EL Dr. Ayu Wirastiti 25.03 PK 18.00

LONG CASE REPORT
SUSPECT TYPE 1 DIABETES MELLITUS (E10) DIFERENTIAL

DIAGNOSIS TYPE 2 DIABETES MELLITUS, AKI INJURY,
CLINICALLY DOWN SYNDROME, WELL NOURISHED, SHORT
STATURE
By:
Ni Made Ayu Wirastiti
Local Evaluation
Denpasar, April 1th, 2019
POSTGRADUATE PEDIATRIC TRAINING PROGRAMME

DEPARTMENT OF CHILD HEALTH
FACULTY OF MEDICINE UDAYANA UNIVERSITY/
SANGLAH HOSPITAL DENPASAR
2019
I. Identity
a. Patient identity
Name : NKGC
Age on case determination : 14 years 7 months old
Date of birth : August 25th, 2004
Sex : Female
Address : Indonesia
Date of admission : March 21st, 2019
Date of case determination : March 22nd, 2019
Medical record number : 19012697
b. Parents identity
Father Mother
Name (initial) IWS NS
Age 54 years old 37 years old
Education Uneducated Junior high school
Occupation Farmer Farmer
II. History Taking (Subjective)

History of illness was taken from the parents.
1. History of present illness
Chief complaint: high blood glucose level
Patient was referred from T State Hospital with diagnosis of post diabetic
ketoacidosis. She was referred for further management of blood sugar.
Patient arrived at pediatric emergency unit with chief complaint of high
blood sugar initially noticed since 4 days before admission to hospital. At
that time, she was taken to T Hospital due to weakness of the body and
decrease of consciousness. After being treated for four days, her
condition improved but the blood glucose remained high. The
measurement of her blood sugar at the time of admission to T Hospital
was 749 mg/dL.
Weakness of her body was noticed two days before admission to T
Hospital. Her parents said that at home she would most likely lie down in
1
bed. She remained alert and responsive but was unable to walk even to
the bathroom. There was no history of stomachache, vomiting, nor
shortness of breath before nor during that period of treatment.
Upon arrival to our hospital, she appeared alert and conscious, she
responded adequately to her surroundings.
Her parents noticed that she has been experiencing an increase of
urination since 1 month before admission to hospital. In one day she
would urinate up to 6-7 times. She would wake up at night frequently to
just go to the bathroom.
Her parents noticed decreased appetite since the fever started.
Before these symptoms occur, she could eat about 1,5 portions of rice
with the accompanying meals. She would regularly eat three times daily.
This eating habit started since approximately 1 year ago, and due to that
eating habit her parents noticed her figure appeared overweight.
However, since her condition deteriorated she only managed to eat half a
portion of meals.
Her figure was said to appear thinner significantly since
approximately 1 month ago. At that time they said her appetite had not
changed. However, they noticed she appears much thinner since her
appetite decreased 5 days prior to admission, but they never measure her
body weight before.
She started menstruating since the age of … teratur/tidak?
History of snoring during sleeping is denied.
2. History of past illness
Patient had never experienced similar complaints like this one
previously. Her parents were aware that her development was unlike
other children.
She was admitted to T Hospital due to decrease of consciousness and
high blood sugar level. She was treated for diabetic ketoacidosis at that
hospital for 4 days, before being referred to our hospital. The treatment
given to her included: cefotaxime 500 mg three times daily (iv) (given
2
for 4 days), ranitidine 1 ampoule twice daily (iv), and insulin drip 2
units/hours (iv).
3. Family medical history
Patient is the third child of four siblings. All her siblings are healthy.
They are 22 years old, 18 years old, and 10 years old. All her siblings are
able to interact appropriately with her.
There are no family members who have similar complaint. No
family history of diabetes mellitus or other diseases such as hypertension,
pulmonary disease, kidney disease, and liver disease were reported.
4. Social history
1. Prenatal history
She was born from a 22-year old mother with full term pregnancy.
Her mother had antenatal care with a midwife at least 4 times
throughout her pregnancy. Mother only took vitamin supplements
without any other medication. Her blood pressure was always normal,
so was her blood sugar level. There was no history of X-ray exposure,
fever, rash, pain, edema, and other illness during pregnancy.
Conclusion: no problem appeared during pregnancy.
2. Intranatal history
She was born by spontaneous vaginal delivery, assisted by doctor in a
hospital. She was vigorous and her birth weight was 3350 grams. No
history of shortness of breath, cyanotic, and jaundice were reported.
Conclusion: no problem appeared during delivery.
3. Postnatal history
She was able to suck breast milk immediately after birth. No history
of hospitalization due to jaundice, seizure, nor bleeding was reported.
Conclusion: no problem appeared during postnatal period.
4. Nutritional history
She was exclusively breastfed for six months and continued until 24
months. She started to eat soft food at the age of 6 months old,
steamed rice at the age of 9 months old, and adult food at the age of
12 months old. The food combination mainly consists of white meat,
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fish, vegetables, and fruits. She was thought to be allergic to eggs due
to experiencing itchiness of the skin after every time consuming eggs.
Prior to admission, her appetite was said to have decreased. She
usually ate one and half portion of rice but before admission she only
managed to eat half portion of rice in every mealtime with half a piece
of fried tempe and chicken. She ate 3 times the day prior to admission.
The calorie intake for 24 hours was 1770 kcal/day. Calories fulfilled
were 54% of the recommended dietary allowance (RDA).
Conclusion: decreased food intake.
5. Growth and development history
Her body weight was reported to increase throughout her growth.
Since she was 8 years old, her parents notice her body seemed
overweight compared to other children her age. However, they never
measure her body weight so they cannot be precisely sure of how
much weight she has lost after she became ill. Her parents notice her
figure is shorter than other children her age, but they also never
measure her height routinely.
Her parents understand that she had a delayed development history.
She started to be able to stand up at the age of 16 month, and started
walking at the age of 18 months. She was only able to speak a few
words at the age of 3 years old. Currently, she is able to speak simple
words like mentioning her name (“Mang”), calling her parents (“Pak”,
“Ibu”), or asking for food, and occasionally she can form a simple
sentence. She entered school for children with special needs until 5th
grade.
She isn’t generally physically active. She prefers to sit down in front
of the television and watch television programs in most of her hours at
home. She is not fond of physical activities such as playing outside the
house or being involved in outdoor games with her peers.
Conclusion: weight loss was noticed, although not objectively
measured. There is delayed development, which was
6. Immunization history
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History of immunization is as follows: BCG once with scar (1 month
old), DPT 3 times (2, 3, 4 months old), Hepatitis B 4 times (0, 2, 3, 4
months old), Polio 4 times (0, 2, 3, 4 months old), and measles once (9
months). Her mother couldn’t recall her having a booster
immunization at age 18 months. She did recalled her having one
immunization at school which was MR (1 year ago), but she had not
had her JE immunization.
Conclusion: immunization status is not appropriate with the basic
immunization requirements.
7. Basic needs history
Stimulation : she receives sufficient stimulation from her parents.
She is able to get along well with her peers. She
attended school for children with special needs at the
age of 8 years old and stayed in school until Grade
5, after which she dropped out of school due to
being unhappy because her friends were said to be
mean to her. Her last day at school was over 1 year
ago. Since then she was given stimulation at home
by her parents.
Parenting : she is the third child in her family and was born
from a happy marriage. She is loved and supported
by both parents.
Caring : she was breastfed exclusively for six months.
Immunization was received at Posyandu. Health
care was received from a midwife or doctors from
primary health care and hospital. She lives with her
parents and siblings in a permanent house.
Conclusion : basic needs history is sufficient.
8. Family socio-economic condition
She lives with her parents and three siblings in a permanent house in a
village. The building of the house was funded by a house-funding
program. The size of the housing space is approximately 30 sq.
5
meters, including a small kitchen. The bathroom is outside of the main
building. Water source is from the well, whereas electricity is sourced
from the state electricity company (PLN).
Both her parents work as farmers in another person’s farm. Average
family income per month is approximately 600.000 IDR.
The family has good relationship with the surrounding neighbours.
The patient uses government health insurance for seeking health care.
Conclusion: low socioeconomic level, patient has public health
insurance.
III. History During Admission Until Determination as Case

On the first and second day of hospitalization (March 21 and 22, 2019),
the patient looked alert, no shortness of breath was noticed, he had good
appetite, but still had excessive urination. On physical examination, he
appeared moderately ill, he was alert with level of consciousness 12/12,
blood pressure was 100/70 mmHg (50-90th percentile), pulse rate was 98
beats/minute, regular, good pulse quality, respiratory rate was 24
times/minute, regular, axillary temperature was 36.8°C, pain score
(FLACC) was 0 (no pain), fall risk (Humpty-Dumpty) was 9 (low risk to
fall), body weight (BW) was 34 kg, body height (BH) was 142 cm, ideal
body weight (IBW) was 36 kg, mid upper arm circumference (MUAC)
was 23,5 cm, nutritional status based on Waterlow was 94% (normal). On
laboratory findings, WBC 4,42 K/µL (neutrophils 3,13 K/µL (70,94%);
lymphocyte 0,66 K/µL (14,93%)), hemoglobin 7,71 g/dL (MCV 75,16 fL;
MCH 22,79 pg; MCHC 30,32 g/dL), trombosit 103,90 K/µL, serum iron
34,38 µg/dL, Total iron binding capacity 196 µg/dL, ferritin 51,57 ng/mL,
sodium 135, mmol/L; potassium 1,99 mmol/L; calcium 7,5 mg/dL;
chloride 98,1 mmol/L, ureum 22,90 mg/dL, creatinin 1,35 mg/dL, Hb-A1c
12,6%, blood glucose 473 mg/dL. Result of blood gas analysis pH 7.42,
pCO2 31,7 mmHg, pO2 190,70 mmHg, HCO3- 20,20 mmol/L, BE -4,3
mmol/L, SO2 99,3%. On urinalysis, pH was 6.50, cloudy, leucocyte (1+)25
leuco/uL, protein (1+)20 mg/dL, Glukosa (2+) 200 mg/dL, blood (1+)
6
ery/Ul, no keton was found on macroscopic examination, while urine
sedimentation showed white blood cell 10, red blood cell 11, epithel cell 5
per field of view. TSHs 2,15 µIU/mL, free T4 1,13 ng/Dl.
Echocardiography evaluation was found normal echocardiography finding.
The patient was suspect type 1 diabetes mellitus (E10) differential
diagnosis type 2 diabetes mellitus (E11), clinically down syndrome (Q90) ,
well nourished. He was given insulin short acting (novorapid) 0,05
IU/BW/hour with rate 2ml/hour, Kalium correction 0,5 mmol/BW/hour .
His maintenance fluid requirements was 1900 ml/day (fulfilled from oral
intake), calorie requirements 3430 kcal/day, carbohydrate requirements
428 grams/day, protein requirements 137 grams/day, fat requirements 114
grams/day with the following calorie diet arrangement: 20% breakfast,
10% snacks, 25% lunch, 10% snacks, 25% dinner, 10% snacks. The
patient was monitored for vital signs, urine production, fluid balance and
evaluation of blood glucose stick before insulin injection and meals. He
was planned for C-peptide examination.
IV. Physical Examination (Objective) on March 22nd, 2019

