correction internal medicine portfolio 1-nurdiyanah ghafar-.assessed
TRANSCRIPT
INTERNAL MEDICINE
PORTFOLIOSEM 10
STUDENT NAME: NURDIYANAH BT GHAFAR
ID NO: M0608119
NAME OF SUPERVISOR: DR VELAYUDHAN MENON
STUDENT NAME: NURDIYANAH BT GHAFAR ID NO: M0608119
SUPERVISOR: DR VELAYUDHAN MENON ROTATION: INT MEDICINE
Good.
---------------------------------------------------------------------------------------------------------------PATIENT’S DETAIL
Age : 21 years old IC No : 901113-01-6702
Sex : Female Date of admission : 19th of December 2011
R/N: 1690004 Date of clerking : 19th of December 2011
1.CASE SUMMARY
Miss JLP, a 21 year-old, unmarried, Chinese lady, who has been diagnosed with
Type 1 Diabetes Mellitus at the age of 17 years old, currently treated with subcutaneous
Humulin (30/70) ; 30 units pre-breakfast and 12 units pre-dinner and tablet Metformin 1g
twice daily was presented to emergency department due to sudden onset of abdominal pain
as well as vomiting and difficulty in breathing. She had not taken her medication for the past
2 weeks due to run out of her medication when she forgets her last follow-up appointment.
In casuality, she appeared dehydrated. However, there was no Kussmaul’s breathing
or ketotic breath. Her vital sign was stable. On palpation of the abdomen, there was
tenderness over the epigastric region.
Her VBG showed metabolic acidosis with pH 7.08 and HCO3 was 6.5mmol/L. Her
random blood sugar was 17.8mmol/L and her serum ketone was 3.4. Her UFEME and Chest
X Ray were normal
She was treated as moderate diabetic ketoacidosis secondary to non-compliance to
medication. Her dehydration was corrected with Normal Saline based on the suggested
regime and her hypoglycaemia was corrected by infused her with intravenous Actrapid.
Within one day, her repeated VBG showed some improvement. However in the ward, her
potassium level decreased to 2.8mmol/L. She was given potassium supplement
intravenously and orally.
1 day later, her metabolic acidosis had resolved. Her serum ketone was 0.4.Twice
daily subcutaneous Humulin was substituted and intravenous Actrapid infusion was stopped
2 hours after the first Humulin injection.
Even though the blood glucose was still not normalize and the potassium level was
3.0mmol/L, she still requested for discharge because of her cousin’s engagement ceremony
on the next day. She was discharged with tablet slow K and subcutaneous Humulin.
STUDENT NAME: NURDIYANAH BT GHAFAR ID NO: M0608119
SUPERVISOR: DR VELAYUDHAN MENON ROTATION: INT MEDICINE
-------------------------------------------------------------------------------------------------------------
PATIENT’S DETAIL
Age : 21 years old IC No : 901113-01-6702
Sex : Female Date of admission : 19th of December 2011
R/N Number : 1690004 Date of clerking : 19th of December 2011
2. CLINICAL HISTORY
Chief complaint and history of presenting illness :
Miss LJY, a 21 year-old, Chinese, unmarried lady who has been diagnosed with Type
1 Diabetes Mellitus at the age of 17 years old and is currently treated with subcutaneous
Humulin ; 30 unit pre-breakfast and 12 unit pre-dinner as well as tablet Metformin 1g BD was
presented to emergency department for sudden onset of abdominal pain for one day.
The abdominal pain was in epigastric region. It was burning in nature, non-radiating,
not related to posture and non- colicky in nature. However, there was no retrosternal burning
sensation.
The abdominal pain was associated with one episode of vomiting. She vomited out
food particles. However, there was no blood or bile in the vomitus.
On the day of admission, she also complained of difficulty in breathing. However, she
did not have any runny nose, cough and fever. Few days prior to this current admission, she
had history of runny nose, non-productive cough and fever and did not seek any treatment for
her upper respiratory tract symptoms.
On further history, she claimed that she had defaulted her last follow-up which was
scheduled on November 2011 because she forgot the appointment date. She ran out of her
medication for 2 weeks and did not inject herself with insulin for 2 weeks.
She did not complained of any hypo and hyperglycemic symptoms. She also did not
complained of any end-organ target damage symptoms such as chest pain, palpitation,
paroxysmal nocturnal dyspnoea, orthopnea, leg swelling, blurry vision, headache, numbness
and weakness of the limb as well as urinary symptoms.
Her oral intake was good. There was no change in her weight recently. Her
micturition was normal. She passes urine 4 times per day. There was no urinary tract
infection symptoms such as dysuria, frequency, hematuria. Her bowel opening was normal
which was once a day. There was no altered bowel habit. Her energy level was normal.
