Diabetes
Mellitus
Gill
is a 7-year-old Indian girl with a background history of IDDM now presenting
with a 2-day duration of abdominal pain.
HISTORY
Presenting
complaint
Gill
had been having on-off episodes of abdominal pain since she was diagnosed with
IDDM at 3 years of age. She never had a previous hospital admission for
abdominal pain. This present episode of abdominal pain occurs 2 days ago. It is
localized to the right iliac fossa with no radiation to other parts of the
abdomen. The pain is of a colicky nature and occurs intermittently. There are no
relieving or precipitating factors. She has no vomiting, diarrhoea, headache,
loss of consciousness, deep sighing breathing (Kussmaul�s breathing) or other
signs of DKA. She was diagnosed to have gastroenteritis and was kept under
observation in the ward for 3 days.
Initial
diagnosis of diabetes
Gill
was diagnosed to have IDDM at 3 years of age. She presented with polyuria,
polydipsia, nocturia and a weight loss of 23 kg to 15 kg 3 months before the
diagnosis. Her parents also noticed that she had seemed to lose interest in her
daily activities, looks lethargic and is easily irritable. She was seen by the
polyclinic and referred to NUH after a urine dipstick test shows the presence of
glucose in her urine. After the diagnosis, her family was given counseling and
education on IDDM and its management by a dietician and a diabetic nurse.
Progress
of disease
Gill
had 5 episodes of hospital admissions for hypoglycaemia, but her father was not
able to recall the admission dates and the length of stay. She was usually given
glucose and glucagon to correct the hypoglycaemia and discharged after a few
days. She has no complications of IDDM such as blurring of vision due to
cataracts or retinopathy, joint problems with limited joint mobility or renal
problems. Neither does she has any complications of the treatment such as
localized fat hypertrophy, insulin allergic reactions or episodes of
ketoacidosis and hypoglycaemia. She does not have other associated autoimmune
diseases such as Hashimoto�s disease, Addison�s disease and pernicious
anaemia. She was on 3-monthly follow-up with Prof Loke Kah Yin for her IDDM
where her glucose level will be monitored and a yearly check-up for assessment
of her vision, blood pressure and renal status. There were no changes in the
management since she was diagnosed and her father is still responsible for
giving her insulin.
Current
status
Gill
appears to be well and energetic. She is now on Actropid and Insulatard, 3 times
daily before breakfast, dinner and sleep with the following dosages
respectively: 3 units of Actropid & 10 units of Insulatard before breakfast
and 2 units and 3 units of each before dinner and sleep. Her father has been
giving her the insulin on time and she is compliant with the medication. He
usually injects them into the abdomen. Gill did not adhere to any specific diet.
Her father forbids her to eat sweet foods like ice-cream, sweets, chocolates and
tibits and will only allow her small portions once a week. She is an obedient
child and listens to his father�s instructions. Her father monitors her blood
glucose levels 4 times a day using a glucometer and whenever she developed signs
of hypoglycaemia such as sweating, headache and lethargy. He would administer IM
glucagon into her thigh when the blood glucose level is below 1.5 mmol/L. These
episodes occurred 6 to 7 times a month. There were no other signs of
hypoglycaemia such as vomiting, convulsions, loss of consciousness or dizziness.
Her IDDM is well controlled as her blood glucose levels are usually kept within
the range of 5 to 9 mmol/L. She is now in primary one and did not ever miss any
school because of poor health except when for her medical appointments at NUH.
She is doing well in her studies and has been passing all her tests.
Social
Gill is an obedient and understanding child. She understands that because of her illness, she is not able to live a normal lifestyle as other children in the way that she has to have daily injections of insulin and she is not able to eat sweet foods as often. She is an active, energetic and outgoing child and her illness does not affect her social life in any way as she has many friends in school who are truly concerned for her welfare. She is the only child of the family. Her medical bills inclusive of the medication amounts to a few hundreds a month. Her father is using his Medisave to pay for her expenses supplemented by some contribution from the MSW. Her father is working as a Fire Security Officer at Suntec City. He has to take frequent leaves to attend to his child and he says that his employers are not very understanding towards him. His father will attend the clinic with Gill without fail and also support group and education sessions conducted by NUH.
Family
Gill�s
paternal grandmother has IDDM and her grandfather has NIDDM. Her parents does
not have DM or any other associated autoimmune diseases. The family is currently
coping well with Gill�s disease though her father wishes they can receive more
financial support from the MSW.
PHYSICAL
EXAMINATION
Gill
is well, alert, comfortable at rest and able to respond to speech in full
sentences. Her paramenters are between the 25th and 50th percentile of her age
group. Her vital signs are stable. She is well hydrated and nourished. There
were fingertip pricks and plasters on both forearms. There are no trophic
changes or cutaneous infections.
She
has no squint or cataracts. Examination of her eyes reveals no abnormalities.
Her thyroid was not enlarged. Examination of the abdomen reveals 6 injection
sites as evidenced by needle pricks on the skin. There were no signs of fat
atrophy or hypertrophy.
I
would like to request for her latest glucometer readings and urinalysis results.
SUMMARY
Gill
is a 7-year-old Indian girl with a background history of IDDM which is well
controlled with no complications of the illness or treatment, now presenting
with a 2-day duration of abdominal pain with no signs of DKA and being diagnosed
as an innocent gastroenteritis. She is currently under observation in the ward
and appears to be in good health.
MANAGEMENT
IDDM
is a chronic lifelong condition which can give rise to many complications with a
high morbidity rate is if is not well-controlled. Its management involves the
use of insulin, diet and regular exercise with the following aims:
1.
Control of blood glucose level, maintaining close to normoglycaemia.
2.
Prevention of acute complications such as DKA and hypoglycaemia.
3.
Ensure optimum growth and development.
4.
Normal unrestrictive lifestyle.
5.
Adequate education of patients and parents.
6.
Early detection and treatment of associated features, e.g. Hashimoto
thyroiditis.
Gill�s
father has been her primary care-giver all along. He must be placed in the
driver�s seat in the management of Gill�s IDDM and be actively involved in
all decision-making and discussion with the doctors. He should be given adequate
education on the daily monitoring of blood glucose level, administration of
insulin and detection of signs of hypoglycaemia or DKA which he has been well
taught by the nursing staff and doctors of NUH and the experience he gained over
the years through caring for Gill. As Gill becomes older, she should gradually
be involved in her own management and be taught how to give her own insulin and
take for herself. Issues such as peer acceptance, increased expectations of life
and seeking independence and own lifestyle will become more important. Gill
should be educated on how she can live a life as normal and unrestrictive as
anybody else her age without compromising on her management. She should be
introduced to Diabetic support groups where she can know other peers with the
same disease. This can help to improve living with DM and is a good way to learn
more about living and coping with the disease together. She should continue her
3-monthly appointment with Prof Loke and yearly assessment for eye examination
and renal status to detect any arising of possible complications and to treat
them at an early stage to prevent deterioration.
CONCLUSION
IDDM
is a life-long progressive illness and its successful management not only
requires a multi-disciplinary team involving the doctor, nurse, dietician and
maybe the medical social worker and psychotherapist, much of it also revolves
its daily management by the patient himself or his primary care-giver. Certain
issues not seen in adult patients are the management of the psycho-social
aspects of the patient�s life as he or she becomes older and may have a
different perception of his/her disease and expectations. Adolescence is a
period when teenagers seek a sense of self-identity and they may find the
treatment interfering with the lifestyle they aspire to and such conflicts must
be resolved before they lead to non-compliance and neglect.