a. Present status
General condition : moderatelly ill
Level of consciousness : E4V5M6 15/15 (compos mentis)
Blood pressure : 100/70 mmHg (50-90th percentile)
50th percentile : 106/63mmHg
90th percentile : 119/77 mmHg
Pulse rate : 98 beats/minute, regular,
good pulse quality
Respiratory rate : 24 times/minute, regular
Axillary temperature : 36.8°C
Oxygen saturation : 98% in room air
Pain scale (FLACC) : 0 (no pain)
7
Fall risk (Humpty-Dumpty) : 9 (low risk to fall)
b. General status
Head : normocephaly, black hair, not easily plucked.
Face : no abnormality, no edema, dysmorphic face, no
hirsutisme, no acne
Eye : no sunken eyes, no palpebral edema, symmetrical
eyelids, no pale conjunctiva, no icteric sclera, round
pupils with both diameter 3 mm and good light
reflexes, no deviation conjugae, strabismus in both
eyes, no exopthalmos.
Ear : normal shape, no discharge.
Nose : no nasal flare, no discharge, no bleeding, no septal
deviation.
Throat : no pharynx hyperemia, tonsil T1/T1.
Mouth : no cyanosis on surrounding mouth, tongue and gum,
symmetrical corners of the mouth, no drooling, no
tongue enlargement, no white plaque on tongue and
mouth, no caries dentis.
Neck : no neck stiffness or enlargement of lymph nodes, no
acanthosis nigricans at posterior of the neck
Chest
Heart :
Inspection : precordial bulging not visible, ictus cordis not visible.
Palpation : ictus cordis was palpable in the intersection of left
midclavicular line and fourth intercostals space, no
thrill, LV lift and RV heave not palpable.
Auscultation : first and second heart sound was normal, M1>T1 and
A2>P2 regular, no murmur.
Lung :
Inspection : normal chest shaped, no pectus excavatum, no pectus
carinatum, symmetrical on static and dynamic state,
without subcostal retraction.
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Palpation : symmetrical chest movement.
Auscultation : vesicular breath sound, without crackles and wheezing
on both lungs.
Abdomen :
Inspection : no distention, superficial vein was not visible.
Auscultation : normal peristaltic sound.
Palpation : liver and spleen was not palpable.
Percussion : tympanic, shifting dullness not found.
Limbs : no edema, no cyanosis on fingers, palms were not pale,
warm on palpation, capillary refill time 2 second,
simian crease on both hands.
Inguinal : no enlargement of inguinal lymph nodes.
Buttocks : no rash.
Skin : no cutis marmorata, no makulopapular rash
Genital : labia mayora cover labia minora, pubic hair becomes
more coarse and curly, and begins to extend laterally,
no candidiasis vulvovaginalis
Neurological examination of four limbs:

Upper limbs Lower limbs
Power 555 555
Tone Normal Normal
Trophy Normal Normal
Physiological reflex Normal Normal
Pathological reflex Negative Negative
c. Pubertal status
Mammae : breast begins to become more elevated, and extends
beyond the borders of the areola, which continues to widen but remains
in contour with surrounding breast.
Pubic hair : hair becomes more coarse and curly, and begins to
extend laterally.
Appropriate with M3P3 (Tanner stage 3)
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d. Anthropometric status (based on WHO growth chart)
Body weight, weight for age : 34 kg, P<3 (underweight)
Body height, height for age : 142 cm, P<3 (underweight)
Weight for height : P25-50
Ideal body weight : 36 kg
MUAC : 23,5 cm
Nutritional status (Waterlow) : 94% (normal)
Father height : 165 cm
Mother height : 150 cm
Genetic height potential : 142,5-159,5 cm (the patient’s height
is within his genetic height
potential)
e. Developmental status
The result of PedsQL evaluation score on both the patient and the
parents is 98.37. This indicates that there is never a problem in the
child’s quality of life. In addition, the score of Pediatric Symptom
Checklist-17 questionnaire is 1.
Conclusion: there is no developmental disturbances in the patient.
V. Resume
A 14 year 7 months old boy was referred from T State Hospital
with diagnosis of post diabetic ketoacidosis. She was referred for further
management of blood sugar. Patient with chief complaint of high blood
sugar initially noticed since 4 days before admission to hospital. At that
time, she was taken to T Hospital due to weakness of the body and
decrease of consciousness. After being treated for three days, her condition
improved but the blood glucose remained high. The measurement of her
blood sugar at the time of admission to T Hospital was 749 mg/dL.
Weakness of her body was noticed two days before admission to T
Hospital. Her parents noticed that she has been experiencing an increase of
urination since 1 month before admission to hospital. In one day she
would urinate up to 6-7 times. Her parents noticed decreased appetite since
10
the fever started. Before these symptoms occur, she could eat about 1,5
portions of rice with the accompanying meals. She would regularly eat
three times daily. This eating habit started since approximately 1 year ago,
and due to that eating habit her parents noticed her figure appeared
overweight.
On physical examination, he appeared in moderately ill, level of
consciousness was 15/15, blood pressure was 100/70 mmHg (50-90th
percentile), pulse rate was 98 beats/minute, regular, good pulse quality,
respiratory rate was 24 times/minute, regular, axillary temperature was
36.8°C, and he’s well nourished based on Waterlow’s nutritional status. A
significant laboratory finding revealed Hb-A1c level 12,6%.
VI. Workup Diagnosis

Suspect type 1 diabetes mellitus (E10) dd type 2 diabetes mellitus (E11),
Clinically down syndrome (Q90), Acute kidney injury stage injury (N17),
well nourished.
VII. Problems
a. At this moment
1. Diagnosis
To establish the definitive diagnosis of diabetes mellitus and
Clinically down syndrome in this patient.
2. Management
a. Management of insulin regiment.
b. Nutrition management.
c. Self-monitoring of blood glucose.
d. Clinically down syndrome management.
3. Complications
a. Patient could suffered retinopathy.
b. Patient could suffered neuropathy.
c. Patient could suffered nephropathy.
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4. Prognosis
a. Routine monitoring of the HbA1C.
b. The possibility of experiencing growth and developmental
problem.
5. Prevention
Prevention of ketoacidosis diabetic and hypoglicemia
b. Long term
1. Management of diabetes mellitus in long term, treatment
compliance, drug adverse event, complication, risk of growth and
development impairment.
2. Intervention and stimulation focused on language sector to reach
normal milestone of development.
3. Psychological impact and quality of life of children and their
parents.
Some of these issues will be solved by journal searching using
evidence based medicine (EBM) method.
VIII. Planning
1. Medical treatment plan with insulin
i. Management of type 2 diabetes uses basal bolus insulin
administration. Provision of insulin with an initial dose of 0.05
IU/kg/hour. Preferred insulin is Humalog insulin which is a rapid
acting insulin. Currently the dose of insulin is still being adjusted.
ii. sodium replacement based on laboratory monitoring. Potassium
replacement in patients is carried out carefully according to serum
potassium levels and urine production. KCL drip is given at a dose
of 0,5 mmol / kg body weight / hour.
2. Nutrition management and dietary regulation in type I diabetes

mellitus
Provision of nutrition with calculation of caloric needs based on RDA
according to ideal body weight based on height on WHO Growth Chart.
12
Calorie distribution in 24 hours given 3 times the main meal and 3
times snack as follows: 20% of breakfast, 10% in the form of snacks,
25% in the form of lunch, 10% of snacks, 25% of dinner, 10% of
snacks. Dietary composition of carbohydrate 50%, 35% fat, and 15%
protein. Recommended diet is high in fiber and contains a low glycemic
index.
3. Planning monitoring
a. Monitoring of short-term complications that can occur in people
with type 2 DM include DKA, hypoglycemia and hyperglycemia.
The occurrence of short-term complications above is associated with
a monitor of glucose levels that must be done continously. There are
two ways to monitor daily glucose levels, namely Self monitoring
Blood Glucose (SMBG) and Continuous Glucose Monitoring
System (CGMS). Monitoring Blood Glucose is with intermittent
blood glucose monitor generally 2 - 6 times per day.
b. Monitoring and treatment of long-term complications of type 2
diabetes melitus
- HbA1c examination every 3 months for monitoring of metabolic
conditions.
- Monitoring the risk of comorbidities including macrovascular and
microvascular complications.
- Monitoring of macrovascular complications such as hypertension
and lipid profile. Screening of hypertension by measuring the
blood pressure since diagnosed and monitored every time of
follow up. If the hypertension diagnosed, ACE inhibitor is the
drug of choice. Screening of lipid profile is proceed as soon as 2
years after diagnosis confirmed, if the result normal, it can be
repeated every 5 year.
- Monitoring of microvascular complications such as retinopathy
(eyes evaluation screening every year or more often if any risk of
blindness), nephropathy (evaluate 2 years after the diagnosis
confirmed, monitoring every year, with urine examination for
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microalbuminuria) and diabetic neuropathy (as soon as 2 years
after diagnosis confirmed, monitoring the clinical sign every year,
with clinical evaluation) and other complications including
growth disorders, puberty disorders, osteopenia and cataracts.
c. Diagnosis of clinically down syndrome
- Intervention with chromosome examination
- Monitoring patient with developmental evaluation tool to
determine outcome of the therapy
4. Communication, information and education plan