Past Medical /Surgical History
She was diagnosed with Type 1 Diabetes Mellitus at the age of 17 years old and was
under Batu Pahat Hospital follow-up in every 3 months. She presented with polyuria,
nocturia, polydipsia and weight loss for 1 month duration. HbA1C during first time
diagnosed was 17%.
She was started with subcutaneous Actrapid 10 unit three times per day and
subcutaneous Insulatard 6 unit pre-bed. According to her, the dose and type of insulin had
been changed for many times. She injects her insulin by herself. She monitors her blood
glucose once in every 2 days pre-bed. She claimed that the glucose reading ranged from 6-
8mmol/L.
She also claimed that she had few hypoglycemic attacks ; once in every 3 months.
She claimed she knows how to recognise the symptoms and what to do during the attack.
Usually, she will take few sweets.
On Feb 2011, she had one admission in Batu Pahat Hospital with similar
presentation with this current admission. She was diagnosed with Diabetic Ketoacidosis
secondary to not compliance to medication.
Since then, her medication was changed to subcutaneous Humulin (30/70) ; 30 unit
pre-breakfast and 12 unit pre-dinner and tablet Metformin 1g BD. Her latest HBA1C ( May
2011) was 11.3%.
Drugs and Foods Allergy
She does not have any allergy to any drugs as well as foods.
Gynecological History
She attained menarche at the age of 13 years old. Her menses is regular with 7 days
of duration. She uses 6 pads per day with minimal blood soaked. However, there was no
blood clots and dysmenorrhea.
She does not engaged in any sexual activity yet.
Family History
Her father, a 58 year-old, businessman is a healthy person with no known medical
illness. Her mother passed away at the age of 40 years old due to severe asthmatic attack. She
is the last child from 4 siblings. All of her siblings are well and healthy.
There is no family history of chronic illness such as hypetension, diabetes, heart
disease and kidney disease.
Social History
She is a clerk. Her estimated monthly income is RM1000. She does not smoke or
consume any alcohol beverages.
Currently, she is staying with her father and her brother.
She claimed that she eats healthy diabetic diet. Her breakfast consists of non-sugary
tea and bread. Her lunch and dinner consists of half bowl of rice mixed with vegetables,
chicken, meat or fish.
She also claimed that she did not practice of any exercise.
Further asking about her disease, she and her father does not really understand about
her Type 1 Diabetes Mellitus. They keep asking me why they need insulin injection instead of
taking oral tablet like other Diabetic patients. (I assume that they may not understand about
the difference between Type 1 and Type 2 Diabetes Mellitus)
STUDENT NAME: NURDIYANAH BT GHAFAR ID NO: M0608119
SUPERVISOR: DR VELAYUDHAN MENON ROTATION: INT MEDICINE
---------------------------------------------------------------------------------------------------------------3. FINDINGS ON CLINICAL EXAMINATION
General Examination
On general examination, LJP was a small built female who lied comfortably supine on
her bed. There was intravenous Actrapid infusion and intravenous Normal Saline attached to
her right dorsal aspect of her right hand.
She was conscious and cooperative. Her GCS was full;15/15. She was not in pale,
cyanosed or jaundiced. She was mildly dehydrated. There was no Kussmaul’s breathing as
well as ketotic breath.
Her vital signs was stable; Temperature: 37 degree celcius (afebrile), blood pressure :
106/69 mmHg (Normotensive), pulse rate : 90 beats per minutes, regular, good volume with
no radio-radial delay, respiratory rate : 18 breaths per minute, SPO2 under room air was
100%.
There was no clubbing of the fingers. Perfusion was good with capillary refill time
was less than 2 seconds. Throat was not injected. Tonsils was not enlarged. There were no
palpable lymph nodes.
Fundoscopy
Normal red reflex. No diabetic retinopathy change noted.
Respiratory system
Trachea was centrally located. The chest moved up and down with respiration. There
was no chest deformity such as pectus excavatum and pectus carinatum. There was no
intercostal and subcostal recession, no scar, no visible pulsation, no increase in anterior
posterior diameter.
Chest expansion was present and equal on both sides. On percussion, the chest was
resonant on all zones. Tactile fremitus was normal and equal both sides.
On auscultation, vesicular breath sounds were heard with no added sounds.
Cardiovascular Examination
There was no visible pulsation seen. There was no heave and palpable thrill. The
apex beat was at left fifth intercostal space just medial to midclavicular line. Both first and
second heart sounds were heard. There were no murmurs or added heart sounds.
Abdominal Examination
The abdomen was flat. It moved up and down with respiration. There was no scar, no
lipodystrophy, no visible swelling or no visible vein.
