TYPE 1 DIABETES MELLITUS

TYPE 1 DIABETES MELLITUSSUPERVISOR : dr. Johannes Saing, M.Ked (Ped), Sp.A (K)

Presented by : Saravana Selvi Sanmugam (110100426)introductionDiabetes mellitus (DM) is a group of metabolic disorders characterized by a chronic hyperglycemic condition resulting from defects in insulin secretion, insulin action or both.

ETIOLOGYSome causes of insulin resistance :

1 Obesity/overweight2 Excess glucorticoids 3 Excess growth hormone 4 Pregnancy, gestational diabetes5 Polycystic ovary disease6 Lipodystrophy7 Autoantibodies to the insulin receptor8 Mutations of insulin receptor9Hemochromatosis10 Mutations that cause genetic obesity

pathogenesis

PATHOPHYSIOLOGY

INSULIN

GLUCAGON

Clinical manifestations

diagnosis

Treatment

Monitoring blood glucose

Taking medicationGetting regular exerciseFollowing a meal planKey Pieces Of Diabetes Self-ManagementAcute complication1) Hypoglycemia- BG level 240mg/dL must contact healthcare provider Random BG level > 300 mg/dL

prognosisLifespan of individuals with diabetes is about b10 years shorter than that of the non diabetic populationsEventually attain a height within the normal adult range, puberty may be delayed, and the final height may be less than the genetic potential.Insulin pump is one approach to the resolution of these long term problems

Case reportLJ, a 7 yeasrs old female was came to Haji Adam Malik General Hospital on the 25th September 2015Chief Complain: Loss of consciousnessLJ was referred to Haji Adam Malik General Hospital from Pringadi General Hospital. Patient came in the state of unconscious which has been experienced by patient for the past 5 days. Fever (-), seizure (-). Breathlessness has been experienced by patient around 5 days before entering Haji Adam Malik General Hospital. Breathlessness is not affected by whether and daily activity. According to the information given by the patients parents, patient had an increased appetite, but there was no increase in patients body weight, instead there was a decrease in her body weight from 15kg to 14kg in a month. Besides, patient also had history of polyuria with the frequency of urination more than 10 times per day in a month. History of vomiting, cold, and cough was not foundHistory of Previous positionThe patient was referred from RSUP Pringadi with the diagnosis of ketoacidosis. Birth history: RZ was the third boy. Birth spontaneously, helped by tocologist, cried hard. Cyanosis (-), birth weight: 3.0 kg.Pregnancy history: mother age 31 years old, medical history (-), drug exposure (-), herb exposure (-).

Feeding History:From birth to 6 months : Breast feeding onlyHistory of Growth and DevelopmentTurning: 6 bulanSitting: 7 monthsCrawling: 8 monthsStanding: 10 monthsWalking: 15 months

Medical History: Patient was referred from RSU Pringadi with diagnosis of ketoacidosisDrug use history: Humulin R, Ceftriaxone injection 750 mg/12 hours

Labarotary findingsTestResultUnitReferralHemoglobin10,7 G%11,3-14,1Erythrocyte3,37 106/mm34,40-4,48Leucocyte5.51103/mm34,5-13,5Thrombocyte151103/mm3150-450Hematocrite30,4 %37-41Eosinophil0,60%1-6Basophil0,200%0-1Neutrophil79,30%37-80Lymphocyte11,50%20-40Monocyte8,40%2-8Neutrophil absolute5,16103/L2,4-7,3Lymphocyte absolute0.75103/L1,7-5,1Monocyte absolute0,55103/L0,2-0,6Eosinophyl absolute0,04103/L0,10-0,30Basophyl absolute0,01103/L0-0,1MCV90,20fL81-95MCH32,30 pg25-29MCHC35,90 g%29-31Blood Gas AnalysisResultUnitReferralpH7,13 7,35-7,45pCO29,0 mmHg38-42pO2215,0 mmHg85-100Bicarbonate (HCO3)3,0 mmol/L22-26Total CO23,3 mmol/L19-25Excess Base-23,9mmol/L(-2)-(+2)O2 Saturation100%95-100TestResultUnitReferralCarbohydrate MetabolismBlood Glucose241mg/dL< 200ElectrolyteNatrium139mEq/L135-155Kalium2,9mEq/L3,6-5,5Chloride105mEq/L96-106Differential Diagnosis : dd Type 1 DM + AKI stadium Failure Type 2 DMWorking Diagnosis: dd Type 1 DM + AKI stadium Failure Type 2 DMManagement: - O2 1-2 L/i- IVFD D5% NaCl 0,225% 20 gtt/i micro- Insulin (Novorapid)