a. Education about basic knowledge of type 1 or type 2 DM,
management of type 2 diabetes mellitus includes insulin
(administration, type, side effect, adjustment dose), eating
arrangements, exercise, emergency treatment of type 2 DM
complication (hypoglicemia, insulin administration during sickness)
and independent monitoring (home monitoring).
b. Exercise will help the patient to achieve ideal weight, increase heart
capacity, reduce the occurrence of long-term complications, help the
body's metabolism work that can reduce insulin demand. Monitoring
for the possibility of hypoglycemia or hyperglycemia during or after
activities is required.
c. Self monitoring is necessary because diabetes mellitus is a chronic
disease and requires lifelong treatment. Monitoring blood glucose
levels using home made tools is important to adjust daily insulin
requirements.
d. The parents should be educate about how to keep maintaining the
stimulation and routinely take the patient to do milestone evaluation
to detect further problem and determine the treatment outcome.
5. Long-term prognosis
Type 2 diabetes mellitus is a chronic disease with a good prognosis if
the patient in good metabolic control.
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6. Growth and development of the patient
Long-term problems of type 2 diabetes mellitus are not only about the
disease, but also the impact of patient’s growth and development.
Developmental screening tools showed communication disorder and
needed some intervention. Parents role to intervening patients should be
optimized by education. The outcome is patient able to cath up the
normal development milestone.
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IX. Follow Up
Day Subjective Objective Assesment Planning
(Date)
Day 1 alert, Physical examination Suspect type 1 Therapy
(March 23rd, no shortness Present status diabetes mellitus - Fluid requirements 1900 ml/day
2019) of breath, General condition : moderately ill (E10) dd type 2 (intake oral 500 ml/day, NaCL
slightly Conciousness : compos mentis diabetes mellitus 0,9% infusion 58 ml/hour)
decreased Blood pressure : 100/60 mmHg (50-90th percentile) (E11), Clinically - Potassium chloride 0,5
appetite, Pulse rate : 98 beats/minute, regular down syndrome mmol/kgBW/hour in 500 ml
frequent Respiratory rate : 26 times/minute, regular (Q90), Acute kidney maintenance fluid ~ 17
urination Temperature : 36.5oC injury stage risk mmol/hour
O2 saturation : 98% in room air (N17), moderate - Calorie requirements 2520
Pain scale (FLACC) :0 anemia hypochromic kcal/day, protein requirements
Fall risk (Humpty-Dumpty) : 9 (low risk to fall) microcytic et causa 100,4 grams/day with the
chronic infection following programme:
General status well nourished. morning
Eyes : pale conjunctiva (-), sclera icteric (-), 20% breakfast, 10% snacks
strabismus in both eyes afternoon
Thorax : symmetrical, retraction (-) 25% lunch, 10% snacks
Heart : S1S2 normal, regular, murmur (-) night
Lung : vesicular +/+, rales (-), wheezing (-) 25% dinner, 10% snacks
Abdomen : distention (-), normal abdominal sound - Insulin Novorapid 10 IU-10 IU-
Extremities: warm, CRT <2 seconds, simian crease on 10 IU subcutaneously (before
both hands meal)
- Insulin Levemir 10 IU at
Anthropometric status bedtime
BW 34 kg, BH 142 cm, IBW 36 kg, nutritional status
based on Waterlow 94% (well nourished) Diagnostic
- C-peptide examination
- HbA1c examination every 3
months
- Profil lipid examination
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Laboratory findings Monitoring
Blood glucose level - vital signs, urine production, fluid
morning 124 mg/dL, day 235 mg/dL, night 235 mg/dL, balance, blood glucose level
basal 212 mg/dL.
Complete blood count

Hb: 7,71g/dL, hematocrit: 22,44%, WBC: 5,24
10µ/µL, Platelet : 128,5 10µ/µL, Reticulocyte:
2,5%
Electrolyte
Kalium : 3,15 mmol/L, Natrium 143 mmol/L, Chlorida
103 mmol/L, Calsium : 7,6 mg/dL
Ureum : 18 mg/dL, creatinin: 1,06 mg/dL
24 hours fluid balance : -474 ml

Urine production : 1,3 ml/kg/hour
(March 24th, no shortness Present status diabetes mellitus - Fluid requirements 1900 ml/day
2019) of breath, General condition : moderately ill (E10) dd type 2 (intake oral 500 ml/day, NaCL
able to eat Conciousness : compos mentis diabetes mellitus 0,9% infusion 58 ml/hour)
and drink, Blood pressure : 100/60 mmHg (50-90th percentile) (E11), Clinically - Potassium chloride 0,5
frequent Pulse rate : 98 beats/minute, regular down syndrome mmol/kgBW/hour in 500 ml
urination Respiratory rate : 26 times/minute, regular (Q90), Acute kidney maintenance fluid ~ 17
Temperature : 36.5oC injury stage risk mmol/hour
O2 saturation : 98% in room air (N17), moderate - Calorie requirements 2520
Pain scale (FLACC) :0 anemia hypochromic kcal/day, protein requirements
Fall risk (Humpty-Dumpty) : 9 (low risk to fall) microcytic et causa 100,4 grams/day with the
chronic infection following programme:
General status well nourished. morning
Eyes : pale conjunctiva (-), sclera icteric (-), 20% breakfast, 10% snacks
strabismus in both eyes afternoon
Thorax : symmetrical, retraction (-) 25% lunch, 10% snacks
17
Heart : S1S2 normal, regular, murmur (-) night
Lung : vesicular +/+, rales (-), wheezing (-) 25% dinner, 10% snacks
Abdomen : distention (-), normal abdominal sound - Insulin Novorapid 10 IU-10
Extremities: warm, CRT <2 seconds, simian crease on IU-10 IU subcutaneously
both hands (before meal)
- Insulin Levemir 10 IU at
Anthropometric status bedtime
BW 34 kg, BH 142 cm, IBW 36 kg, nutritional status
based on Waterlow 94% (well nourished) Diagnostic
- HbA1c examination every 3
months
Laboratory findings
- Waiting for the result of C-
Blood glucose level
morning 185 mg/dL, day mg/dL, night mg/dL, basal peptide examination
mg/dL - Homeostasis model assessment-
estimated insulin resistance
Profil Lipid (HOMA IR) examination
Total Cholesterol: 100 mg/dL, HDL: 47 mg/dL, LDL:
43 mg/dL, Trigliserida 75 mg/dL Monitoring
- vital signs, urine production, fluid
24 hours fluid balance : -474 ml balance, blood glucose level
Urine production : 1,3 ml/kg/hour
(December 4, able to eat Present status diabetes mellitus - Fluid requirements 1125 ml/day
2017) and drink General condition : well (E10) differential (fulfilled from oral intake)
well Conciousness : compos mentis diagnosis type 2 - Calorie requirements 1150
Blood pressure : 100/60 mmHg (90-95th percentile) diabetes mellitus kcal/day, protein requirements 43
Pulse rate : 100 beats/minute, regular (E11), expressive grams/day with the following
Respiratory rate : 26 times/minute, regular language disorder programme:
Temperature : 36.8oC (F80.1), well morning
O2 saturation : 98% in room air nourished 20% breakfast, 10% snacks
Pain scale (FLACC) :0 afternoon
Fall risk (Humpty-Dumpty) : 14 (high risk to fall) 25% lunch, 10% snacks
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night
General status 25% dinner, 10% snacks
Eyes : pale conjunctiva (-), ikterik sclera (-) - Insulin Humalog 3 IU-3 IU-3 IU
Thorax : symmetrical, retraction (-) subcutaneously (before meal)
Heart : S1S2 normal, regular, murmur (-) - Insulin Lantus 0-0-5 IU
Lung : vesicular +/+, rales (-), wheezing (-) subcutaneously
Abdomen : distention (-), normal abdominal sound - Speech therapy (outpatient)
Extremities: warm, CRT <2 seconds
Diagnostic
Anthropometric status - Waiting for the result of C-
BW 12.5 kg, BH 85 cm, IBW 11.5 kg, nutritional peptide examination
status based on Waterlow 108% (well nourished) - HbA1c examination every 3
months
Laboratory findings
Blood glucose level Monitoring
morning 223 mg/dL, day 277 mg/dL, night 65 mg/dL, - vital signs, urine production, fluid
basal 65 mg/dL balance, blood glucose level
24 hours fluid balance : +137.5 ml
Urine production : 2.8 ml/kg/hour
(December 5, able to eat Present status diabetes mellitus - Fluid requirements 1125 ml/day
2017) and drink General condition : well (E10) differential (fulfilled from oral intake)
well Conciousness : compos mentis diagnosis type 2 - Calorie requirements 1150
Blood pressure : 90/60 mmHg (90-95th percentile) diabetes mellitus kcal/day, protein requirements 43
Pulse rate : 95 beats/minute, regular (E11), expressive grams/day with the following
Respiratory rate : 26 times/minute, regular language disorder programme:
Temperature : 36.6oC (F80.1), well morning
O2 saturation : 98% in room air nourished 20% breakfast, 10% snacks
night
19
Diagnostic
Anthropometric status - Waiting for the result of C-
BW 12.5 kg, BH 85 cm, IBW 11.5 kg, nutritional peptide examination
status based on Waterlow 108% (well nourished) - HbA1c examination every 3
months
Laboratory findings
Blood glucose level Monitoring
morning 215 mg/dL, day 107 mg/dL, night 229 mg/dL, - vital signs, urine production, fluid
basal 52 mg/dL balance, blood glucose level
Day 7 alert, Physical examination Type 1 diabetes Therapy
(December 6, able to eat Present status mellitus (E10), - Fluid requirements 1125 ml/day
2017) and drink General condition : well expressive language (fulfilled from oral intake)
well Conciousness : compos mentis disorder (F80.1), - Calorie requirements 1150
Blood pressure : 90/60 mmHg (90-95th percentile) well nourished kcal/day, protein requirements 43
Pulse rate : 98 beats/minute, regular grams/day with the following
Respiratory rate : 24 times/minute, regular programme:
Temperature : 36.3oC morning
O2 saturation : 98% in room air 20% breakfast, 10% snacks
night
20
Diagnostic
Anthropometric status - HbA1c examination every 3
BW 12.5 kg, BH 85 cm, IBW 11.5 kg, nutritional months
status based on Waterlow 108% (well nourished)
Monitoring
Laboratory findings - vital signs, urine production, fluid
Blood glucose level balance, blood glucose level
morning 95 mg/dL, day 143 mg/dL, night 104 mg/dL,
basal 94 mg/dL
C-peptide
<0.1 (0.9-7.1)

night
21
Diagnostic
Monitoring
morning 241 mg/dL, day 44 mg/dL, night 176 mg/dL,
basal 107 mg/dL
night
22
Diagnostic
Monitoring
morning 318 mg/dL,

