1. Case Presentation 7 Khiddir bin Nasruddin Maisarah binti Ismail Nur Adibah binti Shaharul

2. 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)

3. History taking

4. 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.

5. History of presenting complains Vaginal Discharge (1 week prior to admission)

6. 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.

7. 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.

8. 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.

9. Systemic Review

11. 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.

12. 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.

13. Drug History She been taking insulin on 4 regimes;

14. Diet History

16. Immunisation History Allergies No known allergies to food, medication or weather.

17. 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.

18. 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

19. 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.

20. 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

21. 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

22. Physical examination

23. 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/min Respiratory Rate: 22 breath/min Blood Pressure: 115/70 mm/Hg Temperature: 37.6 ˚C BMI; 22.8 kg/m² (between 75th and 85thcentile) Height: 1.48 m (below 5thcentile, stature for age 2-20 years old girls) Weight: 50 kg

24. 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.

26. 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 necrobiosislipoidica. No Abnormalities Detected

27. 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

28. Sensory Modalities; Light touch: normal Superficial pain: normal Deep pain: normal Temperature: normal Vibration: normal Peripheral Nerve: normal

30. Investigation By Khiddir Bin Nasharuddin

31. Full Blood Count

32. Automated differential

34. Blood glucose test Khayattri – Random Blood Glucose : 4.4 mmol/L and HbA1c : 12.3 %

35. Renal profile

36. Blood culture and sensitivity No growth Culture & Sensitivity-High Vaginal Swab Streptococcus agalactiae Antibiotic sensitivity :-

37. 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.

38. Ultrasound scan of Right Inguinal region

39. Enlarged inguinal lymph nodes with the largest measuring 0.5x1.7x3.3cm. These nodes are matted together. No necrotic nodes seen. No abscesses seen.

40. Management and treatment

41. Uncontrolled Diabetes Mellitus Diet 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

42. Insulin Therapy

44. Progress in the hospital Subcutaneous 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

45. Hypoglycaemia Blood glucose falls below about 4 mmol/L Administration 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.

46. Streptococcus agalactiae infection Patient was treated with IV cloxacillin 1.2g stat and 6 hourly for 2 days of admission On the third day and forth, patient was given capsule cloxacillin 1g quartate intake daily

47. Vaginal Candidiasis During 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.

48. 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

49. 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