On palpation, the abdomen was soft. There was tenderness over the epigastric region.
There was no palpable mass and hepatosplenomegaly. Kidneys were not ballotable.
On auscultation, bowel sounds were heard and normal. There were no renal and
aortic bruits.
Neuromuscular Examination
Sensation of upper and lower limb was intact. Light touch sensation, pin-prick
sensation and proprioception were normal. Power, tone and reflex were normal.
STUDENT NAME: NURDIYANAH BT GHAFAR ID NO: M0608119
SUPERVISOR: DR VELAYUDHAN MENON ROTATION: INT MEDICINE
--------------------------------------------------------------------------------------------------------------
4. PROVISIONAL DIAGNOSIS AND DIFFERENTIAL DIAGNOSES WITH
REASONING
Provisional Diagnosis should mention that it is Type 1 diabetes
Diabetic Ketoacidosis secondary to non-compliance to medication.
Diabetic Ketoacidosis is common in patient with Type 1 Diabetes Mellitus. Usually
there is 1-3 days history of gradual decline into dehydration, acidosis and coma. In acute
presentation, patients usually presented with acute onset of abdominal pain, deep, sighing
breathing, vomiting and dehydration. Patients may also present with hyperglycemic
symptoms such as polyuria, polydipsia and lethargy.
The common precipitants include infection, surgery, myocardial infection, non-
compliance to treatment or wrong insulin dose.
This is what LJP presented in the emergency department. She is a known case of
Type 1 DM and she had very severe abdominal pain as well as vomiting and difficulty in
breathing. She also had not been compliance to her medication for 2 weeks and this may be
the precipitant of her current diabetic ketoacidosis.
Differential Diagnosis
1. Acute gastritis/ peptic ulcer disease
Acute gastritis and peptic ulcer disease should be in mind since LJP complained of
burning sensation of abdominal pain. It may occur at any age and usually related to food.
However, she does not have any risk factor that may contribute to this disease such as
smoking, drinking alcohol, usage of NSAIDS and stress even though H. Pylori may be the
major cause of this disease.
Acute gastritis or peptic ulcer disease may be the first priority if the patient is not a
known case for Type 1 Diabetes Mellitus.
2. Acute pancreatitis
Acute pancreatitis also presented with epigastric pain and vomiting. However, the pain
is more related to the posture. It radiated to the back and relieved when the patient sitting
forward.
3. Pregnancy
Pregnancy should be thought of if the young female comes with abdominal pain and
vomiting. This is the common presentation of pregnancy beside missing period. The ectopic
pregnancy should be thought off too because it may present with severe abdominal pain.
STUDENT NAME: NURDIYANAH BT GHAFAR ID NO: M0608119
SUPERVISOR: DR VELAYUDHAN MENON ROTATION: INT MEDICINE
--------------------------------------------------------------------------------------------------------------IDENTIFY AND PRIORITISE THE PPROBLEMS
1. Possibility of Diabetic Ketoacidosis (DKA)
In patient with Type 1 Diabetes Mellitus, presented with abdominal pain, vomiting,
difficulty in breathing and dehydration, the possibility of DKA should be in mind.
If the diagnosis of DKA is confirmed, several actions must be taken to correct the
dehydration, metabolic acidosis, electrolyte, and hyperglycemia as well as to treat the
precipitating factor. In DKA, patient may loss fluid for an average of 100ml/kg.
In severe DKA, if left untreated, the patient may go into coma.
2. Poor compliance to diabetic medication
Based on Miss LJP’ history, I can concluded that she has poor compliance to her
medication. She had one previous admission due to DKA secondary to poor compliance to
medication. Her last HBA1C which was five months ago also shown that her glycemic
control was not good.
Therefore, Miss LJP should be counselled about the importance of compliance to
treatment in a diabetic patient like her. Family may be counselled too, therefore, she may
have good family support for her diabetic treatment.
3. Poor education about Type 1 Diabetes Mellitus
Compliance is usually related to the level of good understanding about the disease
itself. If patient understand very well about the nature of the disease, they may understand
why they need medication for their condition.
Same goes to Miss LJP and her family. Further asking them, I can conclude that they
may not understand about the nature of Type 1 Diabetes Mellitus. That was why they keep
asking me why the doctor started her with insulin instead of oral medication.
Therefore, patient and her family should be educated about the nature of the disease
itself. Therefore, patient may have the initiative not to skip her insulin injection.
4. In proper medication for Type 1 Diabetes Mellitus
Currently, Miss LJP is on subcutaneous Humulin; 30 units pre-breakfast and 12 units
pre-dinner and tablet metformin 1g twice daily.