23
X. Prognosis
Ad vitam : dubius ad bonam.
The patient currently has a good clinical condition
Ad functionam : dubius ad bonam.
Patient has no morbidity of the eyes, neurological and
kidney due to complication of diabetes mellitus.
Ad sanactionam : dubius ad bonam
The patient will have a longterm experience of insulin
deficiency that requires therapy and tight monitoring
of the blood glucose, and risk of disease
complications.
24
XI. Scheme of Ilness History
March 18th-22nd, March 25th-28th, 2019 (Day 3-6) November 8, 2017 (Day 7)
2017 March 23rd-24th, 2019 (Day 1-2)
Anamnesis Anamnesis Anamnesis

Weakness of the body alert, decreased appetite, no alert, able to eat and drink
and decrease of History of high blood glucose level, frequent
urination, Weakness of the body and decrease of weight loss. well.
consciousness
consciousness
Physical examination Physical examination
Blood pressure 100/60 mmHg Blood pressure 100/60
Physical examination (90-95th percentile), pulse rate mmHg (90-95th percentile),
Admitted to a private
Blood pressure 100/60 mmHg (50-90th percentile), 112 beats/minute, respiratory pulse rate 110 beats/minute,
hospital, diagnosed
pulse rate 98 beats/minute, respiratory rate 24 rate 28 times/minute, regular, respiratory rate 26
diabetic ketoacidosis
times/minute, regular, axillary temperature 36.5°C axillary temperature 37°C times/minute, regular,
axillary temperature 36.8°C
Laboratory findings Laboratory findings
Hb: 7,71 gr/dL, hematocrit: 22,44%, WBC: 5,24 Blood glucose level Laboratory findings
Insulin therapy 2 10µ/µL, Platelet : 128,5 10µ/µL, Reticulocyte: morning 95 mg/dL, day 143 Blood glucose level
unit/hour 2,5%, kalium : 3,15 mmol/L, natrium 143 mmol/L, mg/dL, night 104 mg/dL, morning 241 mg/dL, day
chlorida 103 mmol/L, calsium : 7,6 mg/dL basal 94 mg/dL 44 mg/dL, night 176
ureum : 18 mg/dL, creatinin: 1,06 mg/dL, mg/dL, basal 107 mg/dL
C-peptide
choleterol total : 100 mg/dL, HDL: 47 mg/dL,
LDL: 43 mg/dL, trigliserida 75 mg/dL <0.1 (0.9-7.1)
Symptoms improved Diagnosis Diagnosis
but blood glucose Diagnosis Type 1 diabetes mellitus,
Suspect type 1 diabetes mellitus (E10) dd type 2 Suspect type 1 diabetes mellitus
level remained high (E10) dd type 2 diabetes mellitus expressive language disorder,
diabetes mellitus (E11), Clinically down syndrome well nourished
(Q90), AKI risk (N17), moderate anemia (E11), Clinically down
hypochromic microcytic et causa chronic infection syndrome (Q90), AKI risk
(N17), moderate anemia Treatment
well nourished. Insulin humalog 3 x 3 IU,
hypochromic microcytic et causa
Referred to Sanglah chronic infection well nourished. insulin lantus 0 - 0 - 5 IU,
Hospital Treatment calorie diet settings: 20%
Insulin Novorapid 10 IU-10 IU-10 IU breakfast, 10% snacks, 25%
Treatment
subcutaneously (before meal), Insulin Levemir 10 lunch, 10% snacks, 25%
Insulin Novorapid 10 IU-10
IU at bedtime, calorie diet settings: 20% breakfast, dinner, 10% snacks
IU-10 IU subcutaneously (before
10% snacks, 25% lunch, 10% snacks, 25% dinner, .
10% snacks meal), Insulin Levemir 10 IU at
bedtime, calorie diet settings:
20% breakfast, 10% snacks, 25%
lunch, 10% snacks, 25% dinner,
10% snacks 25
XII. Scheme of Case Analysis
Male, 1 years 11 months

Factors
old
Risk
2nd Journal. Level of Risk Factors: maternal age at delivery > Risk Factors: lack of verbal stimulation
evidence 3B, grade of 35 years old, infection in early life
recommendation C
Clinical symptoms: thirsty,

Diabetes mellitus Can only say one
Problem
frequent urination and

specific word
weight loss
Laboratory finding:
random blood glucose,
HbA1c ↑
Diagnosis
Clinical symptoms: thirsty, frequent

Denver, KPSK, Cat- Expressive language
urination and weight loss Type 1 Diabetes
Mellitus Clams test disorder
Laboratory finding: random blood glucose,
HbA1c, and C-peptide
Therapy
Definitive therapy Monitoring therapy Treatment of long-term Stimulation

complication
1st Journal. Level of Metabolic control

evidence 1b, grade of 3rd Journal. level of evidence 2b,
Prognosis
recommendation A grade of recommendation B