September, 25th 2015SUnconsciousOCons: unconscious, Temp: 36,5 oC. Body weight: 14kg, Body length: 118 cm.Head : light reflexes (+/+), pupil isochoric, inferior conjuctiva pale (+/+), icteric sclera (-/-), face edema (-), inferior and superior palpebrae edema (-), Ear/ Nose/ Mouth: within normal limit/ O2 nasal canule/ within normal limit, bleeding gums (-)Neck :Lymph node enlargement (-).Thorax :Symmetrical fusiformis, Kussmaul breathing (+), chest retraction (-) epigastric and intercostal, breathing sound: vesicular, additional sound: ronchi -/-, wheezing (-), murmur (-), HR : 104x/i, regular, RR : 24x/i, regularAbdomen : Distention (+), peristaltic (+) normal, liver and Spleen difficult to palpateExtremities :Pulse 104x/i, regular, adequate pressure and volume, warm, CRT < 3. AHypoglycemia + dd/ -DM type 1 - DM type 2 PManagement:-O2 1-2 L/i-IVFD D 10% KCl 45cc/hour GIR : 5,3mg/kg/min- Humulin R 5 unit in 50cc Nacl 0,9% 2,5cc/hour (0,05 unit/ hour)- Blood glucose target : 90-180mg/dL- Dipstick to evaluate ketone- Consul eye department for papil oedem evaluation - Elektrolyte result : K 2,2meq/L ECG- Consul answer : Normofundus. Papil oedema is not found for time being- Blood glucose level : 13.30/14.00/14.30/ 15.30/16.00/16.15/19.30/20.00/20.30 : 29/74/83/66/66/50/85/153/101Diagnostic Plannings : Check Blood gas analysis, blood glucose level and electrolyte value per 3 hours September, 26th 2015SUnconscious (+) OCons: unconscious, Temp: 36,1 oC. Body weight: 14kg, Body length: 118 cm.Head :light reflexes (+/+), pupil isochoric, inferior conjuctiva pale (+/+), icteric sclera (-/-), face edema (-), inferior and superior palpebrae edema (-), Ear/ Nose/ Mouth: within normal limit/ O2 nasal canula/ within normal limit, bleeding gums (-)Neck :Lymph node enlargement (-).Thorax :Symmetrical fusiformis, Kussmaul breathing (+), chest retraction (-), breathing sound: vesicular, additional sound: ronchi -/-, wheezing (-), murmur (-), HR : 100x/i, regular, RR : 40x/i, regularAbdomen :Distention (+), peristaltic (+) normal, liver and Spleen difficult to palpateExtremities:Pulse 100x/i, regular, adequate pressure and volume, warm, CRT < 3. BP : 90/50mmHgAHypoglycemia + dd/ - DM type 1 + AKI stadium Failure - DM type 2PManagement:- O2 nasal canula 1L/min-IVFD D5% + KCl 4cc/hour GIR : 5,3mg/kg/min- Humulin R 5 unit dalam 50cc Nacl 0,9% 7,5cc/hour (0,05 unit/hour)- Dipstick every 6 hours- Blood Glucose level 10.30/12.00/13.00/14.00/15.00/16.00/17.00 : 134/134/173/212/426/538/500Diagnostic Planning:Check Blood gas analysis, Elektrolyte, Blood glucose level per hour, Dipstick urineDiet : RDA x Ideal body weight = 70 x 17 = 1820 kkal + 227 gr carbohydrateSeptember, 27th 2015S Conscious, Kussmaul breathing (-), diarrhea (-)OCons: alert, Temp: 36,9oC. Body weight: 14 kg, Body length: 118 cm.HeadEye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-).Ear/ Nose/ Mouth: within normal limit/ nasal canule / within normal limit. NeckLymph node enlargement (-).ThoraxSymmetrical fusiformis, Chest retraction (-).HR: 104x/i, regular, murmur (-), RR: 40x/i, reguler, rhonchi (-/-)AbdomenDistention(+), peristaltic (+) normal, liver and Spleen difficult to palpateExtremitiesPulse 104x/i, regular, adequate pressure and volume, warm, CRT < 3. Add/ - DM type 1 + AKI stadium Failure - DM type 2PManagement:O2 nasal canule 1L/minIf blood glucose level : 250mg/dL NaCl 0,9% + KCl 10meqInsulin dosis : 0,5 IU/kgBW/day 