Name: JAR

Age: 7 year old/Male

Address: Mandaluyong City
Informant: Mother
Reliability: Good

Chief Complaint: Difficulty of breathing

History of Present Illness:

One year and 4 months prior to admission (PTA), he had unintentional weight loss and polyuria (>10 times
per day). Consult was done with a general pediatrician where CBG was high hence sent to the emergency
room and was subsequently admitted at the intensive care unit as a case of diabetic ketoacidosis and
diabetes mellitus type 1. He was discharged stable after five days, maintained on insulin aspart 0.8u/kg/day
and advised 3-point CBG monitoring with pre-meals ranging from 63- 110 mg/dL.

Interim showed he was still compliant with insulin administration, however was lost to follow up since he
was asymptomatic and CBG monitoring was discontinued. His diet during this time consisted of mostly
sweets as he would sneak eating candies and chocolates for his snacks.

One week PTA, had decreased activity and was noted to be weak looking with sunken eyeballs. No other
symptoms at that time. CBG was done which was 527 mg/dL hence was given due dose of insulin. No
repeat CBG was done after.

Interim, he had improved appetite and activity. No consult was done.

One day PTA, he had four episodes of vomiting of previously ingested food, non bilious, non projectile
amounting to 2 cups in total, with generalized vague abdominal pain. CBG was 293 mg/dL and was
subsequently given his due dose of insulin. No repeat CBG and consult was done.

Nine hours PTA, he had decreased activity and appetite with CBG’s of “HIGH” on 2 successive readings.
Insulin was given and repeat CBG was 500 mg/dL. Still no consult was done.

Two hours PTA, had difficulty of sleeping due to difficulty of breathing hence was brought to the emergency
room.

Review of systems:
• General: (-) fever, (-) weight loss/gain
• Cutaneous: (-) rashes, (-) pruritus
• HEENT: (-) headache, (-) dizziness, (-) eye itchiness, (-) redness, (-) discharge, (-) ear pain, (-) aural
discharge, (-) nasal congestion, (-) epistaxis, (-) sore throat
• Respiratory: (-) cough, (-) colds
• Cardiac: (-) cyanosis (-) easy fatigability
• Gastrointestinal: (-) diarrhea, (-) constipation
• Genitourinary: (-) dysuria, (-) frequency, (-) urgency
• Neurologic: (-) tremors, (-) loss of consciousness, (-) seizure, (-) behavioral change
• Musculoskeletal: (-) limitation of movement, (-) bone, joint or muscle pain
• Hematologic: (-) easy bruisability, (-) gum bleeding, (-) pallor

Past medical history:

Immunizations:

Claims to be updated until 1 year old with no booster doses at a local health center

Nutritional History
24 Hour Food Recall:

Food intake Calories

Breakfast 1 cup lugaw + egg 160 + 90
Lunch Maling (luncheon meat) + 11/2 150+240
cup rice
PM snacks Peanuts (1/2 cup) 250
Dinner Sinigang + 1 cup rice 250+160
ACI 1300 kcal
RENI 1600 kcal
% 19%
deficiency

Feeding history: eats homecooked meals but not fond of vegetable. Eats chocolates/sweets at least 2x
per day. Water intake per day is approximately 1 liter.

Previous Disease: None

Previous accidents: None
Previous blood transfusion: None
Previous Surgeries: None

Family History:
(+) Diabetes mellitus Type 2- maternal grandmother; on Metformin
(-) Hypertension/Cardiovascular diseases
(-) Allergies/Asthma
(-) Tuberculosis
(-) Kidney Diseases
(-) Cancer/Malignancies
(-) Blood dyscrasia

Family Profile:
Age Occupation Health Status

Father 31 Businessman Asthma

Mother 29 Teacher Healthy

Socioeconomic and environmental history:

Originally from Bulacan but since January 2021, lives in a condominium unit in Mandaluyong City with both
parents, brother, maternal aunt and uncle. Has 2 pet dogs, no exposure to cigarette smoke, does not live
near busy roads/factories. Water source is from a refilling station. Garbage segregated and collected daily

Physical Examination:
General Survey: conscious, coherent, in distress (Kussmaul’s breathing), ill-looking, moderately
dehydrated, undernourished, carried
Vital Signs: BP 90/60 mmHg HR 128 bpm RR 37 cpm Temp 36.9 SpO2 91%
Anthropometrics: Wt 19.6kg (z at -2) Ht 113cm (z below -2) BMI 15.3 (z below 0)
Skin: warm, moist, no active dermatoses
HEENT: (+) sunken eyeballs, pink palpebral conjunctivae, anicteric sclerae, 2-3mm ERTL, (-) tragal
tenderness, nonhyperemic external auditory canal, intact tympanic membrane, septum midline, non-
congested turbinates, no nasal discharge, (+) dry lips and mucosa, (-) sores or ulcers, tonsils not enlarged,
non-hyperemic posterior pharyngeal wall, (+) dental caries
Neck: no palpable lymph nodes, thyroid gland not enlarged
Chest/lungs: symmetrical chest expansion, no retractions, clear breath sounds
Heart: adynamic precordium, (-) heaves/lifts/thrills, (-) murmurs
Abdomen: flat, normoactive bowel sounds, tympanitic on all quadrants, soft, (+) direct tenderness over the
epigastric area
Extremities: warm extremities, pulses full and equal, CRT <2s