Even though, Miss JLP claimed that her blood glucose reading ranged from 6-
8mmol/L, her latest HBA1C was 11.5%. This showed that her blood glucose was not being
controlled with this twice daily pre-mixed insulin regime.
Therefore, the regime and dosage of insulin should be revised, therefore good control
of sugar can be achieved as well as slow the progression of diabetic complication.
STUDENT NAME: NURDIYANAH BT GHAFAR ID NO: M0608119
SUPERVISOR: DR VELAYUDHAN MENON ROTATION: INT MEDICINE
-------------------------------------------------------------------------------------------------------------
6. PLAN OF INVESTIGATION, JUSTIFICATIONS FOR THE SELECTION OF
TESTS OR PROCEDURES AND INTERPRETATION OF RESULTS
1. Venous Blood Gas : Help to diagnose Diabetic Ketoacidosis which there will be metabolic
acidosis.
Component Value Interpretation
pH 7.080 Low
PCO2 21.8mmHg Low
PO2 22.5mmHg Low
HCO3 6.5mmol/L Low
BE -21.7mmol/L Low
Comment : VBG shows metabolic acidosis. The pH < 7.3 and HCO3 < 15 mmol/L fits in one
of the criteria of Diabetic Ketoacidosis.
2. Random Blood Sugar : to measure the blood glucose level and help in diagnosis of
diabetic ketoacidosis.
Result : 17.8 mmol/L
Comment : The random blood glucose level shows high reading and this fits in one of the
criteria of diabetic ketoacidosis which is blood glucose level > 14mmol/L
3. Serum ketone : In Diabetic Ketoacidosis, there will be ketonemia.
Result : 3.4
Comment : There is ketonemia. This fits in one of the criteria of Diabetic Ketoacidosis.
Comme
4. Full Blood Count : To screen for any precipitating factor for her diabetic ketoacidosis such
as infection.
Parameter Value Normal Value Interpretation
WBC 16.9 x 10^9 4-11 x 10^9/L High
Hg 16 12-16g/dL Normal
Hct 49.1% Normal
MCV 95 76-98 fl Normal
MCH 32.3 27-32 pg/cell Slightly High
MCHC 34 32-36 G/dL Normal
Plt 400 x 10^9 150-400 x 10^9 Normal
Lymphocytes 20% 20-45% Normal
Monocytes 2.1% 2-10% Normal
Neutrophil 80.2% 40-75% High
Comment : The white blood cell count is high. So, there may be bacterial infection that
precipitates the Diabetic Ketoacidosis. However, in Diabetic Ketoacidosis, the white blood cell
count may be high and is not indicative of bacterial infection.
3. Renal Profile: To assess the patient’s hydration status and to detect any electrolyte imbalance
due to vomiting as well as due to Diabetic Ketoacidosis
Component Value Normal Value Interpretation
Urea 4.3 2.8-7.8 mmol/L Normal
Na 134 135-184mmol/L Low
K+ 3.8 3.5-5.1mmol/L Normal
Creatinine 89 63-124 mmol/L Normal
Cloride 105 95-108 mmol/L Normal
Comment : Sodium is slightly low. Anion gap ( Na – [ Cl + HCO3] ) is 22.5 which is raised in
Diabetic Ketoacidosis.
4. UFEME : to find any precipitating cause for Diabetic Ketoacidosis and any ketone and glucose in
urine
Component Value Normal Value Interpretation
Specific Gravity 1.03 1-1.03 Normal
pH 5 4.5-8 Normal
Leucocyte Negative Negative Normal
Nitrite Negative Negative Normal
Protein Negative < 0.5 Normal
Glucose 56 < 1.7 High
Ketone 15 < 0.5 High
Bilirubin Negative < 3.4 Normal
Erytrocyte Negative 0-5 Normal
Comment : No urinary tract infection picture is seen. There are high glucose and ketone in
urine. The glycosuria shows that the blood glucose level is not control well. And the ketonuria
fits in one of the criteria for Diabetic Ketoacidosis.
5. ECG : to see any cardiac cause that precipitate the diabetic ketoacidosis. At the same time,
to monitor the potassium level.
Comment: Sinus tachycardic. Heart rate is 119 beats/ min. No acute ischemic changes. No
ECG changes of hypo and hyperkalemia.
6. Chest X Ray : To screen any respiratory tract infection that may precipitate the diabetic
ketoacidosis
Comment : Normal heart size. No hazziness or opacities that may suggest of lung infection.
7. Serum amylase : To rule out pancreatitis
Comment : 4.1 ( Normal reading < 220). No pancreatitis.