Optimal growth
Quality of life Ad vitam: dubius ad bonam
Ad functionam: dubius ad bonam and 26
th
4 Journal. level of evidence 3b,
Ad sanactionam: dubius ad bonam Stimulation, development
grade of recommendation C
parenting, caring,
XIII. Case Analysis
Diabetes mellitus (DM) is a disorder of the metabolic homeostasis
controlled by insulin resulting in abnormalities of carbohydrate and lipid
metabolism. There are two main types of diabetes mellitus: Type 1 diabetes
( also called juvenile-onset diabetes melitus and insulin-dependent diabets
melitus), is caused by an absolute insulin deficiency, the result of a loss of
the insulin insulin-producing beta cells of the pancreas. Type 2 diabetes,
also called non-insulin dependent diabetes mellitus (NIDDM), is caused by
decreased sensitivity of target tissues to insulin. The effect of lack insulin or
insulin resistance on glucose metabolism is to prevent the efficient uptake
and utilization of glucose by most cells of the body, except those of the
brain. As a result, blood glucose concentration will increase, cell utilization
of glucose falls increasingly lower and utilization of fats and proteins
increases.1,2
According to the American Diabetes Association criteria for diabetes
melitus is confirmed if fulfilled one of the criteria: 1.Clinical manifestation
of polyuria, polydipsi, ployfagia, nocturia, enuresis, weight loss, random
boold glucose ≥ 200mg/dL (11.1 mmol/L), or 2. Fasting blood glucose ≥126
mg/dL(7 mmol/L), or 3. Plasma blood glucose ≥ 200mg/dL (11.1 mmol/L)
on oral glucose tolerance test, or 4. The level of HbA1c > 6.5%.
Asymptomatic patient with increase random blood glucose level ≥
200mg/dL need to be confirmed with fasting blood glucose or with oral
glucose tolerance test.3
The distinction between T1DM and T2DM may not be apparent until
insulin requirements have declined significantly. Distinguishing children
with type 1 diabetes mellitus (T1DM) from those with T2DM may be
difficult. Increasing obesity in the general population further blurs the
distinction between T1DM and T2DM in children. C-peptide is a useful and
widely used method of assessing pancreatic beta cell function. C-peptide has
been shown to denote endogenous insulin production and correlates with
type of disease, duration of diabetes, as well as age of diagnosis. In insulin-
treated individuals, fCP less than 0.2 nmol/L and GST of less than 0.32
nmol/l have been found to correlate significantly with T1DM.3 In this case,
the patient is a 14 years 7 month old female came to hospital with chief
complain high with glucose, patient also complained always feel thirsty and
hungry with random plasma glucose was 473 mg/dL. From other laboratory
examination found with HbA1c 12,6 %, and C-peptide level 1.8 ng/mL.
Patient diagnosed by type 2 diabetes mellitus.
T2DM results from an interaction between genetic and environmental
factors. Genes and the environment together are important determinants of
insulin resistance and β-cell dysfunction. Changes in the gene pool cannot
account for the rapid increase in prevalence of T2DM in recent decades,
environmental changes are essential to the understanding of the epidemic.
Risk factors of diabetes melitus are obesity, family with diabetes, low birth
weight, sedentary lifestyles etc.3 Based on this problems we was conducted
searches for the journal to determine risk factors of diabets melitus type 2.
We found a journal entitled “Risk factors for type 2 diabetes mellitus: An
exposure-wide umbrella review of metaanalyses ” Vanesa B, Lazaros B ,
Ioanna T, Evangelos E. Plosone. 13 (3): e0194127. This journal was valid,
important and applicable (level of evidence 1A and grade of
recommendation A). Based on this journal, Adiposity, low hip
circumference, serum biomarkers (increased level of alanine
aminotransferase, gamma-glutamyl transferase, uric acid and C-reactive
protein, and decreased level of adiponectin and vitamin D), an unhealthy
dietary pattern, low level of education and conscientiousness, decreased
physical activity, high sedentary time and duration of television watching,
low alcohol drinking, smoking, air pollution, and some medical conditions
(high systolic blood pressure, late menarche age, gestational diabetes,
metabolic syndrome, preterm birth) presented robust evidence for increased
risk of T2DM. In the case, the patient had history of obesity, her father
suffered from diabetes, unhealthy dietary pattern and sedentary lifestyles.
Management of type 2 diabetes in youth, consist of acute and long
term management. The treatment approach to alleviate insulin resistance
and β-cell failure, achieve glycemic control, and prevent further
complications.5,6,7,8 Management of newly diagnosed type 2 diabetes
mellitus (T2DM) from the American Academy of Pediatrics in children and
adolescents consist of six recommendations.5
The first recommendation, insulin therapy is initiated for children and
adolescents with T2DM who are ketotic or in diabetic ketoacidosis and in
whom the distinction between types 1 and 2 diabetes mellitus is unclear and,
in usual cases, should initiate insulin therapy for patients (a) who have
random venous or plasma BG concentrations ≥250 mg/dL, or (b) whose
HbA1c is >9%.5 In this case, The patient had random BG concentrations
≥250 mg/dL (473 mg/dL) and HbA1c 12,6 %, patient got metformin 500
mg every 12 hours and insulin lantus 10 unit at night.
We performed journal searching to find out the medical treatment for
children with diabetes melitus type 2 and found evidence-based journal
entitled “Treatment of pediatric type 2 diabetes” by Smith et al. 2016. This
journal was valid, important, and applicable (level of evidence 1a, grade of
recommendation A). Based on this journal, we concluded that metformin
and insulin are the main treatment in children with diabetes melitus.
The second recommendation, in all other instances, clinicians should
initiate a lifestyle modification program, including nutrition and physical
activity, and start metformin as first-line therapy for children and
adolescents at the time of diagnosis of Type 2 Diabetes Mellitus. In this
case, diagnosis of type 2 diabetes is made, with history signs of ketotic or
diabetic ketoacidosis, with blood plasma glucose 473 mg/dL and HbA1c
12,6 %. The patient were treated with metformin previously a year ago with
metformin and on current admission the patient treated with metformin and
insulin. Patient was ancouraged to do lifestyle modification (especially diet
modification and exercise).
The third recommendation, the committee suggests that clinicians
monitor HbA1c concentrations every 3 months and intensify treatment if
treatment goals for finger-stick BG and HbA1c concentrations are not being
met.1 The fourth recommendation, the committee suggests that clinicians
advise patients to monitor finger-stick BG concentrations in patients who (a)
are taking insulin or other medications with a risk of hypoglycemia,or (b)
are initiating or changing their diabetes treatment regimen, or (c) have not
met treatment goals, or (d) have intercurrent illnesses. Self monitoring of
blood glucose (SMBG) should be performed regularly. The frequency of
self monitoring depends on the target fasting blood glucose and target of
HbA1C. Patient with basal bolus regiment need to monitor blood glucose>3
times a day. During acute illness or when symptoms of hyper- or
hypoglycemia occur, patients should perform more frequent testing and be
in contact with their diabetes care team for advice. Patients on insulin or
sulfonylureas need to monitor for asymptomatic hypoglycemia.6 In this
case, since it was first established with type 2 diabetes, parents are taught to
perform self monitoring of blood glucose by using finger-stick blood
glucose test. At this time we initiating the diabetes treatment regimen so self
monitoring of blood glucose is performed by parents and patient.
The fifth recommendation, the committee suggests that clinicians
incorporate the Academy of Nutrition and Dietetics Pediatric Weight
Management Evidence-Based Nutrition Practice Guidelines in their dietary
or nutrition counseling of patients with T2DM at the time of diagnosis and
as part of ongoing management.5
Nutritional management is one most important of diabetes care and
education. Dietary recommendations for children with diabetes are based on
healthy eating recommendations suitable for all children and adults and
therefore the whole family. Nutritional advice must be adapted to cultural,
ethnic and family traditions, and the psychosocial needs of the individual
child.Energy requirement for the patient is based on Recommended Dietary
Allowances (RDA). Allocation of the calories per 24 hours divided into
thrice main food, and thrice snack as follows 20% for breakfast, 10% snack,
25% for lunch, 10% snack, 25% for dinner and 10% snack. Recommended
calories composition are 50-55% from carbohydrate, 15-20% from protein,
25-35% from fat.9 Dietary management should include, (i) initial focus on
eliminating sugar-containing soft drinks and juices in large quantities, (ii)
increase fruits and vegetables food, (iii) recommending that meals should
be taken on schedule, in one place, with no other activity (television,
studying, reading, playing), preferably as a family unit, (iv) portion control.
Food and snacks should be served in a plate or bowl and not eaten directly
from a box or can, (v) limiting availability of high-fat, high caloric density
food and drink in the home, the reading of labels and control of purchasing,
(vi) encouraging positive reinforcement of minor achievement (e.g. no or
minimal weight gain, reduction in high caloric drinks) and avoiding blame
for failure.3,6,7.10,11
The sixth recommendation, the committee suggests that clinicians
encourage children and adolescents with T2DM to engage in moderate-to-
vigorous exercise for at least 60 minutes daily and to limit nonacademic
“screen time” to less than 2 hours a day.5 In this case, she was taught to do
more physical activity both at home and outside home. If there is free time
at home, she was asked to help clean the house, more playing in the yard,
and reduce watching TV or playing a computer which is not related to
education. On weekends (Saturday and Sunday) children are invited to swim
or exercise in the field so she can increase her physical activity. The long-
term vascular complications of diabetes include retinopathy, nephropathy,
neuropathy and macrovascular disease. The outcomes are: visual
impairment and blindness due to diabetic retinopathy, renal failure and
hypertension due to diabetic nephropathy, pain, paraesthesiae, muscle
weakness and autonomic dysfunction due to diabetic neuropathy, cardiac
disease, peripheral vascular disease and stroke due to macrovascular
disease.6,7,8,12
Complication testing specific to type 2 diabetes mellitus in young
people: Testing for either micro or macro-albuminuria, should be performed
at the time of diagnosis and annually thereafter, blood pressure should be
monitored at every visit according to standardized techniques specific for
children, testing for dyslipidemia should be performed soon after diagnosis
when BG control has been achieved and annually thereafter, hyperlipidemia
should also be managed with a goal of LDL 100 mg/dL, triglycerides 150
mg/dL, and HDL 35 mg/dL, evaluation for non-alcoholic fatty liver disease
(NAFLD) should be done at diagnosis and annually thereafter, inquiries
about puberty, menstrual irregularities and obstructive sleep apnea should
be made at diagnosis and regularly thereafter, Female patient with diabetes
melitus has higher possibility to have vaginal candidiasis. Examination for
retinopathy should be performed at diagnosis and annually thereafter.6,7,12
In this case, Based on anamnesis, history of blurred vision, snoring
during sleep, sleepy during the morning or at school, of pain, paraesthesiae,
muscle weakness and autonomic dysfunction were denied. On physical
examination, we did not found the presence of hypertension. In the urine
examination there were no presence of protein in the urine, the renal
function tests are also still in the normal range. On examination of the lipid
profile was also obtained in the normal range. In this case, the patient had
candidiasis vulvovaginitis but has not found signs and symptoms of
microvascular complications (retinopathy, nephropathy, neuropathy) or
macrovascular complications (cardiac disease, peripheral vascular disease,
and stroke). Monitoring of these complications be done regularly to prevent
the complications. Complications due to macrovascular disease is
associated with hypertension, high blood sugar levels which are not
controlled and the duration of diabetes, based on this problems we was
conducted searches for the journal to determine the parameters/ indicators in
adolescents with type 2 diabetes which are associated with cardiovascular
complications. We found a journal entitled “Clinical and Biochemical
Predictors of Increased Carotid Intima-Media Thickness in Overweight
and Obese Adolescents with Type 2 Diabetes ” Nesreen A Kotb, Rania
Gaber, Mai Salama, Hala M Nagy and Abdou Elhendy Diabetes & Vascular
Disease Research 9(1) 35–41.This journal was valid, important and
applicable (level of evidence 3b and grade of recommendation C). Based
on this journal, carotid intima-media thickness (CIMT) is increased in
adolescents with type 2 diabetes. Poor glycemic control, HOMA, increased
C-reactive protein, body mass index, duration of diabetes, and elevated
blood pressure are associated with early atherosclerosis in these patients
Diabetes could bring psychosocial problems to the patient and family.
Education about the disease that diabetes mellitus is a life time disease, the
important of long term and routine follow up, takes time, patience and cost.
Patients with diabetes required long-term treatment and collaboration of
various modalities. The smaller age of occurrence of DM will have a higher
likelihood of complications if the patient has no treatment adherence. Where
a child will be difficult to adjust the diet so that the complication of the
disease more quickly arise due to uncontrolled blood glucose. Based on
these issues we conducted evidence-based journal searches and found a
journal entitled “Health-related Quality of life of Children and Adolescents
with Type 1 or type 2 Diabetes Melitus” by Michelle JN et al. Arch Pediatr
Adolesc Med. 2008. This journal was valid, important and applicable (level
of evidence 3b and grade of recommendation C). Based on this journal,
we concluded that among with youths with type 2 DM, HRQOl was lower
compared with those with type 1 diabetes.
a. References
Case analysis
1. Ozougwu JC, Obimba KC, Belonwu CD, Unakalamba CB. The
pathogenesis and pathophysiology of type 1 and type 2 diabetes
mellitus. Academic journals. 2013; 4(4):46-57.
2. David W, Cooke MD, Leslie P.Type 1 Diabetes Melitus in
Pediatrics.Pediatrics in review.2008;29(11):374-84
3. Julia M, Utari A, Moelyo AG, Rochmah N. Konsensus Ikatan Dokter
Anak Indonesia: Konsensus nasional pengelolaan diabetes melitus tipe
2 pada anak dan remaja. Jakarta: Badan Penerbit IDAI; 2015. p. 5-21.
4. American Diabetes Association. Classification and Diagnosis of
Diabetes. Diabetes Care 2017;40(Suppl. 1):S11–S24.\
5. Copeland KC, Silverstein J, Moore KR, Prazar GE, Raymer T,
Shiffman RN, et al. Management of Newly Diagnosed Type 2 Diabetes
Mellitus (T2DM) in Children and Adolescents. Pediatrics.
2013;131:364-82.
6. Hanas R, Donaghue K,Klingensmith G, Swift P, Colagiuri S. Global
IDF/ISPAD Guideline for Diabetes in Childhood and Adolescence.
International Diabetes Federation. 2011: 1-128.
7. Rosenbloom AL, Silverstein JH, Amemiya S, Zeitler P, Klingensmith
GJ. ISPAD Clinical Practice Consensus Guidelines 2009 Compendium.
Type 2 Diabetes in The Child and Adolescent. Pediatric Diabetes.
2009;10 (supplement 12): 17–32.
8. Flint A, Arslanian S. Treatment of Type 2 Diabetes in Youth. Diabetes
Care. 2011; 34 (supplement 2):177-83
9. Shenoy, Greening. Pediatric management of diabetic ketoacidosis
Guideline. Children’s Service Medical Guideline NHS. 2004;13:1-12.
10. Court JM, Cameron FJ, Berg-Kelly K, Swift PGF. ISPAD Clinical
Practice Consensus Guidelines 2009 Compendium. Diabetes in
Adolescence. Pediatric Diabetes 2009; 10 (Supplement 12): 185–194.
11. Robertson K, Adolfsson P, Riddell M, Scheiner G, Hanas R. ISPAD
Clinical Practice Consensus Guidelines 2009 Compendium. Exercise in
Children and Adolescents with Diabetes. Pediatric Diabetes 2009; 10
(Supplement 12): 154–168.
12. Donaghue KC, Chiarelli F, Trotta D, Allgrove J, Dahl-Jorgensen K.
ISPAD Clinical Practice Consensus Guidelines 2009 Compendium.
Microvascular and macrovascular complications associated with
diabetes in children and adolescents. Pediatric Diabetes 2009; 10
(supplement 12): 195–203.
2. Journal (evidence based practice)
1. Bellou V, Belbasis L, Tzoulaki L, Evangelou E. Risk factors for type
2 diabetes mellitus: An exposure-wide umbrella review of
metaanalyses. PloS ONE. 2017.13(3):1-27
2. Jennifer D, Elizabeth M, Sara EC. Treatment of pediatric type 2
diabetes.Annals of Pharmacotherapy.2016.1(10):1-10
3. Nesreen AK, Rania G, Mai S, Hala MN, Abdou E. Clinical and
biochemical predictors of increased carotid intima-media thickness
in overweight and obese adolescents with type 2 diabetes.
2011.9(1):35-41
4. Michelle JN, Andrea MG, Jean ML, Giuseppina I, Debra AS et al.
Health-related quality of life of children and adolescents with type 1
or type 2 diabetes melitus.Arch Pediatr adolesc med. 2008;162
(7):649-657
XV. ABBREVIATION
ACE : Angiotensin-Converting Enzyme
ALT : Alanine Aminotransferase
AST : Aspartate Aminotransferase
BCG : Bacille Calmette Guerrine
BH : Body Height
BW : Body Weight
CBC : Complete Blood Count
CGMS : Continuous Glucose Monitoring
CIMT : Carotid Intima-Media Thickness
DKA : Diabetic Ketoacidosis
DM : Diabetes Mellitus
EBM : Evidence Based Medicine
FLACC : Face, Legs, Activity, Cry, Consolability
GST : Glutathione-S-Transferase
HbA1C : Hemoglobin A1C
HDL : High-Density Lipoprotein
HOMA : Homeostasis model assessment
IBW : Ideal Body Weight
IU : International Unit
IV : Intra Venous
JE : Japanese Encephalitis
LDL : Low Density Lipoprotein
LV : Left Ventricular
MCH : Mean Corpuscular Volume
MCHC : Mean Corpuscular Hemoglobin Concentration
MCV : Mean Corpuscular Volume
MR : Measles & Rubella
MUAC : Mid Upper Arm Circumference
NAFLD : Non-Alcoholic Fatty Liver Disease
NIDDM : Non Insulin Dependent Diabetes Mellitus
PedsQL : Pediatric Quality of Life Inventory
pH : Potential of Hydrogen
PLN : Perusahaan Listrik Nasional
RDA : Recommended Dietary Allowance
RV : Right Ventricular
SMBG : Self Monitoring Blood Glucose
T1DM : Type 1 Diabetes Mellitus
T2DM : Type 2 Diabetes Mellitus
WBC : White Blood Count
WHO : World Health Organization
XVI. ATTACHMENTS
Attachment 1. Growth Charts for Children with Down Syndrome
Name : NNGC
Record : 19012697
2 to 20 years: Girls Weight-for-age percentiles