0,5x14=7 IU/day (Novorapid 3-2-2) SCDiet : 1820 kkal with 227gr carbohydratesBlood glucose level : 07.00/08.00 : 213/317Laboratory findings :pH/pCO2/pO2/HCO3/TCO2/BE/O2 Sat : 7,22/25/184/10,2/11,6/-15,3/99%September, 28th 2015SConscious, Kussmaul breathing (-), diarrhea (-)OCons: alert, Temp: 37,0oC. Body weight: 14 kg, Body length: 118 cm.HeadEye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-).Ear/ Nose/ Mouth: within normal limit/ nasal canule / within normal limit. NeckLymph node enlargement (-).ThoraxSymmetrical fusiformis, distention (+), Chest retraction (-). HR: 110x/i, regular, murmur (-). RR: 36x/i, reguler, rhonchi (-/-)AbdomenDistention (+), peristaltic (+) normal, liver and spleen difficult to palpateExtremitiesPulse 100x/i, regular, adequate pressure and volume, warm, CRT < 3, BP 90/70 mmHG Add/ - DM type 1 + AKI stadium Failure - DM type 2PManagement:O2 nasal canula 1L/minIf blood glucose level : 250mg/dL NaCl 0,9% + KCl 10meqInsulin dosis : 0,5IU/kgBW/day 0,5x14=7IU/day (Novorapid 3-2-2)Diet : 1820kkal with 227gr carbohydratesBlood Glucose level : 12.30 : HIGHDosage Correction : 1800/7 = 250 mg/dLTarget blood glucose level : 90-180 mg/dL Every increase of 250mg/dL in blood glucose level above target dose 180mg/dL increase 1 unit of novorapid dosageConsul nephrologySeptember, 29th 2015SUnconscious (-) OCons: unconscious, Temp: 36,1 oC. Body weight: 14kg, Body length: 118 cm.Head :light reflexes (+/+), pupil isochoric, inferior conjuctiva pale (+/+), icteric sclera (-/-), face edema (-), inferior and superior palpebrae edema (-), Ear/ Nose/ Mouth: within normal limit/ O2 nasal canal/ within normal limit, bleeding gums (-)Neck :Lymph node enlargement (-).Thorax :Symmetrical fusiformis, Kussmaul breathing (+), chest retraction (-), breathing sound: vesicular, additional sound: ronchi -/-, wheezing (-), murmur (-), HR : 100x/i, regular, RR : 40x/i, regularAbdomen :Distention (+), peristaltic (+) normal, liver and Spleen difficult to palpateExtremities:Pulse 100x/i, regular, adequate pressure and volume, warm, CRT < 3. BP : 90/50mmHgAdd/ - DM type 1 + AKI stadium Failure - DM type 2PManagement:O2 nasal canule 1L/minIf blood glucose level : 250mg/dL NaCl 0,9% + KCl 10meqInsulin dosis : 0,5 IU/kgBW/day 0,5 x 14=7 IU/day (Novorapid 3-2-2)Blood glucose level target : 90-180mg/dLEvery increase of 250mg/dL in blood glucose level above target dose 180mg/dL increase 1 unit of novorapid dosageDiet : 1820kkal with 227gr carbohydratesBlood glucose level : 07.00 : HIGHSeptember,30th 2015SUnconscious (-)OCons: unconscious, Temp: 36,8 oC. Body weight: 14kg, Body length: 118 cm.Head :light reflexes (+/+), pupil isochoric, inferior conjuctiva pale (-/-), icteric sclera (-/-), face edema (-), inferior and superior palpebrae edema (-), Ear/ Nose/ Mouth: within normal limit/ O2 nasal canal/ within normal limit, bleeding gums (-)Neck :Lymph node enlargement (-).Thorax :Symmetrical fusiformis, Kussmaul breathing (+), chest retraction (-), breathing sound: vesicular, additional sound: ronchi -/-, wheezing (-), murmur (-), HR : 90x/i, regular, RR : 20x/i, regularAbdomen :Distention (+), peristaltic (+) normal, liver and Spleen difficult to palpateExtremities:Pulse 90x/i, regular, adequate pressure and volume, warm, CRT < 3. BP : 90/60mmHgAdd/ - DM type 1 + AKI stadium Failure - DM type 2PManagement:O2 nasal canula 1L/minIf blood glucose level : 250mg/dL NaCl 0,9% + KCl 10meqInsulin