Case Reflection
By: Thanuja, Nora, Ju Yu, and Imaad
Overview
Presenting Complaint
Investigations
Management
Reflection
Case Vignette
12 year-old girl presented with generalised abdominal pain and vomiting.
History taken on 25/1/2022
Any differentials?
History Of Presenting Complaint (HOPC)
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Abdominal pain and vomiting happened at night around 8.30pm
Vomited
○ 12 times.
○ Mainly food content.
○ No blood/bile. (She ate at 4.30, started vomiting around 8.30)
Abdominal Pain
○ Generalized
○ Continuous
○ Pain scale 9/10
○ Nothing worsened/relieved the symptoms
○ Felt burning sensation but it reduces after each vomiting episode
HOPC
● Next day did not go to school. Straight to clinic. Was given antiemetics, pain
relievers and ORS
● Condition deteriorated further later that day. Started experiencing dyspnoea,
dizziness, palpitations. Urine output decreased.
● No diarrhea and said mouth was not dry
● Father brought her to hospital kluang ED. She was immediately warded on that
day.
● Blood tests taken. Child has high glucose and acidosis
● First day of admission, glucose reading was 24.8mmol (as of 23/1/2022)
● Further questioning, mom admitted polydipsia and polyuria since December
Birth History :●
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2.9kg
Full term baby born at 38 weeks
Vaginal delivery with labour induction
Admitted to NICU for 2 days for Jaundice
Immunization History :●
Up to date. Completed COVID-19 vaccines.
Diet History :●
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Mom said child used to be a picky eater and had to give appetite stimulating vitamins (started around 4 years old
and stopped it when she turned 7)
Generally eats home cooked food
Prefers to eat rice based foods
Admits to snacking a lot as parents are in the vending machine business
Loves canned drinks
Has the freedom to buy whatever she likes in school canteen
Social History :●
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Total 5 people at home . She lives with both parents and her two younger sisters
Father works in the vending machine business
Mother is a housewife
Household income is roughly RM8000 per month. No financial difficulties.
At school, she is able to cope with studies. Interacts with teachers fine. Generally talks to her
classmates but does not have any close/best friends. Mom says she has a shy personality.
Past Medical History :●
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Was previously admitted at hospital Kluang when she was 1 years old for swallowing a coin.
Was given liquid paraffin and passed the coin through faeces
No surgical Hx
Drug History :- NIL/NKDA
Family History :- Mom has HTN. Maternal grandfather has T2DM.
ICE : NIL
Systemic Enquiry: NIL
Diagnosis: Diabetic Ketoacidosis (DKA)
Currently
Weight : 31kg
Height : 145cm
3rd day on ward. (Day of clerking 25/1/2022)
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On insulin actrapid
On fluids 10% NaCl/dextrose +KCl
Fasted for 3 days. Started eating a little on day of clerking
Glucose reading on day of clerking 6.8mmol
Follow up next day (26/1/2022)
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Followed ward round
Consultant decided to start child on subcutaneous insulin (Insulatard if not
mistaken)
He was stopping her fluids. Just on KCl twice daily on that specific day
Pharmacist was instructed to explain insulin regimens to mom and child
(Counselling)
Dietician was scheduled to meet mom and child on that day to discuss meal plans
(Carbo-counting)
Child appears less weak and pale on this day
Examination
General Inspection : She looked weak and slightly pale. Was on fluids and IV insulin.
Continuous BP monitoring and catheter was inserted
Vitals :BP 114/85 HR:80 RR:14, warm peripheries, no cyanosis
Cardiovascular: Dual Rhythm No Murmur (DRNM)
Respiratory: Vesicular breathing. No added breath sounds
Neurological : (Ideally should have done)
Abdominal : Soft Abdomen, No pitting edema
Investigation
Blood
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FBC
U’s & E’s
Blood Glucose
Blood Ketones
HBA1c for monitoring
Others
● Strict Fluid Input/Output Chart
Management
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Biological
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Psychological
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Insulin
■ 1 long acting dose + 1 short acting dose
Fluids (Normal Saline +KCl)
Diet Control
■ Regular Meal Timings
Referral to therapeutic counselling to ease patient anxiety and worries avout their condition
Social
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Informing school about diagnosis and procedures involved in cases of emergencies (i.e,
hypoglycaemia episode)
REFLECTION
Dose Reduction
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Aimed due to the hormonal imbalances that occur during puberty
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High insulin levels -> more testosterone from ovaries -> more facial hair and acne
High insulin levels -> lower sex hormone binding globulins -> oestrogen excess -> heavy
menses, fibroids
May cause variability in blood sugar readings
Other considerations when Prescribing
1. Psychosocial
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Age - Patient is 12 years old and therefore, attends school.
i. She might not want to take medication at school in front of her peers
How does this condition affect her mental and physical state
Cost of medication
Drug interactions
2. Patient counselling and check knowledge
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The doctor understood what the patient was experiencing and adjusted the
dosage to suit her
Good patient understanding improves compliance and patient-doctor relationship
3. Patient’s ability to live a normal life
Counselling
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Provides opportunity to assess
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Patient Understanding
Laying out the procedures and intricacies involved
Clarifying patient and caretaker’s ideas, concerns and expectations in regards to the
management
Allows information about support groups and other MDT members to achieve
optimal control of patient symptoms
Thank You for
Listening