CASE Report

Doctor Name: Ziena Ferdan

Student Name: AbdulHadi Mohammed Ahmasani
ID : 438802263
Serial N : 114
HiSTOry :- (the source of history is from the patient and some information from mother )
Lana Abdullah Motleg ALGamdi , 12 year old Saudi girl from Abha,
admitted to Maternity and Children Hospital in Abha throw ER at
10/1/2023 , with a complaints of excessive water drinking & Increased
frequency of urination for 2 weeks .
The child was in her usual status of health until 2 weeks back ,then she
started complaining of thirsty , drinking water excessively & also increase
urination frequency that wake her up from sleep 1-2 times every night , the
mother noticed this abnormality and she suspect DM , so the family
decided to bring their child to hospital to seek medical advice .
Her urine color was light and increased in amount but no dysuria or change
in urine odor and no Hx of recent infections or fever , She had history of
weight loss , she lost around 2kg during the last month , there is no loss of
appetite , or night sweating .
There is no abdominal pain ,no vomiting , diarrhea , constipation or jaundice,
no photophobia or drowsiness ,no fits , abnormal movements or behavioral
abnormality , No weakness , numbness or headache .
Other Systemic review were unremarkable , There is no palpitation ,
syncope or chest pain .
no History of skin rash ,joint swelling , pain, or stiffness .
no SOB , no cough or runny nose .
past medical history revealed no previous diseases or chronic illnesses .
she didn’t take any medication before . No history of surgery or blood
transfusion & she has allergy for Augmentin .
Pregnancy & neonatal History , Her mother didn’t face any problem
during pregnancy and she didn’t take any medication except folic acid &
Iron supplement , no history of exposure to radiation or infection during
pregnancy ,with normal fetal movement , she was delivered full term by
vaginal delivery , her birth weight was 3kg without complication or NICU
admission .
Nutritional History , When she was a baby she was on exclusive
breastfeeding until age of 2 months then she start take formula (S26 milk )
along with breastfeeding and start weaning at age of 6 months
And currently , she is on regular family diet with prober weight gain and she
wasn’t
eat much of sweet or fast food.
She completed the recommended vaccination schedule of Saudi
Arabia without history of complication or reaction.
Her development is appropriate compare to her sibling , she is in primary
school in 6th grade with excellent school performance .
Family & social History , Her father is 40 year old , he is teacher , and
her mother is 36 year old , she is teacher , they are not consanguine , she
had 3 siblings and they didn’t have any medical condition , no family
history of celiac disease , vitiligo or other autoimmune diseases .
No history of smoking among family members , they live on their own
house with good economic status .
PhYSICAL Examination :-
On General appearance , the child is conscious and oriented , looks well,
with thin body built. she is not pall , cyanosed or jaundiced .
she is not in respiratory distress and there is no signs of dehydration
and no dysmorphic features
she is connected to IV cannula at right hand.
Vital signs:
Temperature : 36.8°C
Oxygen saturation : 94% at room air
Respiratory rate : 22 breaths/min
Heart rate : 130 beat/min
Blood pressure : 115/75 mmHg on 50th percentile
Growth parameters:
Wight : 39kg on 50th percentile
height : 147cm between 50th & 75th percentile
head circumference : 52 cm between 10th & 25th percentile
General Examination:-
Hands:
There is no pallor , clubbing , peripheral cyanosis or pigmentation ,
no muscle wasting , palmar erythema or scratch marks .
Head and neck examination:
There is no pallor noticed in her eyes or jaundice ,no redness or purulent
discharge , no periorbital edema, there is no central cyanosis, no mouth
ulcer and no signs of tonsillar inflammation , or enlargement of parroted
gland.
There is no signs of ears inflammation.
No enlargement of submental , submandibular , periauricular ,
postauricular or occipital lymph nodes.
No enlargement of cervical and supraclavicular lymph nodes , and
there is no enlargement of thyroid gland.
Skin :
There is no skin pigmentation (no Acanthosis nigricans) at neck , axilla or
other body folds , no skin rash and no evidence of neurocutaneous stigmata