8. Urine Pregnancy Test : To rule out pregnancy since pregnancy may present with
abdominal pain and vomiting
Result : Negative
9. Suggested investigations :
1. Serum phosphate : will be low in Diabetic Ketoacidosis
2. HBA1C : to monitor the diabetic control for the past 3 months.
STUDENT NAME: NURDIYANAH BT GHAFAR ID NO: M0608119
SUPERVISOR: DR VELAYUDHAN MENON ROTATION: INT MEDICINE
-------------------------------------------------------------------------------------------------------------
7. WORKING DIAGNOSIS AND PLAN OF MANAGEMENT ON ADMISSIONWorking Dignosis
Moderate Diabetic Ketoacidosis Secondary to Poor Compliance to Medication
Plan of Management
1. Vital sign ( Temperature, pulse, respiratory rate, heart rate and blood pressure) as well as
SPO2 are monitored.
2. 3L/min oxygen via nasal prong is given to the patient and SPO2 is maintained > 95%
3. Large bore branula is inserted. Random blood glucose, ABG, serum ketone, renal
profile, full blood count is taken to confirm the diagnosis of Diabetic Ketoacidosis.
4. Cardiac changes are monitored by ECG or cardiac monitoring.
5. Patient is hydrated with 0.9% Normal Saline according to suggested regime ; 1 litre in 1
hour, then 1 litre in 2 hours, then 1 litre in 4 hours, then 1 litre in 6 hours, then 1 litre in 8
hours. When blood glucose is < 15mmol/L, change to 5-10% dextrose water or alternating
dextrose saline with 5% dextrose.
6. Start continuous intravenous insulin (Actrapid) infusion ; 50unit of Soluble insulin is
diluted in 50ml of Normal Saline ( 1 unit = 1ml). IV bolus 10 unit ( 0.15 unit/kg) soluble
insulin is given, followed by 6 unit/hour ( 0.1unit/kg/hour) by infusion pump. The insulin
infusion rate will be halved (3unit/hour), if the blood glucose is < 15mmol/L.
7. Blood glucose is monitored hourly. Glucose level is maintained at 8-12mmol/L. The
drop of glucose should be aimed at a rate of 3mmol/L.
8. Renal profile and ECG monitoring is done every 4-6 hourly. 1g KCL in each 0.5 litre of
fluid is added if the plasma K is < 5mmol/L or the ECG shows evidence of hypokalaemia.
9. Daily VBG, serum ketone is done to monitor whether the DKA has resolved or not.
10. If the metabolic acidosis or ketonemia has resolved, start the subcutaneous insulin. The
infusion is stopped 1 hour after the first subcutaneous insulin dose to prevent rebound
hyperglycemia.
11. Diabetic diet is served.
Long Term Management Plan
1. To educate the patient and her family about Type 1 Diabetes Mellitus.
2. To counsel the patient and his family about the important of compliance to medication in Type 1 Diabetes Mellitus.
3. To revise the treatment for her Type 1 Diabetes Mellitus
- Twice Daily Pre-mixed insulin may not enough for Type 1 Diabetic patient
STUDENT NAME: NURDIYANAH BT GHAFAR ID NO: M0608119
SUPERVISOR: DR VELAYUDHAN MENON ROTATION:INT MEDICINE
------------------------------------------------------------------------------------------------------------
8. SUMMARY OF INPATIENT PROGRESS
In ward, patient was hydrated with Normal saline accordingly based on the suggested
regime. She was also started with continuous intravenous infusion of Actrapid. Her repeat
VBG showed some improvement. The pH increased to 7.186 and the HCO3 increased to 12.1
mmol/L. She did not complaint of abdominal pain anymore. However, she was still
dehydrated.
On the next day, her repeat VBG showed that the pH increased to 7.253 and the
HCO3 increased to 19.3 mmol/L. Serum ketone was decreasing to 0.4 and renal profile
showed low potassium ( 2.8 mmol/L) and low sodium (131 mmol/L). Anion gap was 11.7.
She was given 1g KCL in every alternate 0.5 litre of Normal Saline, mist KCL 15mls TDS
and 2 tablets Slow K once a day.
In ward, under the insulin infusion, her blood glucose ranged from 6-12 mmol/L.
When her metabolic acidosis had resolved (pH : 7.36 and HCO3 : 24), she was started with
subcutaneous humulin 14 units pre-dinner. Intravenous infusion of actrapid was stopped 2
hours after the administration of the first subcutaneous Humulin. The random blood glucose
pre-bed after stopping the infusion was 12 mmol/L.
On day 3 of admission, she was on her regular insulin regime which was 2 daily pre-
mixed insulin. Renal profile was repeated and her potassium level was still low which was
3.0 mmol/L. The blood glucose level was ranging from 17-25mmol/L.
