INTERNAL MEDICINE PORTFOLIO SEM 10

STUDENT NAME: NURDIYANAH BT GHAFAR ID NO: M0608119 NAME OF SUPERVISOR: DR VELAYUDHAN MENON

STUDENT NAME: NURDIYANAH BT GHAFAR SUPERVISOR: DR VELAYUDHAN MENON Good.

ID NO: M0608119 ROTATION: INT MEDICINE

--------------------------------------------------------------------------------------------------------------PATIENTS DETAIL Age : 21 years old Sex : Female R/N: 1690004 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 Kussmauls 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. IC No : 901113-01-6702 Date of admission : 19th of December 2011 Date of clerking : 19th of December 2011

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 cousins engagement ceremony on the next day. She was discharged with tablet slow K and subcutaneous Humulin.

STUDENT NAME: NURDIYANAH BT GHAFAR SUPERVISOR: DR VELAYUDHAN MENON

ID NO: M0608119 ROTATION: INT MEDICINE

------------------------------------------------------------------------------------------------------------PATIENTS DETAIL Age : 21 years old Sex : Female R/N Number : 1690004 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. IC No : 901113-01-6702 Date of admission : 19th of December 2011 Date of clerking : 19th of December 2011

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 68mmol/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 SUPERVISOR: DR VELAYUDHAN MENON

ID NO: M0608119 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 Kussmauls 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 SUPERVISOR: DR VELAYUDHAN MENON

ID NO: M0608119 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, noncompliance 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 SUPERVISOR: DR VELAYUDHAN MENON

ID NO: M0608119 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 68mmol/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 SUPERVISOR: DR VELAYUDHAN MENON

ID NO: M0608119 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 pH PCO2 PO2 HCO3 BE Value 7.080 21.8mmHg 22.5mmHg 6.5mmol/L -21.7mmol/L Interpretation Low Low Low Low 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.

4. Full Blood Count : To screen for any precipitating factor for her diabetic ketoacidosis such as infection. Parameter WBC Hg Hct MCV MCH MCHC Plt Lymphocytes Monocytes Neutrophil Value 16.9 x 10^9 16 49.1% 95 32.3 34 400 x 10^9 20% 2.1% 80.2% 76-98 fl 27-32 pg/cell 32-36 G/dL 150-400 x 10^9 20-45% 2-10% 40-75% Normal Value 4-11 x 10^9/L 12-16g/dL Interpretation High Normal Normal Normal Slightly High Normal Normal Normal Normal 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. Comme 3. Renal Profile: To assess the patients hydration status and to detect any electrolyte imbalance due to vomiting as well as due to Diabetic Ketoacidosis Component Urea Na K+ Creatinine Cloride Value 4.3 134 3.8 89 105 Normal Value 2.8-7.8 mmol/L 135-184mmol/L 3.5-5.1mmol/L 63-124 mmol/L 95-108 mmol/L Interpretation Normal Low Normal Normal Normal

Comment : All parameter is low, indicating that the patient lost a lot of electrolyte due to vomiting.

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 Specific Gravity pH Leucocyte Nitrite Protein Glucose Ketone Bilirubin Erytrocyte Value 1.03 5 Negative Negative Negative 56 15 Negative Negative Normal Value 1-1.03 4.5-8 Negative Negative < 0.5 < 1.7 < 0.5 < 3.4 0-5 Interpretation Normal Normal Normal Normal Normal High High Normal 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 SUPERVISOR: DR VELAYUDHAN MENON

ID NO: M0608119 ROTATION: INT MEDICINE

------------------------------------------------------------------------------------------------------------Working Dignosis 7. WORKING DIAGNOSIS AND PLAN OF MANAGEMENT ON ADMISSION 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 SUPERVISOR: DR VELAYUDHAN MENON

ID NO: M0608119 ROTATION:INT MEDICINE

-----------------------------------------------------------------------------------------------------------In ward, patient was hydrated with Normal saline accordingly based on the suggested 8. SUMMARY OF INPATIENT continuous intravenous infusion of Actrapid. Her repeat regime. She was also started with PROGRESS 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 premixed 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 cousins engagement ceremony on the next day. She was discharged with tablet slow K and subcutaneous Humulin.