dosis : 0,6 IU/kgBW/day 12 IU/day Basal insulin dosage 80% x 12 = 9,6~10 (Novorapid 5 unit 2-2-1) (Levemir 5 unit)Dosage correction : 1800/10 = 180Blood glucose level target : 90-180mg/dLEvery increase of 180 mg/dL in blood glucose level above target dose 180mg/dL increase 1 unit of novorapid dosageDiet : 1820kkal with 227gr carbohydratesBlood glucose level : 1830 : HIGHNephrology : Given Captopril 2 x 6,25mg (dr.Rosmayanti M.Ked (Ped),Sp.A)October, 1st 2015SUnconscious (-) OCons: alert, Temp: 35,6oC. Body weight: 14kg, Body length: 118 cm.HeadEye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-).Ear/ Nose/ Mouth: within normal limit/ nasal canule / within normal limit. NeckLymph node enlargement (-).ThoraxSymmetrical fusiformis, Chest retraction (-). HR: 80x/i, regular, murmur (-). RR: 26x/i, reguler, rhonchi (-/-)AbdomenDistention (+), peristaltic (+) normal, liver and spleen difficult to palpateExtremitiesPulse 76x/i, regular, adequate pressure and volume, warm, CRT < 3. BP: 100/50 mmHgAdd/ - DM type 1 + AKI stadium Failure - DM type 2PManagement:Visit dr. Siska M.Ked (Ped),Sp.A -stop infusionIncrease in insulin dosage 0,7 unit/kgBW/day = 14 unit/dayBasal insulin dosage 80% x 14 = 12 unit (novorapid 6 unit : 2-2-2) (Levemir 6 unit)Blood glucose target level : 180mg/dLCorrection dosage : 150mg/dl Every increase of 150mg/dL in blood glucose level above target dose 180mg/dL increase 1 unit of novorapid dosageIf blood glucose level : 250mg/dL NaCl 0,9% + KCl 10meqDiet : 1820kkal with 227gr carbohydratesNephrology : Given Captopril 2 x 6,25mg (dr.Rosmayanti M.Ked (Ped),Sp.A)October, 2nd 2015SUnconscious (-) OCons: alert, Temp: 36,9oC. Body weight: 14kg, Body length: 118 cm.HeadEye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-).Ear/ Nose/ Mouth: within normal limit/ nasal canule / within normal limit. NeckLymph node enlargement (-).ThoraxSymmetrical fusiformis, Chest retraction (-). HR: 80x/i, regular, murmur (-). RR: 26x/i, reguler, rhonchi (-/-)AbdomenDistention (+), peristaltic (+) normal, liver and spleen difficult to palpateExtremitiesPulse 76x/i, regular, adequate pressure and volume, warm, CRT < 3. BP: 100/50 mmHgAdd/ - DM type 1 + AKI stadium Failure - DM type 2PManagement:Blood glucose level : 12.45 : HIGHIncrease in insulin dosage 0,6 unit/kgBW/day = 12 unit/dayBasal insulin dosage 80% x 12 = 9,6 ~10 unit (novorapid 5 unit : 2-2-1) (Levemir 5 unit)Blood glucose target level : 180mg/dLEvery increase of 250mg/dL in blood glucose level above target dose 180mg/dL increase 1 unit of novorapid dosageIf blood glucose level : 250mg/dL NaCl 0,9% + KCl 10meqDiet : 1820 kkal with 227gr carbohydratesOctober, 3rd 2015SUnconscious (-) OCons: alert, Temp: 36,9oC. Body weight: 14kg, Body length: 118 cm.HeadEye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-).Ear/ Nose/ Mouth: within normal limit/ nasal canule / within normal limit. NeckLymph node enlargement (-).ThoraxSymmetrical fusiformis, Chest retraction (-). HR: 84x/i, regular, murmur (-). RR: 24x/i, reguler, rhonchi (-/-)AbdomenDistention (+), peristaltic (+) normal, liver and spleen difficult to palpateExtremitiesPulse 76x/i, regular, adequate pressure and volume, warm, CRT < 3. BP: 100/60 mmHgAdd/ - DM type 1 + AKI stadium Failure - DM type 2PManagement:Increase in insulin dosage 0,6 unit/kgBW/day = 12 unit/dayBasal insulin dosage 80% x 12 = 9,6 ~10 unit (novorapid 5 unit : 2-2-1) (Levemir 5 unit)Blood glucose