Even though the blood glucose was still not normalize, she requested for discharge
because of her cousin’s engagement ceremony on the next day. She was discharged with
tablet slow K and subcutaneous Humulin.
STUDENT NAME: NURDIYANAH BT GHAFAR ID NO: M0608119
SUPERVISOR:DR VELAYUDHAN MENON ROTATION: INT MEDICINE
--------------------------------------------------------------------------------------------------------------
9. DISCHARGE PLAN, COUNSELLING AND MOCK PRESCRIPTION
Discharge Plan
1. Tablet Slow K TDS
2. Subcutaeous Humulin ; 30 units pre-breakfast, 14 units pre-dinner
3. Follow up in outpatient department in one month time
Counselling
1. Educate the patient about her condition which is Type 1 Diabetes mellitus. Educate her
about:
- Brief and simple pathophysiology of Type 1 Diabetes Mellitus
- Reason why she needs insulin for the rest of her life and how it works
- Complications that may arise if the diabetes is not well controlled
2. Counsel her about the important of compliance to the medication especially in her Type 1
Diabetes Mellitus.
3. Counsel her to do regular self blood glucose monitoring at home and document it in a
book that can be brought along during follow-up. Therefore, any adjustment to insulin dose
can be done by the doctor who treats her.
4. Educate her briefly about diabetic ketoacidosis and counsel her not to omit insulin
especially during illness because it may precipitate diabetic ketoacidosis.
5. Educate her about hypoglycemic symptoms, how to recognise the symptoms and how to
act.
6. Educate her about diabetic diet and the important of regular exercise.
7. Counsel her about the important to go for follow-up that has been scheduled for her.
Therefore, any complication that may arise from her diabetic condition can be detected early.
Mock presentation
Name LJP ( Patient’s Full Name) Prescription :
1. T. Slow K II/II tds x 1/52
2. S/C Humulin ;30 unit OM,
14 unit ON x 1/12
R/N 1690004
IC No
Date 22/12//2011
Diagnosis Moderate Diabetic
Ketoacidosis secondary to
non- compliance to treatment
Doctor’s name and name
stamp
You must again comment here on whether you think this prescription is adequate for her
STUDENT NAME: NURDIYANAH BT GHAFAR ID NO: M0608119
SUPERVISOR: DR VELAYUDHAN MENON ROTATION: INT MEDICINE
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10. REFERRAL LETTER (IF APPLICABLE)
Nurdiyanah Binti Ghafar,
International Medical University,
83000 Batu Pahat,
---------------------------------------------------------------------------------------------------------------
Specialist In Charge/Medical Officer,
Ophthalmology Department,
Hospital Batu Pahat,
83000 Batu Pahat,
Johor Darul Takzim. 21st of Dec 2011
To whom it may concern,
RE: LJP (I/C of the patient) Type 1 Diabetes Mellitus
Thank you for seeing this 21-year old female who has been diagnosed with Type 1
Diabetes Mellitus at the age of 17 years old, currently treated with subcutaneous Humulin;
30 unit pre-breakfast and 14 unit pre-dinner. She was admitted on 19th of Dec 2011 for
moderate diabetic ketoacidosis secondary to non-compliance to medication. During that
admission, she did not complaint of any end-organ target damage such as blurring of vision,
numbness, chest pain, palpitation.
Currently, she is under medical specialist clinic in Batu Pahat Hospital. Her latest
HBA1C was 11.5%. She was not on any ophthalmology clinic follow-up previously.
Therefore, I would like to refer her to your clinic for her retinopathy screening.
Please kindly asses the patient and treat accordingly. Thank you.
Yours sincerely,
NURDIYANAH GHAFAR, Final year medical student of IMU
STUDENT NAME: NURDIYANAH BT GHAFAR ID NO: M0608119
SUPERVISOR: DR VELAYUDHAN MENON ROTATION: INT MEDICINE
11. LEARNING ISSUES IN THE 8 IMU OUTCOMES
1. APPLICATION OF BASIC SCIENCE IN THE PRACTICE OF MEDICINE
Miss JLP and her family seemed not to have a clear understanding about her Type 1
Diabetes Mellitus. They kept asking why she was started with insulin injection instead of
oral hypoglycemic agent like other diabetic patient
What is the pathophysiology of Type 1 Diabetes Mellitus?
Type 1 Diabetes Mellitus is characterized by autoimmune destruction of insulin-
producing B cells in the pancreas by CD4+ and CD8+ T cells and macrophages infiltrating
the islets1 by the presence of islet autoantibodies such as autoantibodies to insulin (IAAs),
autoantibodies to GAD (GADA) and antoantibodies to IA-26. Genetic and as yet undefined,
environmental factors act together to influence the development of islet autoimmunity.