GI Examination :-
Inspection :
There is no abdominal distention , the umbilicus was central and inverted ,
no scars , no rash ,no scratch marks or visible vain , there is no visible
mass & no hernia.
Palpation:
superficial palpation : the abdomen was soft and lax ,normal
temperature , no tenderness or superficial masses .
deep palpation : no tenderness , no deep masses and no liver or spleen
enlargement
and the kidneys wasn’t palpable .
Percussion:
There is no sign of ascites , the liver span is 9 cm which is normal.
Auscultation:
Bowel sounds are present and it was normal , there is no friction rub over
the liver or spleen , no arterial bruit over liver and renal and no venous
hum.
CNS Examination :-
Mental Status:
Normal mental status , she is oriented to time , place and person ,
GCS 15/15 Her attention and memory( immediate , short and long )
are intact ,
and normal language and praxis ( normal Fluency ,
Comprehension ,Naming , Repetition ,Reading & Writing ).
And normal Cranial Nerve examination
Motor System In Upper & Lower Limbs :
General Inspection : normal posture & muscle bulk ( no wasting or
hypertrophy) and there are no Fasciculations or involuntary movements .
Normal tone , power and all deep tendon reflexes are normal.
Sensory System In Upper & Lower Limbs :
normal sensation of Light touch, vibration and
proprioception. normal sensation of pain & temperature .
She have Normal Coordination and Gait.
RESPIRATory Examination:-
inspection:
Normal chest shape , no deformity ( no pectus carinatum or excavatum )
there is no retraction and chest movement is symmetrical.
palpation:
Trachea centralized , not deviate with symmetrical chest
expansion Apex beat was palpable at left side.
There was no pain or tenderness during palpation and no enlargement
of axillary lymph nodes.
Percussion:
symmetrical resonant percussion all over the chest with normal dullness
over liver and cardiac area .
Auscultation:
equal bilateral air entry and Normal vesicular breathing
sounds. There are no abnormal or added sounds .
Back examination :
No back deformity or asymmetry ( no scoliosis , kyphosis or
kyphoscoliosis ) , no scars.No tenderness or palpable masses, Resonance
on percussion bilaterally ,Equal bilateral air entry with normal vesicular
breathing . There are no abnormal or added sounds .
Cardiac Examination :-
Apex beat felt at left side in the 5th inter costal space mid
clavicular line . Normal heart sounds , no murmur or gallop and
no added sound .
MUSCULOSKeletal Examination :-
No skin rash , no joint deformity , swelling or tenderness .

SUmmary :-
HISTORY:
a 12 year old Saudi girl was medically free and vaccinated presented with
Polyuria, polydipsia and nocturia for 2 weeks , she had lost 2kg of her
weight during the last month but no fever or recent history of infections .
No associate symptoms , other systemic review unremarkable.
EXAMINATION:
she is conscious and alert , looks well, with normal growth parameter ,
no signs of dehydration , no Acanthosis nigricans , with unremarkable
other systemic examination .

Deferential DiagnOSIS :-
Diabetes mellitus (Type 1, insulin dependent)
Diabetes mellitus (Type 2,–non-insulin dependent)
Diabetes insipidus
Primary polydipsia ( Psychogenic)
Renal glucosuria ( Stress , Benign glycosuria)
Electrolytes Disturbance (Hypercalcemia /
Hypokalemia) High Output Renal Failure
INVESTIGATIONS:
lab results that were done :
RBS : 342 mg/Dl
Urine dipstick : glucoses (3+)and Ketones (–ve) and others are –ve
VBG :
CBC:
LFT and RFT:
Other labs that should order:

Hemoglobin A1C level : 9%

TFT: TSH: 5.43 mU/L
TFT: T4: 21 pmol/L
TFT: T3: 7.75 pmol/L
ADMISSION DIAGNOSIS :-
Newly diagnosed DM Type 1 , not in DKA