target level : 90-180mg/dLCorrection dosage : 1800/7 = 250 mg/dLEvery increase of 250mg/dL in blood glucose level above target dose 180mg/dL increase 1 unit of novorapid dosageIf blood glucose level : 250mg/dL NaCl 0,9% + KCl 10meqDiet : 1820 kkal with 227gr carbohydratesOctober, 4th 2015SUnconscious (-) OCons: alert, Temp: 36,9oC. Body weight: 14kg, Body length: 118 cm.HeadEye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-).Ear/ Nose/ Mouth: within normal limit/ nasal canule / within normal limit. NeckLymph node enlargement (-).ThoraxSymmetrical fusiformis, Chest retraction (-). HR: 86x/i, regular, murmur (-). RR: 26x/i, reguler, rhonchi (-/-)AbdomenDistention (+), peristaltic (+) normal, liver and spleen difficult to palpateExtremitiesPulse 76x/i, regular, adequate pressure and volume, warm, CRT < 3. BP: 100/60 mmHgAdd/ - DM type 1 + AKI stadium Failure - DM type 2PManagement:Insulin dosage 0,6 unit/kgBW/day = 12 unit/day (novorapid 7 unit : 3-2-2) (Levemir 5 unit )Blood glucose target level : 180mg/dLEvery increase of 250mg/dL in blood glucose level above target dose 180mg/dL increase 1 unit of novorapid dosageIf blood glucose level : 250mg/dL NaCl 0,9% + KCl 10meqDiet : 1820kkal with 227gr carbohydratesOctober, 5th 2015SUnconscious (-) OCons: alert, Temp: 36,8oC. Body weight: 14kg, Body length: 118 cm.HeadEye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-).Ear/ Nose/ Mouth: within normal limit/ nasal canule / within normal limit. NeckLymph node enlargement (-).ThoraxSymmetrical fusiformis, Chest retraction (-). HR: 80x/i, regular, murmur (-). RR: 24x/i, reguler, rhonchi (-/-)AbdomenDistention (+), peristaltic (+) normal, liver and spleen difficult to palpateExtremitiesPulse 80x/i, regular, adequate pressure and volume, warm, CRT < 3. BP: 100/50 mmHgAdd/ - DM type 1 + AKI stadium Failure - DM type 2PManagement:Increase in insulin dosage 0,8 unit/kgBW/day = 16 unit/dayBasal insulin dosage 80% x 16 = 13unit (novorapid 7 unit : 3-2-2) (Levemir 6 unit)Blood glucose target level : 90-180mg/dLEvery increase of 250mg/dL in blood glucose level above target dose 180mg/dL increase 1 unit of novorapid dosageIf blood glucose level : 250mg/dL NaCl 0,9% + KCl 10meqDiet : 1820kkal with 227gr carbohydratesOctober, 6th 2015SUnconscious (-) OCons: alert, Temp: 37,0oC. Body weight: 14kg, Body length: 118 cm.HeadEye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-).Ear/ Nose/ Mouth: within normal limit/ nasal canule / within normal limit. NeckLymph node enlargement (-).ThoraxSymmetrical fusiformis, Chest retraction (-). HR: 92x/i, regular, murmur (-). RR: 22x/i, reguler, rhonchi (-/-)AbdomenDistention (+), peristaltic (+) normal, liver and spleen difficult to palpateExtremitiesPulse 92x/i, regular, adequate pressure and volume, warm, CRT < 3. BP: 100/50 mmHgAdd/ - DM type 1 + AKI stadium Failure - DM type 2PManagement:Increase in insulin dosage 0,8 unit/kgBW/day = 16 unit/dayBasal insulin dosage 80% x 16 = 13 unit (novorapid 7 unit : 3-2-2) (Levemir 6 unit)Blood glucose target level : 180mg/dLEvery increase of 250mg/dL in blood glucose level above target dose 180mg/dL increase 1 unit of novorapid dosageIf blood glucose level : 250mg/dL NaCl 0,9% + KCl 10meqDiet : 1820kkal with 227gr carbohydratesCulture findings :Urine test result : E.Coli, ESBL (+)Sensitive on amoxicillin/clavulanic acid, imipenem, sulbectam, gentamycin, Meropenem, nitrofurantein, and fosfomycinOctober, 