STUDENT NAME: NURDIYANAH BT GHAFAR SUPERVISOR:DR VELAYUDHAN MENON

ID NO: M0608119 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 R/N IC No Date Diagnosis 22/12//2011 Moderate Diabetic Ketoacidosis secondary to non- compliance to treatment You must again comment here on whether you think this prescription is adequate for her LJP ( Patients Full Name) 1690004
Prescription :

1. T. Slow K II/II tds x 1/52 2. S/C Humulin ;30 unit OM, 14 unit ON x 1/12 Doctors name and name stamp

STUDENT NAME: NURDIYANAH BT GHAFAR SUPERVISOR: DR VELAYUDHAN MENON

ID NO: M0608119 ROTATION: INT MEDICINE

------------------------------------------------------------------------------------------------------------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. 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. 21st of Dec 2011

Yours sincerely,

NURDIYANAH GHAFAR, Final year medical student of IMU

STUDENT NAME: NURDIYANAH BT GHAFAR SUPERVISOR: DR VELAYUDHAN MENON 11. LEARNING ISSUES IN THE 8 IMU OUTCOMES

ID NO: M0608119 ROTATION: INT MEDICINE

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 insulinproducing 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 Bcell 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 cows 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 patients 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.

REFERENCES 1. Foulis AK, McGill M, Farquharson MA. Insulitis in type 1 (insulin-dependent) diabetes mellitus in man macrophages, lymphocytes, and interferon-gamma containing cells. J Pathol 1991;165:97-103. 2.. Cudworth AG, Woodrow JC. HLA system and diabetes mellitus. Diabetes 1975;24:345-9. 3. Devendra D, Eisenbarth GS. Immunologic endocrine disorders. J Allergy Clin Immunol 2003;111:S624-36. 4. Caillat-Zucman S, Garchon HJ, Timsit J, et al. Age-dependent HLA genetic heterogeneity of type 1 insulin-dependent diabetes mellitus. J Clin Invest 1992;90:2242-50. 5. Nairn C, Galbraith DN, Taylor KW, Clements GB. Enterovirus variants in the serum of children at 1. Demoly P, Bousquet J : mellitus. between asthma and allergic rhinitis. the onset of type 1 diabetes The relationDiabet Med1999;16:509-13. Lancet 2006;368:7113. 6. Peter Achenbach, Ezio Bonifacio, Kerstin Koczwara and Anette-G. Ziegler. Natural History of Type 1 Diabetes. Diabetes December 2005 vol. 54 no. suppl 2 S25-S31 8. IRL B. HIRSCH, M.D. Type 1 Diabetes Mellitus and the Use of Flexible Insulin Regimens. Am Fam Physician. 1999 Nov 15;60(8):2343-2352 9. Irl B. Hirsch, Jay S. Skyler. Endotext,Chapter 17-Management of Type 1 Diabetes 10. Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HA (2008) .10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 359:15771589 11. Moon RJ, Bascombe LA, Holt RI (2007) The addition of metformin in type 1 diabetes improves insulin sensitivity, diabetic control, body composition and patient well-being. Diabetes Obes Metab 9:143145 12. S. Vella, L. Buetow, P. Royle, S. Livingstone, H. M. Colhoun and J. R. Petrie. The use of metformin in Type 1 Diabetes: a systematic review of efficacy. Diabetologia Volume 53, Number 5, 809-820, DOI: 10.1007/s00125-009-1636-9 13. Canadian Diabetes Association 14. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med. Sep 30 1993;329(14):977-86. 15. Nathan DM, Cleary PA, Backlund JY, Genuth SM, Lachin JM, Orchard TJ, Raskin P, Zinman B: Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med 353:2643-2653, 2005 16. Chaturvedi N, Bandinelli S, Mangili R, Penno G, Rottiers RE, Fuller JH: Microalbuminuria in type 1 diabetes: rates, risk factors and glycemic threshold. Kidney Int 60: 219-227,2001 17. Agency for Healthcare Research and Quality U.S. Department of Health and Human Service. Diabetes Education for Children With Type 1 Diabetes Mellitus and Their Families