HOSPITAL COURSE :-
patient admit to pediatric medical ward as newly diagnosed DM Type 1
not in DKA Allow oral intake on (diabetic diet ) & diabetic education for
mother.
To Check RBS pre meals , 2 p.m. and 10 p.m.
The child started on S.C insulin
Triseba (12 IU) S.C OD
NoVo rapid (4 IU pre-breakfast )(4 IU pre-lunch)(3 IU pre-dinner) S.C
If pre-meals (RBS more than 250 mg/dl) give (1 IU) extra from NoVo
rapid insulin S.C
If (RBS more than 350mg/dl) do VBG & Urine dipstick
1ST day of admiSSion (10/1/2023)
Subjective:
A 102 year old girl presented with Polyuria, polydipsia and nocturia for 2
weeks .
No associate symptoms , other systemic review unremarkable.
Admit as newly diagnosed DM Type 1 not in DKA
She is doing well , no fever , with full oral intake on diabetic diet and
tolerating , still there is polydipsia , polyuria , and nocturia
.
Objective:
Vital signs:
Temperature : 36.8°C
Oxygen saturation : 94% at room air
Respiratory rate : 22 breaths/min
Heart rate : 130 beat/min
Blood pressure : 115/75 mmHg
Systemic exam:
she is conscious , alert and oriented (to time , place & person) , looks
well, not in respiratory distress and there is no signs of dehydration .
she is connected to IV cannula at right hand.
Chest : equal air entry bilaterally , no add sounds
CVS : normal heart sounds , no murmur
Abdomen : is soft and lax , no tenderness or
organomegaly CNS : GCS 15/15 , normal power , tone ,
and reflexes
Assessment and plan:
Child clinically was stable ,no new active issue apart from high
RBS
RBS: at the end of day is 151 mg/dl
Plan :
Teach mother about DM type 1 by diabetic educator
Continue Lantus insulin 12 IU S.C at 7:47 am
NoVo rapid (4 IU pre-breakfast )(4 IU pre-lunch)(3 IU pre-dinner)
S.C Blood sugar monitoring pre meal , at 2 pm and 10 pm
Follow HbA1C and TFT result
D/C Lantus insulin at 12:00 pm
Triseba insulin 12 IU S.C OD at 12:00 pm
Thyroid US
2nd day of adMISSion (11/1/2023)
Subjective:
A 120 year old girl , previously healthy
admit as newly diagnosed DM Type 1 not in DKA
Today , she is fine , no fever , no active complaints , with good appetite and
activity .
The child was seen by dietitian and diabetic educator , mother is educated
and she is the one giving insulin injection to the patient independently and
she is confidant now regarding how to deal with the disease during hypo &
hyper glycemia and the importance of compliant to diet and medication in
preventing future complication , and the importance of regular clinic follow
up .

Objective:
Vital signs:
Temperature : 36.5°C
Oxygen saturation : 95% at room air
Respiratory rate : 26 breaths/min
Heart rate : 1130 beat/min
Blood pressure : 108/65 mmHg
The child was seen she looks well , afebrile , not distress with stable vital
signs Chest : equal air entry bilaterally , no add sounds
CVS : normal heart sounds , no murmur
Abdomen : is soft and lax ,no tenderness or organomegaly
CNS : conscious and alert , no neurological deficit

Assessment:
Patient is improving , and mother is involved in her child
care HbA1C is 9 % and TFT result: TSH: 5.43 mU/L
. TFT: T4: 21 pmol/L
. TFT: T3: 7.75 pmol/L
Just still there is high RBS reading but compared to yesterday is coming done
 plane:
Triseba insulin 12 IU S.C. OD at 7:40 am
NoVo rapid (4 IU pre-breakfast )(4IU pre-lunch)(3IU pre-dinner) S.C
Dietitian counseling
Request at 12:26 pm of: Vit D
Request at 12:26 pm of: Bone profile
Request at 12:26 pm of: TFT

discharge home on : 11/1/2023

Triseba insulin 12 IU S.C OD at 12:26 pm
NoVo rapid (4 IU pre-breakfast )(4 IU pre-lunch)(3 IU pre-dinner) S.C
DISCHARGE SUMmary:-

Brief history :-
a 12 year old , Saudi , girl presented with Polyuria, polydipsia and nocturia
for 2 weeks , she had history of weight loss for the last month but no fever
or recent history of infections . No associate symptoms , other systemic
review unremarkable.

Physical examination :-
she was conscious and alert , looks well, with normal growth parameter ,
no signs of dehydration , no Acanthosis nigricans , with unremarkable
systemic examination .
Investigation :-
Her initial RBS : 342 mg/dl
Urine dipstick : glucoses (3+) and Ketones (–ve) and others –ve
On discharge repeat Urine dipstick : glucoses (3+)and Ketones (0)
others –ve
VBG :-
PH : 7.36
PCO2 : 39 mmHg
HCO3 : 20.6 MMOL/L
HbA1C : 9%
TFT : Abnormal need further investigations.

Diagnosis :-
Newly diagnosed DM type 1 , not in DKA .
Course in the hospital :-
patient was admit to pediatric medical ward as newly diagnosed DM Type 1
not in DKA for education and started on insulin injection S.C (0.7 IU/kg/day)
initially but blood sugar was still high so, the dose of Lantus was adjusted
and change to Triseba
also , patient was seen by diabetic educator and dietion for education
After that , the child improved with resolved symptoms and after achieved a
good blood sugar control .
Plan :-
Triseba insulin (12 IU) S.C OD
NoVo rapid insulin (4 IU pre-breakfast )(4 IU pre-lunch)(3 IU pre-dinner)
S.C pre- meals