2 to 20 years: Girls Height-for-age percentiles
2 to 20 years: BMI-for-age percentiles
Attachment 2. Pediatric Quality of Life Inventory.
ID# __________________________
NNGC
Date: 22/03/2019
_________________________
™
PedsQL
Pediatric Quality of Life
Inventory
Version 4.0 English (Canada)
PARENT REPORT for TEENS (ages 13-18)
DIRECTIONS
On the following page is a list of things that might be a problem for your
teen. Please tell us how much of a problem each one has been for your
teen during the past ONE month by circling:
0 if it is never a problem
1 if it is almost never a problem
2 if it is sometimes a problem
3 if it is often a problem
4 if it is almost always a problem
There are no right or wrong answers.

If you do not understand a question, please ask for help.
In the past ONE month, how much of a problem has your teen had
with …
PHYSICAL Never Almost Some- Often Almost

Never times Always
FUNCTIONING
(problems with…)
1. Walking more than one 0 1 2 3 4
block
2. Running 0 1 2 3 4
3. Participating in sports 0 1 2 3 4
activity or exercise
4. Lifting something 0 1 2 3 4
heavy
5. Taking a bath or 0 1 2 3 4
shower by him or herself
6. Doing chores around 0 1 2 3 4
the house
7. Having hurts or aches 0 1 2 3 4
8. Low energy level 0 1 2 3 4
EMOTIONAL Never Almost Some- Often Almost

Never times Always
FUNCTIONING
(problems with…)
1. Feeling afraid or 0 1 2 3 4
scared
2. Feeling sad or blue 0 1 2 3 4
3. Feeling angry 0 1 2 3 4
4. Trouble sleeping 0 1 2 3 4
5. Worrying about what 0 1 2 3 4
will happen to him or her
SOCIAL FUNCTIONING Never Almost Some- Often Almost

Never times Always
(problems with…)
1. Getting along with 0 1 2 3 4
other teens
2. Other teens not 0 1 2 3 4
wanting to be his or her
friend
3. Getting teased by 0 1 2 3 4
other teens
4. Not able to do things
0 1 2 3 4
that other teens his
or her age can do
5. Keeping up with other 0 1 2 3 4
teens
SCHOOL FUNCTIONING Never Almost Some- Often Almost

Never times Always
(problems with…)
1. Paying attention in 0 1 2 3 4
class
2. Forgetting things 0 1 2 3 4
3. Keeping up with 0 1 2 3 4
schoolwork
4. Missing school 0 1 2 3 4
because of not feeling
well
5. Missing school to go to 0 1 2 3 4
the doctor or hospital
Result:
Attachment 3. Pediatric Symptom Checklist-17 (PSC-17)
Caregiver Completing this Form: Date: 22/03/2019

_______________________
WS _____________________
Name of Child:
_______________________
NNGC
Please mark under the heading that For Office Use

best fits your child
SOME- I A E
NEVER OFTEN
TIMES
1. Fidgety, unable to sit still  1

2. Feels sad, unhappy  1
3. Daydreams too much  1
4. Refuses to share  1
Does not understand
 2
5. other people’s feelings
6. Feels hopeless  0
Has trouble
 2
7. concentrating
Fights with other
 1
8. children
Is down on him or
 0
9. herself
10 Blames others for his or 0

