female a known
case of Diabetes Mellitus Type 1 since 3 years old, admitted to hospital due to uncontrolled blood sugar level and having pus discharge at her right inguinal area three month prior to admission. On examination, there is swelling at right inguinal region, 2cm x 3cm seen.
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Provisional Diagnosis
Uncontrolled blood sugar level in Type 1 Diabetes Mellitus secondary to infection in right inguinal area, and vaginal candidiasis.
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INVESTIGATION By Khiddir Bin Nasharuddin
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Full Blood CountTest Result Unit Normal Range
WBC 9.36 10^3 uL 5 - 15
RBC 4.74 10^6 uL 2 – 10
Haemoglobin 12.5 g/dL 10 – 20
Haematocrit 38.1 % 33 – 40
Mean corpuscular volume 80.3 fl 70 – 86
Mean corpuscular haemoglobin 26.3 pg 27 – 30
Mean corpuscular haemoglobin concentration
32.7 g/dL 27 – 33
Red cell distribution width 14.6 % 11 – 15
Platelet 482 10^3 uL 150 – 400
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Automated differentialTest Result Unit Normal Range
Percentage of Neutrophil 49.9 % 40 – 75
Absolute Neutrophil 4.67 10^3 uL 2.9 – 7.9
Percentage of Lymphocyte
38.8 % 20 – 45
Absolute Lymphocyte 3.63 10^3 uL 1.8 – 4.0
Percentage of Monocyte 2.8 % 0 – 8
Absolute Monocyte 0.26 x10 10^3 uL 0 – 1.6
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Test Result Unit Normal range
Percentage of Eosinophil
4.9 % 0 – 5
Absolute Eosinophil
0.46 10^3 uL 0.4 – 2.1
Percentage of Basophil
1.5 % 0 – 2
Absolute Basophil
0.14 10^3 uL 0 – 0.2
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Blood glucose test
Khayattri – Random Blood Glucose : 4.4 mmol/L and HbA1c : 12.3 %
Test Unit Hyperglycaemic value
Random blood glucose mmol/L > 11.1
Fasting blood glucose mmol/L > 7
HbA1c % > 7.5
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Renal profileTest Result Unit Normal Range
Urea 2.3 mmol/L 1.7 – 6.4
Creatinine 47.2 mmol/L 27 – 62
Sodium 142 mmol/L 135 – 150
Potassium 3.90 mmol/L 2.5 – 6.5
Chloride 104 mmol/L 98 – 108
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Blood culture and sensitivityNo growth
Culture & Sensitivity-High Vaginal SwabStreptococcus agalactiaeAntibiotic sensitivity :-
Antibiotic Sensitivity
Penicillin 10 S
Erythromycin 15 S
Cotrimoxazole 25 R
Gentamicin 10 R
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Culture and Sensitivity-Pus:Culture : Mixed growth of 3 types organism
isolated.
Culture and Sensitivity –Mid Stream Urine : Colony count 10,000 -
100,000 organisms/ml urine. Culture Mixed growth.
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Ultrasound scan of Right Inguinal region
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Enlarged inguinal lymph nodes with the largest measuring 0.5x1.7x3.3cm. These nodes are matted together. No necrotic
nodes seen. No abscesses seen.
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Management and treatment
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Uncontrolled Diabetes MellitusDiet
○ In this patient, she was advised to follow basal-bolus regimen which require her to take 3 meal with three injection of rapid-acting insulin followed by injection of long-acting insulin before bedtime.
○ Snack was advised to be taken between dinner and before bedtime to avoid hypoglycaemia due to action of long-acting insulin.
○ Healthy diet recommended with a high complex carbohydrate and low fat content also high in fibre
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Insulin TherapyTypes of insulin
Examples Onset of Action
Peak Duration
Rapid acting insulin
NovoRapid, Humalog
5 – 15 min 30 – 60 min 3 – 5 hours
Short-acting insulin (regular)
Actrapid, Humilin R
30 min 2 – 3 hours 3 – 6 hours
Intermediate insulin acting
Insulatard, Humulin N
2 – 4 hours
4 – 12 hours 12 – 18 hours
Long acting insulin
Levemir, Lantus (glargine)
1 hours No peak 24 hours
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Progress in the hospitalSubcutaneous injection of novorapid 11/13/13 ,
lantus 16 (2 Dec)Subcutaneous injection of novorapid 11/13/13 ,
lantus 16 (3 Dec) Subcutaneous injection of novorapid 11/13/13 ,
lantus 16 (4 Dec) Doctor noted that at 4/12 there were 2 episodes
of hypoglycemia. ○ Prelunch 2.4 ○ Predinner 4.2 ○ Prebed 3.1
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HypoglycaemiaBlood glucose falls below about 4 mmol/LAdministration of easily absorbed glucose in the
form of glucose tablets (e.g. Dextrosol or similar) or a sugary drink
Parents and school should be provided with a glucagon injection kit for the treatment of severe hypoglycaemia and taught how to administer it intramuscularly to terminate severe hypoglycaemia.
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Streptococcus agalactiae infectionPatient was treated with IV cloxacillin 1.2g
stat and 6 hourly for 2 days of admissionOn the third day and forth, patient was given
capsule cloxacillin 1g quartate intake daily
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Vaginal CandidiasisDuring 1st day of admission, patient was given
miconazole cream to apply at vagina.On 2nd day of admission – iv fluconazole 200mg
was started then reduced to 100mg once daily.On the third day, iv fluconazole was replaced by
tablet 100mg once daily.Miconazole cream also was used accompanied
the patient’s fluconazole treatment.
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On the day of discharge…. Patient was required to complete capsule cloxacilin for 1 more day Patient was advised to record down in a notebook of all her daily oral
intake and also activities done Strict diabetic diet To continue with current insulin regime subcutaneous injection of
novorapid 7 unit three times daily and lantus 14 unit once nightime Aim glucose level between 4-8 mmol/L to adjust insulin according to glucose level if high, 10 - 15 mmol - to
give 8 unit, 15 - 18 mmol - to give 9 unit, 18 mmol - to give 10 unit If developed hypoglycemia, patient are required to take
two tablespoon of glucose diluted in water as planned previously by dietician
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Progress of the patient…
Patient was feeling better and was afebrile for the past one week
Hydration was good Glucose level pre breakfast was
7.6mmol/L Vital signs was stable Right inguinal swelling, mildly tender.
punctum not discharging anymore She was discharged in 18 Dec 2010