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061215101861
11Y 3M / MALE / INDIAN
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EMR Patient Dashboard Clinical Note Inpatient Patient History Session : ACTIVE User : NURAIN BINTI OTHMAN

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PATIENT HISTORY
Reason of admission:

Admission:
s/b Dr Tae SK

11 years 3 months old boy

CW 28kg

U/L:
1) Type 1 DM (diagnosed since March 2014)
- presented with hyperglycaemia without DKA
- Autoantibodies positive
- admitted to 5PB on 11/2/18-15/2/18 for diabetic education

Currently on
s/c lantus 14unit ON
s/c actrapid 6unit TDS
s/c novorapid 6unit TDS

Weight in Feb 2018: 28kg

Weight today 28kg

Issue: Moderate DKA

This is first episode of DKA
initial presentation was without DKA

Came due to being unwell for past 3 days

Mother noted lethargy and vomiting each day
No fever
No cough/rapid breathing
But complaining of shortness of breath and chest pain
Mother doesn't recall if there is any increase frequency of urination or colour of urine

Child has been giving himself insulin for past 3 days despite reduced appetite
Mother recalls child taking one bowl of rice with side dish after s/c lantus and actrapid (morning and afternoon dose)
However will vomit in the evening
Vomitus - food particles and phlegm
Child became increasingly tired and lethargic today

Blood glucose monitoring (checked from the glucometer as they did not bring book)
Reflo since 1/3-17/3 pre breakfast 3.3-22.7 pre Research
tea (10amFolder
meal) 6.4 -18.4 pre lunch 21.7 Referral
Notifications OT Booking Order Report/Result

For past 3 days

20/3 : LO (mother informed she gave child food when low - pre 10am meal)
21/3 18.8 (pre 10am meal)
22/3 12.1 (pre 10am meal)
23/3 - didn't check
24/3 pre breakfast HI pre lunch LO pre dinner HI
Last insulin 7unit given at 8pm because glucometer reading was HI but child didn't take any food
Reflo checked in ED 26 (using ED glucometer - using own glucometer was 22.6)

Reflo is 22 --> post hydration 15 (on 7.5% correction over 48H with maintenance 1/2NS)
subsequently add on 1/2NSD5% --> reflo furtehr dropped to 11.2

ketone remains 6

last urine output at ED around 11pm - mother claimed large amount, not able to quantify
since admission, no PU yet

no insulin/boluses given in ED

given IVD NS 70ml/hr (maintenance drip)

ABG: pH 7.208 pCO2 26.9 pO2 25.3 Lac 2.7 HCO3 11.7 BE -16.1
Blood ketone stat (using strip) 6.7
Urine dipstick stat ketone 4+
(moderate DKA)

History of Present Illness:

Social History

Social history
Mother works shift from 4pm to 4am
Usually child injects himself insulin supervised by grandmother
Child himself checks glucose using glucometer
Previously in school, he will skip insulin at 10am tea time because doesn't want to inject in school, therefore pre lunch glucose can be raised up to 21.7

Previous Investigation

Na 131
K 3.9
Ca 2.5
Mg 0.8

Urine ketone 4+ at 2312H

Diagnosis:

Moderate DKA;

Investigation/Plan:

change to NSD10 + 1.5g KCL in each pint for maintenance drip at 70cc/H
cont 7.5% correction over 48 hours - run at 44cc/H NS (started at 12am 25/3/18)
reflo hourly
strict I/O charting
RP, urine/blood ketone, blood gas 4 hourly
hourly GCS charting
no need to insert CBD now (pt obeying command, mother not keen for CBD)
start IVI insulin 2.8 Unit/H (= 0.1 unit/kg/H)
if reflo is less than 15, or drop more than 5mmol/L/H to further increase dextrosity in maintenance drip
adjust K in drip according to RP
adjust correction fluid according to corrected serum Na
update endocrine team tomorrow
cont augmentin
for blood taking line

Completed by: DR. AISYAH BINTI JAAFAR, PEGAWAI PERUBATAN SISWAZAH UD41, JABATAN PEDIATRIK, 25/03/2018 03:11
Lastupdate by: DR. AISYAH BINTI JAAFAR, PEGAWAI PERUBATAN SISWAZAH UD41, JABATAN PEDIATRIK, 25/03/2018 05:18

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