. her troubles 
11 Seems to be having less 1
. fun 
12
. Does not listen to rules  1
13 Acts as if driven by a 0
. motor 
14
. Teases others  0
15
. Worries a lot  0
16 Takes things that do not 0
. belong to him or her 
17
. Distracted easily  1
2 5 5
Total: 12 (normal behavior)
EVIDENCE-BASED CRITICAL APPRAISAL
CASE
A 1 year 11 months old boy was referred from private hospital in rural area
with suspected Diabetes Mellitus type 1. The patient’s family had complained
about high blood glucose level since 10 days before admitted to the hospital about
weight loss since a month before admitted to the hospital. High blood glucose
level was first determined at the private hospital when he was admitted due to
decreased of consciousness. He also had frequent urination since three weeks
before admitted to the hospital. Frequent urination occured especially at night, the
frequency increased twice than before. He frequently felt thirsty and drank plenty
amount of water. His mother had complained of delayed speech. The patient can
only speak one specific word (“ma-em”) which his mother recognized it as a
delay compared to other children at his age.
On physical examination, he appeared in moderatelly ill, level of
consciousness was 12/12, blood pressure was 100/60 mmHg (90-95th percentile),
pulse rate was 110 beats/minute, regular, good pulse quality, respiratory rate was
24 times/minute, regular, axillary temperature was 36,8°C, and he’s well
nourished based on Waterlow’s nutritional status. A significant laboratory finding
revealed Hb-A1c level 10,8%. C-peptide <0,1 %.
DIAGNOSIS
Type 1 diabetes mellitus (E10), expressive language disorder (F80.1), well
nourished
PROBLEMS
1. How does the management of insulin administered in type 1 diabetes
mellitus, what insulin regimen should be administered?
2. What are the risk factors for diabetes mellitus?
3. What factors play a role in the metabolic control of people with type 1
diabetes mellitus?
4. How is the quality of life of children with type 1 diabetes mellitus?
PROBLEM 1
PICO
According to the problems, PICO can be described as follows:
P (Patient/Problem) : Children with type 1 diabetes mellitus
I (Intervention) : Insulin detemir
C (Comparation/Control) : NPH (Neutral protamine Hagedorn)
O (Outcome) : Glycaemic control
CLINICAL QUESTION
In children with type 1 diabetes mellitus, is insulin detemir compared to NPH
(Neutral protamine Hagedorn) improving glycaemic control?
JOURNAL SEARCHING STRATEGY
Keywords: type 1 diabetes mellitus AND detemir AND NPH AND glycaemic
control.
RESULT
“Insulin analogues in children with type 1 diabetes:a 52-week randomized
clincal trial”
N. Thalange, A. Bereket, J. Larsen, C. Hiort and V. Peterkova.
Diabetic Medicine. 2013;30:216–25.
ABSTRACT
Background: The challenge of achieving good glycaemic control is more
difficult in children and adolescents compared with adults because of the
characteristics of the paediatric population. Consequently, an ideal insulin
regimen would be flexible and predictable, whilst protecting against
hypoglycaemia and inappropriate weight. The aim of the current study was to
establish the efficacy and safety of insulin detemir in children aged 2–16 years
with Type 1 diabetes over 52 weeks of treatment.
Methods: A randomized, multinational, open-label, parallel-group, non-
inferiority trial investigated the efficacy and safety of basal–bolus treatment with
insulin detemir vs. NPH (neutral protamine Hagedorn) insulin, in combination
with insulin aspart. Children with Type 1 diabetes for at least 12 months (n =
347), aged 2–16 years was randomized, 177 received insulin detemir and 170
NPH insulin, both administered once or twice daily in combination with mealtime
insulin aspart. Glycaemic measurements and weight were followed over 52
weeks.
Results After 52 weeks, insulin detemir was shown to be non-inferior to NPH
insulin with regard to HbA1c [mean difference insulin detemir–NPH: 1.30
mmol/mol, 95% CI –1.32 to 3.92 (0.12%, 95% CI –0.12 to 0.36) in the full
analysis set and 1.41 mmol/mol, 95% CI –1.26 to 4.08 (0.13%, 95% CI –0.12 to
0.37) in the per protocol analysis set]. Hypoglycaemic events per subject-year of
exposure of 24-h and nocturnal hypoglycaemia were significantly lower with
insulin detemir than with NPH insulin (rate ratio 0.76, 95% CI 0.60–0.97, P =
0.028 and 0.62, 95% CI 0.47–0.84, P = 0.002, respectively). Weight standard
deviation (SD) scores (body weight standardized by age and gender) decreased
with insulin detemir, but increased slightly with NPH insulin (change: –0.12 vs.
0.04, P < 0.001). At end of the trial, median insulin doses were similar in both
treatment groups.
Conclusions Insulin detemir was non-inferior to NPH insulin after 52 weeks
treatment of children and adolescents aged 2–16 years, and was associated with a
significantly lower risk of hypoglycaemia, together with significantly lower
weight SD score when compared with NPH insulin.
Evidence-based Critical Appraisal: Clinical Trial

Are the results of the trial valid? (Internal Validity)
1. Was the assignment of patients to Yes, this study was a randomized,

treatments randomised? multinational, open-label, parallel-group,
non-inferiority trial
2. Were the groups similar at the start of Yes, The treatment groups were similar
the trial? with respect to withdrawal and baseline
characteristics (Table 2)
3. Aside from the allocated treatment, Yes. Both groups received insulin aspart
were groups treated equally? 4 times daily, with main meals.
4. Were all patients who entered the trial Yes, they used intention to treat analysis
accounted for? – and were they and preprotocol analysis.
analysed in the groups to which they
were randomised??
5 Were measures objective or were the No, this study was open label study,
patients and clinicians kept “blind” to because of Insulin detemir
which treatment was being received? and NPH are visually distinguishable
This study is valid
What were the results?
1 How large was the treatment effect?  Mean difference insulin detemir–NPH:
2 How precise was the estimate of the 1.30 mmol/mol, 95% CI (–1.32 to 3.92)
treatment effect?  Hypoglycaemic events per subject-year

of exposure of 24-h and nocturnal
hypoglycaemia were significantly lower
with insulin detemir (rate ratio 0.76,
95% CI 0.60–0.97, P = 0.028 and 0.62,
95% CI 0.47–0.84, P = 0.002,
respectively).
 Weight standard deviation (SD) scores
decreased with insulin detemir, but
increased slightly with NPH insulin
(change: – 0.12 vs. 0.04, P < 0.001)
This study is important
Will the results help me in caring for my patient?

(ExternalValidity/Applicability)
1. Is my patient so different to those in the No.

study that the results cannot apply?
2. Is the treatment feasible in my setting? Yes.
3 Will the potential benefits of treatment Yes.

outweigh the potential harms of
treatment for my patient?
This study is applicable
Conclusion: Valid, Important, and Applicable.
Level of evidence 1B with grade of recommendation A.
PROBLEMS 2
PICO
I (Intervention) :-
C (Comparation/Control) :-
O (Outcome) : maternal age, pre-eclampsia, taking medications
during pregnancy, infection in early life, low birth
weight children, consumption of cow's milk, and
vitamin D supplementation.
CLINICAL QUESTION
In Children with type 1 diabetes mellitus, are maternal age, pre-eclampsia, taking
medications during pregnancy, viral infection in early life, low birth weight
children, consumption of cow's milk, and vitamin D supplementation as a risk
factor of type 1 diabetes mellitus?
Keywords: diabetes mellitus type 1 AND child AND risk factors.
RESULT
“Environmental Factors and the Risk of Type 1 Diabetes Mellitus-A Case-

Control Study.”
Basma Abdelmoez Ali, Mostafa Ahmed Elfoly, Eman Ramadan Ghazawy and
Rania Rashad Bersom.
J Diabetes Metab.2017;8:379-84.
ABSTRACT:
Background: An interaction between genetic susceptibility and environmental
factors is assumed to be elaborate in the etiology of type 1 diabetes mellitus
(T1DM). Autoimmunity may be induced in first years of life, suggesting that
environmental agents encountered early in life could be triggers of the disease
process. The aim of the study was therefore to investigate the associations of
T1DM with several environmental factors.
Methods: A case-control study was conducted in Minia University Maternity and
Children Hospital, Minia governorate, Egypt. One hundred and ten children aged
from 2-16 years old who were diagnosed with T1DM and 110 age and sex-
matched controls were included. Data regarding environmental factors during
gestation, neonatal period, and early years of life were collected by a structured
questionnaire.
Results: On multivariable logistic regression analysis, maternal age >35 years at
delivery, the presence of gestational diabetes, pre-eclampsia and taking
medications during pregnancy were significantly associated with the occurrence
of T1DM. Also, viral infection in early life, low birth weight children (<2500
grams) and those who suffered from neonatal diseases (respiratory distress,
jaundice, and infection) were 4.71 and 2.17 folds increased the risk of T1DM.
Consumption of cow's milk during the 1st year of life was a significant predictor
for developing T1DM with OR 3.83 (1.64-8.96), However, vitamin D supplement
and increased duration of breast feeding were significant protective factors.
Conclusions: n the present study, certain environmental risk factors were
associated with the development of T1DM.
Evidence-based Critical Appraisal: Causation

Is the study design valid?
1. Were there clearly defined groups of Yes, this study was case control study
patients, similar in all important ways and has been matched by age and sex
other than exposure to the treatment or between two groups
other causes?
2. Were treatments/exposures and clinical Yes, exposures were measured in the
outcomes measured in the same way same way for both groups.
for both groups? Was the assessment of
outcomes either objective or blinded to
exposure?
3. Was the follow-up of study patients No, this study using case control method
sufficiently long for the outcome to
occur?
4. Is it clear that the exposure preceded Yes, it is clear that the exposure
the onset of the outcome? preceded the onset of the outcome
5. Is there a dose-response gradient? No, this study was not associated with
dose response gradient
6 Is the association consistent from study Yes, Similar results were reported by
to study? Stene et al.
7 Does the association make biological Possible that the introduction of foreign
sense? proteins in early infancy, when the
maturation of the gut immune system is
not complete, is someway harmful and
predisposes to β-cell autoimmunity
This study is valid
Are the results important?

1. How strong is the association between potential risk factors during pregnancy of
exposure and outcome, i.e. the estimate the index child; mother age, presence of
of risk? gestational diabetes, pre-eclampsia and
taking medications during pregnancy
2. How precise is the estimate of risk? were significantly associated with
occurrence of T1DM, OR (95% CI) were
(1.93 (1.37-2.73), 4.16 (1.53-11.28), 3.97
(1.19-13.24) and 3.15 (1.72-5.77)).
Consumption of cow's milk during the
1st year of life was a significant predictor
for developing T1DM with OR 3.83
(1.64-8.96), However, vitamin D
supplement and increased duration of
breast feeding were significant protective
factors
Are the results important for my patient?

1. Is my patient so different from those No, characteristic type of subjects in
included in the study that its results this study similar with our patients
don’t apply?
2. What is my patient’s risk of the adverse Yes, this evidence is worth for our
event? What is my patient’s potential clinical practices.
benefit from therapy?
3 What are my patient’s preferences, By knowing these risk factors, we can
concerns and expectations from this explain to the patient the possibility of
treatment? the next outcome.
Level of evidence 3B with grade of recommendation C.
PROBLEM 3
PICO
I (Intervention) : risk factor
O (Outcome) : glycemic control
CLINICAL QUESTION
In children with type 1 diabetes mellitus, what are the factors associated with
glycaemic control?
Keywords children AND type 1 diabetes AND glycaemic control
RESULT
Glycaemic Control in Type 1 Diabetes Mellitus Among Children and
Adolescents in a Resource Limited Setting in Dar es Salaam - Tanzania”
Noorani M, Ramaiya K, Manji K.
BMC Endocrine Disorders. 2016;16(29):1-8.
ABSTRACT
Background: Type 1 Diabetes Mellitus is a rapidly growing problem in Tanzania.
Children and adolescents with type 1 diabetes have previously been found to have
poor glycaemic control and high prevalence of complications. Strict glycaemic
control reduces the incidence and progression of chronic complications. The aim
of this study was to identify the factors associated with glycaemic control among
children and adolescents.
Methods: A cross sectional study was done at the diabetes clinic for children and
adolescents. Data on socioeconomic, demographic and diabetes specific variables
including adherence, diabetes knowledge, caregivers knowledge and their
involvement in the care of the child was obtained. Glycaemic control was
assessed by measuring glycosylated hemoglobin. (HbA1C). Linear regression
analysis was done to determine factors associated with glycaemic control
Results: Seventy-five participants were recruited into the study (51 % males). The
mean HbA1c was 11.1 ± 2.1 %. Children aged <10 years were found to have a
significantly better glycaemic control (9.8 %) as compared to 10–14 year olds
(11.5 %) and >14 year olds (11.4 %) (P value = 0.022). Sixty-eight percent of
patients had good adherence to insulin while adherence to blood glucose
monitoring regimen was 48 % and to diet control was 28 %. Younger age, having
the mother as the primary caregiver, better caregiver knowledge of diabetes, better
adherence to blood glucose monitoring regimen and diabetes duration of less than
1 year were associated with better glycaemic control. In multivariate analysis, age,
adherence to blood glucose monitoring regimen and the mother as the primary
caregiver were found to independently predict glycaemic control (R2 = 0.332, p
value = 0.00).
Conclusions: Children and adolescents with type 1 diabetes in Dar es Salaam
have poor glycaemic control. In order to improve metabolic control, adherence to
blood glucose monitoring should be encouraged and caregivers encouraged to
participate in care of their children especially the adolescents
Evidence-based Critical Appraisal: Prognostic Aspect