Neurologic Examination:
Cerebral: conscious, coherent, oriented to 3 spheres
Cranial Nerves:
CN I – intact
CN II – pupils 2-3 mm, ERTL
CN III, IV, VI – EOMs full and intact
CN V – no sensory deficits on V1 V2 and V3, muscle of mastication intact
CN VII –able to smile, frown, raise eyebrows, no facial asymmetry
CN VIII – gross hearing intact
CN IX, X – uvula midline, (+) gag reflex
CN XI – can shrug shoulders; turn head side to side against resistance
CN XII – tongue midline
Motor: MMT 5/5 on all extremities
Cerebellar: no dysmetria, no dysdiadochokinesia
Sensory: no sensory deficits on all extremities
Reflexes: DTR ++ on both upper and lower extremities
Meningeal: (-) Nuchal rigidity (-) Brudzinski (-) Kernig’s

Course in the ward:

At the emergency room, spot hgt was 454 mg/dL and he was placed on NPO. He was hooked to O2 support
at 10 lpm and PNSS 10 mL/kg over 1 hour was given. Ancillaries requested included arterial blood gas,
CBC, urinalysis, serum Na and K, BUN and creatinine, 15L ECG and portable CXR. Repeat CBG after 1st
hour of hydration was 401 mg/dL then PNSS at moderate rate + 20 meqs of KCl and insulin infusion at
0.1u/kg/hr were started. CBG monitoring was continued every hour. Succeeding CBG’s on the 3rd and 4th
hour of hydration was 339 and 321 mg/dL, respectively. On the 5th hour of hydration, CBG was 181 mg/dL,
hence IVF was shifted to D5NSS at moderate rate + 20 meqs KCl. He was not in distress hence O2 support
was decreased as tolerated to 6 lpm. On the 6th hour of hydration, CBG was 79 mg/dL with urine output of
5 ml/kg. Insulin infusion was stopped and losses in urine output in excess of 4 mL/kg was replaced with
PLRS. Repeat CBG on the 7th hour of hydration was 67 mg/dL. He was then transferred to the pediatric
intensive care unit (PICU).

On the first PICU day, he was conscious, coherent, not in distress and well hydrated. Vital signs were
normal and CBG’s at the 8th to 10th hour of hydration were 113, 131, 98 mg/dL, respectively. Weaning off
O2 was continued as tolerated and insulin infusion was resumed at 0.05 u/kg/hr. Repeat ABG, serum Na
and K, and CBC were done. On the 11th hour of hydration, CBG was 68 mg/dL hence D50W at 1 mL/kg
per slow IV push was given. Repeat CBG after 30 minutes was 190 mg/dL and insulin infusion was stopped.
On the 13th and 14th hour of hydration, CBG’s were 220 and 250 mg/dL respectively, hence insulin infusion
at 0.05u/kg/hr was resumed. The succeeding CBG’s were as follows:

15th hour 260 mg/dL

16th hour 207 mg/dL

17th hour 149 mg/dL

18th hour 103 mg/dL

 19th hour 94 mg/dL

20th hour 81 mg/dL

Repeat ABG was done and insulin infusion was shifted to subcutaneous insulijn of 5 units every 6 hours.
Diet was resumed to soft diet and CBG monitoring was decreased to every 2 hours.

On the second PICU day, he was asymptomatic and tolerated soft diet, hence diet was progressed. Repeat
ABG and serum Na and K were done. IVF was shifted to plain 0.45% NaCl at maintenance rate + 40 meqs
KCl (TFR-oral). SC insulin was continued every 4 hours with CBG’s ranging from 95 to 165 mg/dL.

On the 3rd hospital day, he was transferred to the regular ward. CBG monitoring was decreased to every 6
hours with ranges of 101-197 mg/dL. Repeat electrolytes were done and 2 doses of KCl powder was given.
SC insulin was shifted back to insulin aspart 0.9u/kg/day. Repeat electrolytes was done on initial K
correction. Three more doses of KCl powder was given and bananas were included in the diet. IVF was
was then discontinued.

On the 4th hospital day, he referred to the DM center and subsequently discharge stable and asymptomatic
with take home medication of insulin aspart 0.9 mg/kg/day.

LABORATORY RESULTS:

Labs on admission:
CXR: Normal

Repeat ABG:
1st PICU day 2nd PICU day

pH 7.363 7.453

pCO2 22.7 27.7

pO2 120.8 105.5

SpO2 98.5 98.2

HCO3 13.1 19.6

BE -12.5 -4.5

Repeat Serum Na and K:

2nd PICU day 3rd PICU day #1 3rd PICU day #2

Na 137 136 141

K 2.89 2.97 3.21