Like other organ-specific autoimmune disease, Type 1 DM has human leucocyte
antigen (HLA) associations2 .Two combinations of HLA genes are of particular importance;
DR4-DR8 and DR3-DQ2 are present in 90% of children with Type 1 DM3. The genotype
combining these two susceptibility genes (DR4-DQ8/DR3-DQ2) contributes the greatest risk
of the disease and is most common in children in whom the disease develops very early in
life4 .
Environmental triggers therefore modulate the onset of Type 1 DM in genetically
susceptible individuals. This has been implicated in the recent rapid increase in Type1 DM
incidence, because the gene pool cannot change quickly enough to account for the rapid rate
of increase of Type 1 DM. The role of virus infections such as enterovirus may trigger the B-
cell damaging process in a considerable proportion of patients. Studies have also shown more
enterovirus infections in children who developed islet autoantibodies or subsequent diabetes
or both5. Some studies have shown that cow’s milk ingestion increases the risk for islet
autoimmunity6. However, it is still controversial.
2. SELF-DIRECTED LIFE LONG LEARNING AND INFORMATION
MANAGEMENT
Miss JLP was diagnosed with Type 1 DM at the age of 17 years old and was started with
Subcutaneous Actrapid 10 units TDS and Insulatard 6 units pre-bed. Later, due to her
poor compliance to the medication, her medication was changed to subcutaneous
Humulin 30 units pre-breakfast and 12 units pre-dinner and tablet metformin 1g BD.
Is the twice daily pre-mixed insulin regime sufficient for Type 1 Diabetic patient?
Most patient with Type 1 Diabetes Mellitus will require an insulin dosage of 0.5 to
1.0 unit per kg per day8. Athletes generally require less insulin than sedentary or obese
patients.
In addition, patients with newly diagnosed Type 1 DM generally have smaller
initial insulin requirements in the range of 0.2-0.6 unit/kg/day because of continued
endogenous insulin secretion8. Therefore, twice-daily administrations of short and
intermediate acting of insulin may be effective for at least a short period in patients with
newly diagnosed Type 1 DM who are still producing a significant amount of insulin8.
However, as more complete insulin deficiency develops, this regimen becomes less
effective as it cannot mimic the normal insulin secretion and the time-action profile of these
2 standard insulins do not readily allow for the clear separation of basal and prandial insulin
action9.
In twice-daily regimen, the short acting component is nominally responsible for
meal glucose disposal after breakfast and dinner. However, because of the effective
duration of action of the morning regular insulin approximately 6-7 hours, it may extends
through lunch, making it a prandial insulin for lunch as well and letting it serves as a basal
insulin between breakfast and lunch. At the same time, the morning intermediate acting
component with an effective duration of 10-16 hours, functions as a basal insulin after
absorption of breakfast and lunch, but because of its relatively rapid onset, it also serve as
part of the prandial insulin component at breakfast and as the primary prandial insulin at
lunch. Compensating for the inherent variability of this overlapping action requires strict
and consistent coordination as to the timing of injections and meals.
A simpler approach are preferred by most doctor and patients is to use a distinct
prandial insulin for each meal and a separate basal insulin. Although, these regimens
require more shots than conventional twice-daily regimens, they are considerable more
flexible, allowing greater freedom to skip meals or change mealtimes9.
However, in poor-compliance patient, the twice-daily regimens may be applied9.
Is there any role of metformin in Type 1 Diabetes Mellitus?
Metformin is an established oral glucose-lowering agent widely used in the treatment
of Type 2 Diabetes Mellitus. It is a first-line oral pharmacotherapy for Type 2 Diabetes
Mellitus. It decreases the hepatic glucose production, decreased the fasting plasma glucose, a
reduction in HBA1C level, weight loss, modest reduction in serum triglycerol, VLDL and
LDL levels.
A 10 year follow-up of patient with Type 2 Diabetes Mellitus with metformin therapy
was found to have a substantial 33% reduction in the rate of myocardial infarction10.
Therefore, metformin has properties that make it an attractive potential adjuvant agent in Type
1 Diabetes Mellitus.
In US, there is a number of type 1 DM patient was prescribed with Metformin because
some physicians believed that the potential for insulin reduction and lipid improvement. The
temptation to prescribe it increased because of the high prevalence of metabolic syndrome.
One study reported that the addition of metformin in poorly controlled Type 1 DM
improved insulin sensitivity, diabetic control, body composition and patient well-being12.