Are the results of this prognosis study valid?
1. Was a defined, representative sample Yes. Patients were recruited after
of patients assembled at a common diagnosis of type 1 diabetes mellitus and
(usually early) point in the course of receiving insulin therapy
their disease?
2. Was patient follow-up sufficiently long Yes. Observations were made over a 6
and complete? month period
3. Are clinical outcomes and clinical Yes. The risk factors were obedience,
outcomes measured in the same way in diabetes knowledge, caregiver
both groups? knowledge. The outcome of this is
HbA1C
4. If subgroups with different prognoses Not explained in the study.
are identified, was there adjustment for
important prognostic factors?
5. Was there validation in an independent Not explained in the study
group (“test set”) of patients?
This study is valid
Are the valid results of this prognosis study important?

1. How likely are the outcomes over The mean HbA1c was 11.1 ± 2.1 %.
time? Children aged <10 years were found to
2. How precise are the prognostic have a significantly better glycaemic
estimates? control (9.8 %) as compared to 10–14
year olds (11.5 %) and >14 year olds
(11.4 %) (P value = 0.022). In
multivariate analysis, age, adherence to
blood glucose monitoring regimen and
the mother as the primary caregiver were
found to independently predict
glycaemic control (R2 = 0.332, p value =
0.00)
Can we apply this valid, important evidence about prognosis in caring for
our patient?
1. Were the study patients similar to our Yes, characteristic type of subjects in
own? this study similar with our patients
2. Will this evidence make a clinically Yes, this evidence is worth for our
important impact on our conclusions clinical practices.
about what to offer or tell our patient?
Level of evidence 2B with grade of recommendation B.
PROBLEM 4
PICO
I (Intervention) :-
O (Outcome) : Quality of life
CLINICAL QUESTION
In children with type 1 diabetes mellitus, how is their quality of life?
Keywords: Children AND Type 1 diabetes mellitus AND quality of life
RESULT
“Quality of life in children with type 1 diabetes in Kuwait”
M Abdul-Rasoul, F AlOtaibi, M AlMahdi, H AlKandari
Med Princ Pract 2013;22:379-384.
ABSTRACT
Background: The development and use of pediatric HRQoL measures are
important for identifying at-risk children and applying early intervention
programs. the main aim of modern diabetes care in children and adolescents has
changed from a purely medical approach to one aiming toward optimal glycemic
control, normal psychological development and maximum QoL. To evaluate the
health-related quality of life (HRQoL) of children and adolescents with type 1
diabetes (T1DM) in Kuwait using the Pediatric Quality of Life Inventory
(PedsQL) 4.0 Generic Core Scale and PedsQL 3.0 Diabetes Module, and to
identify the risk factors associated with unsatisfactory QoL and their effects on
metabolic control.
Methods: A total of 436 patients (2–18 years) with T1DM (>6 months) and 389
healthy controls, with the parents of both groups, completed the Arabic Generic
Core Scale. Those with T1DM also completed the Arabic Diabetes Module.
Results: The mean total score of the PedsQL Diabetes Module was 70.2 ± 9.8
reported by children and 59.9 ± 11.1 reported by parents (higher scores indicate
better QoL). Young age and long duration of diabetes were associated with poor
QoL (p < 0.001). Boys had better total scores than girls in most age groups (70.3
± 9.3 vs. 52.3 ± 7.2, p < 0.001); however, girls did better than boys regarding
treatment barriers and adherence (71.3 ± 7.8 vs. 68.1 ± 6.2, p < 0.005). High er
HbA1c values were associated with lower QoL scores (31.1 ± 5.1 at HbA1c of
15% vs. 82.5 ± 6.1 at HbA1c of 6%, p < 0.0001).
Conclusions: HRQoL of children and adolescents with T1DM was consistently
poorer than controls. Parents consistently reported poorer QoL scores than their
children. We recommend that more support should be provided for the care of
children with diabetes in Kuwait.
Evidence-based Critical Appraisal: Causation

Is the study design valid?
1. Were there clearly defined groups of Yes, this study was case control study
patients, similar in all important ways and has been matched by age, sex,
other than exposure to the treatment or socioeconomic status and residence
other causes? between two groups
2. Were treatments/exposures and clinical Yes, exposures were measured in the
outcomes measured in the same way same way for both groups using the
for both groups? Was the assessment of Pediatric Quality of Life Inventory
outcomes either objective or blinded to (PedsQL TM ) 3.0 Diabetes Module, a
exposure? multi-dimensional, diabetes-specific
instrument that assesses children and
adolescents (2–18 years), with both child
and parent reports, was used to assess
HRQoL.
3. Was the follow-up of study patients No, this study using case control method
sufficiently long for the outcome to
occur?
4. Is it clear that the exposure preceded Yes, it is clear that the exposure
the onset of the outcome? preceded the onset of the outcome
5. Is there a dose-response gradient? No, this study was not associated with
dose response gradient
6 Is the association consistent from study Yes, this study has shown that children
to study? with T1DM had lower total generic QoL
than controls, which isconsistent with
previous findings of other researchers
7 Does the association make biological Yes, it does, patient with chronic
sense? complications may account for the low
emotional QoL because of lack of
autonomy and preoccupation.
This study is valid
Are the results important?
1. How strong is the association between The mean total score of the PedsQL
exposure and outcome, i.e. the estimate Diabetes Module was 70.2 ± 9.8 reported
of risk? by children and 59.9 ± 11.1 reported by
parents (higher scores indicate better
2. How precise is the estimate of risk? QoL). Young age and long duration of
diabetes were associated with poor QoL
(p < 0.001). Boys had better total scores
than girls in most age groups (70.3 ± 9.3
vs. 52.3 ± 7.2, p < 0.001); however, girls
did better than boys regarding treatment
barriers and adherence (71.3 ± 7.8 vs.
68.1 ± 6.2, p < 0.005). Higher HbA1c
values were associated with lower QoL
scores (31.1 ± 5.1 at HbA1c of 15% vs.
82.5 ± 6.1 at HbA1c of 6%, p < 0.0001).
Are the results important for my patient?
1. Is my patient so different from those No, characteristic type of subjects in
included in the study that its results this study similar with our patients
don’t apply?
2. What is my patient’s risk of the adverse Yes, this evidence is worth for our
event? What is my patient’s potential clinical practices.
benefit from therapy?
3 What are my patient’s preferences, By knowing this association, We
concerns and expectations from this recommend that assessment of QoL
treatment? after diagnosis of T1DM should be a
routine practice in patients with
diabetes to facilitate communication,
identify early problems and implement
early intervention.
Level of evidence 3B with grade of recommendation C.

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LONG CASE REPORT

SUSPECT TYPE 1 DIABETES MELLITUS (E10) DIFERENTIAL

POSTGRADUATE PEDIATRIC TRAINING PROGRAMME

II. History Taking (Subjective)

III. History During Admission Until Determination as Case

IV. Physical Examination (Objective) on March 22nd, 2019

Neurological examination of four limbs:

VI. Workup Diagnosis

2. Nutrition management and dietary regulation in type I diabetes

4. Communication, information and education plan

Complete blood count

24 hours fluid balance : -474 ml

24 hours fluid balance : +87.5 ml

24 hours fluid balance : +187.5 ml

Anamnesis Anamnesis Anamnesis

Male, 1 years 11 months

Clinical symptoms: thirsty,

frequent urination and

Clinical symptoms: thirsty, frequent

Definitive therapy Monitoring therapy Treatment of long-term Stimulation

1st Journal. Level of Metabolic control

recommendation A grade of recommendation B

Attachment 1. Growth Charts for Children with Down Syndrome

2 to 20 years: Girls Weight-for-age percentiles

PARENT REPORT for TEENS (ages 13-18)

There are no right or wrong answers.

PHYSICAL Never Almost Some- Often Almost

EMOTIONAL Never Almost Some- Often Almost

SOCIAL FUNCTIONING Never Almost Some- Often Almost

SCHOOL FUNCTIONING Never Almost Some- Often Almost

Caregiver Completing this Form: Date: 22/03/2019

Please mark under the heading that For Office Use

1. Fidgety, unable to sit still  1

10 Blames others for his or 0

Evidence-based Critical Appraisal: Clinical Trial

1. Was the assignment of patients to Yes, this study was a randomized,

treatment effect?  Hypoglycaemic events per subject-year

Will the results help me in caring for my patient?

1. Is my patient so different to those in the No.

3 Will the potential benefits of treatment Yes.

“Environmental Factors and the Risk of Type 1 Diabetes Mellitus-A Case-

Evidence-based Critical Appraisal: Causation

Are the results important?

This study is important

Are the results important for my patient?

Evidence-based Critical Appraisal: Prognostic Aspect

Are the valid results of this prognosis study important?

Evidence-based Critical Appraisal: Causation

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