7th 2015SUnconscious (-) OCons: alert, Temp: 37,1oC. Body weight: 14kg, Body length: 118 cm.HeadEye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-).Ear/ Nose/ Mouth: within normal limit/ nasal canule / within normal limit. NeckLymph node enlargement (-).ThoraxSymmetrical fusiformis, Chest retraction (-). HR: 80x/i, regular, murmur (-). RR: 26x/i, reguler, rhonchi (-/-)AbdomenDistention (+), peristaltic (+) normal, liver and spleen difficult to palpateExtremitiesPulse 76x/i, regular, adequate pressure and volume, warm, CRT < 3. BP: 100/50 mmHgAdd/ - DM type 1 + AKI stadium Failure - DM type 2PManagement:Increase in insulin dosage 0,8 unit/kgBW/day = 16 unit/dayBasal insulin dosage 80% x 16 = 13 unit (novorapid 7 unit : 3-2-2) (Levemir 6 unit)Blood glucose target level : 90-180mg/dLEvery increase of 150mg/dL in blood glucose level above target dose 180mg/dL increase 1 unit of novorapid dosageIf blood glucose level : 250mg/dL NaCl 0,9% + KCl 10meqDiet : 1820kkal with 227gr carbohydratesOctober, 8th 2015SUnconscious (-) OCons: alert, Temp: 36,9oC. Body weight: 14kg, Body length: 118 cm.HeadEye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-).Ear/ Nose/ Mouth: within normal limit/ nasal canule / within normal limit. NeckLymph node enlargement (-).ThoraxSymmetrical fusiformis, Chest retraction (-). HR: 80x/i, regular, murmur (-). RR: 26x/i, reguler, rhonchi (-/-)AbdomenDistention (+), peristaltic (+) normal, liver and spleen difficult to palpateExtremitiesPulse 76x/i, regular, adequate pressure and volume, warm, CRT < 3. BP: 100/50 mmHgAdd/ - DM type 1 + AKI stadium Failure - DM type 2PManagement:Increase in insulin dosage 0,8 unit/kgBW/day = 16 unit/dayBasal insulin dosage 80% x 16 = 13 unit (novorapid 7 unit : 3-2-2) (Levemir 6 unit)Blood glucose target level : 90-180mg/dLEvery increase of 150mg/dL in blood glucose level above target dose 180mg/dL increase 1 unit of novorapid dosageIf blood glucose level : 250mg/dL NaCl 0,9% + KCl 10meqDiet : 1820 kkal with 227gr carbohydratesOUTPATIENTdiscussionTheory CaseEpidemiology- 20 million people worldwide is diagnosed with type 1 DM- Girls and boys are almost equally affected but there is a modest female preponderance in some low-risk populations (e.g., the Japanese)- Peaks of presentation occur in 2 age groups: at 5-7 yr of age and at the time of puberty. LJ, 7 years old girl, was diagnosed with type 1 Diabetes Mellitus.Clinical manifestation: 1) Polyuria or nocturia2) Persistent diuresis (with nocturnal enuresis, and polydipsia becomes more apparent)3) Polyphagia4) Weight loss5) Ketoacidosis (leads to Kussmaul respirations, fruity breath odour (acetone), diminished neurocognitive functions, and possible coma) - Breathlessness- Polyuria- Polyphagia-Weight loss- Kussmaul respirationsComplications a) Acute Complications1) Hypoglycemia2) Ketonuria, Ketonemia, Ketoacidosisb) Chronic complications1) Renal Failure2) Loss of visionHypoglycemiaRenal failuresummaryIt has been reported that LJ, a 7 years 5 months girl, came to Haji Adam Malik General Hospital with a chief complain of loss of unconsciousness which has been experienced by patient for the past 5 days and was diagnosed with dd Type 1 DM dd Type 2 DM with AKI stadium Failure. The diagnosis was made based on her history, physical examination, and laboratory findings. The patient was treated with O2 nasal canula, IVFD based on patients glucose level, and insulin (novorapid).