Another study to see the efficacy of adding metformin to insulin therapy in Type 1 DM by
doing systemic review of published clinical trials and clinical trial databases does found that it
reduces insulin-dose requirement but it is unclear whether this is sustained beyond 1 year and
whether there are benefits for cardiovascular12.
However, metformin is not routinely indicated for Type 1 DM because the major
concern is metabolic acidosis and it is contraindicated when ketoacidosis is an ongoing
concern. Therefore, metformin should be avoided unless insulin resistance is clearly
interfering with satisfactory glucose control despite lifestyle interventions and the risk of
ketoacidosis is minimized by an intensive program of insulin, self-monitoring of blood
glucose, urine ketone measurement.
3. DISEASE PREVENTION AND HEALTH PROMOTION
Besides prescribing the diabetic patient with medication, lifestyle modification also plays a
role to control the glucose level. It is believed that good glycemic control may prevent or
slow down the progression of macro and microvascular complication in diabetic patient.
Does good glycaemic control may prevent or slow down the progression of micro and
macrovascular complication in Type 1 and Type 2 Diabetes mellitus patient?
Once a patient is diagnosed with Diabetes Mellitus, he or she must then be managed
much more aggressively13. This is because Diabetes is associated with serious long-term
complications including microvascular and macrovascular disease, which impose an
additional socio-economic burden and account substanstial healthcare costs.
Most patient with type 1 DM develop evidence of retinopathy within 20 years of
diagnosis. In the European Diabetes Prospective Complications Study, the cumulative
incidence of microalbuminuria in patients with Type 1 DM was about 12% during a period
of 7 years16.
Therefore, blood glucose level should be as close to normal as possible. This can be
achieved by aiming for good glycemic control which is HBA1c less than 6.5%.
The fact that chronic hyperglycemia is associated with an increased risk of
microvascular complications of Type 1 DM was demonstrated in the Diabetes Control and
Complications Trial (DCCT). In that trial, intensive therapy designed to maintain normal
blood glucose levels greatly reduced the development and progression of retinopathy,
microalbuminemia, proteinuria and neuropathy as assessed over 7 year14.
The benefits include not only continued reduction in the rates of microvascular
complications but also significant differences in cardiovascular events and overall mortality.
There is study demonstrated that during 17 years of prospective analysis, intensive treatment
of Type 1 DM is associated with a 42% risk reduction in all cardiovascular events and a 57%
reduction in the risk of non-fatal MI, stroke or death from coronary vascular disease15.
4. COMMUNICATION SKILLS
Miss JLP and her family seemed not to have a clear understanding about her Type 1
Diabetes Mellitus. They kept asking why she was started with insulin injection instead of
oral hypoglycemic agent like other diabetic patient. And this may be one of the reasons
why she did not compliance to her medication.
How to counsel a newly diagnosed Type 1 Diabetes Mellitus patient?
In a newly diagnosed Type 1 Diabetes Mellitus, good counselling plays a major rule
to ensure that the patient and their family understand about the disease. With good
understanding about the disease, patient can seriously involve in their own management of
the disease as well as be compliance to the treatment.
The autoimmune destruction of B-cells of the pancreatic islets of Langerhans
which are responsible for insulin production should be explained to the patient and her
family17. The differences between Type 1 and Type 2 Diabetes Mellitus should be
explained to the patient as well, so that patient will understand why their treatment differs
with Type 2 DM.
Patient should be counselled about how he or she will be managed. In Type 1
DM,patient will be managed by a combination of insulin replacement and balancing of diet
and exercise in order to maintain glycemic control. Proper technique of injection and how
to inject insulin should be taught to the patient as well as to rotate the injection site17.
It is generally accepted that in order to effectively manage diabetes, education about
components of management such as blood glucose monitoring, insulin replacement, diet,
exercise, and problem solving strategies must be delivered to the patient and family.
Education seems necessary both at diagnosis, where there is usually no knowledge base
and patient and family are given the basic skills for controlling the disease, and
throughout the patient’s lifetime, with ongoing attention to self-management skills,
screening and prevention of complications, and new developments in these areas. Since
management of diabetes requires lifestyle changes, most clinicians feel it is important for
education to be delivered to the whole family17.
Acute complications of Type 1 DM should be explained to the patient such as DKA
and hypoglycemia17. Recognition of the hypoglycemic symptoms such as tremors,
sweating, hunger, dizziness should be taught to the patient as well as immediate action
following that.
Since Since DKA occurs in an average of 40% of children presenting with diabetes, brief
explanation about DKA should be explained to the patient. Patient should be advised not to
omit insulin treatment during illness.
Chronic complication of DM such as micro and microvascular also should be
discussed with the patient17. Since all of this complications have been linked to poor
glycemic control, therefore patient should be stressed on to be compliance to the medication.
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