Past Medical History

Past Medical History

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MH was diagnosed with IDDM 5 years ago. He was presented earlier with polydypsia, polyphagia, polyuria, increased weight, and lethargy. He was first seen by medical officer in Klinik Kesihatan Ampangan. At that time he did not complain of shortness of breath, vomiting or abdominal pain. His random blood sugar noted to be high (‘HI’). Thus he was send to Hospital Tuanku Jaafar Seremban for further investigation and management. Upon arrival in Hospital Tuanku Jaafar Seremban his blood sugar in casualty was 35.3mmmol/L. He also had significant glucosuria and ketonuria. Blood gases showed metabolic acidosis. Thus, he was managed as Diabetic Ketocidosis. After blood sugar has been stabilized with s/c insulin, he was discharged with s/c actrapid 9 unit TDS and s/c insulatard 8 unit ON. He was given advice regarding the importance of compliant to medication and the complication of poor sugar control.

Three weeks after discharging from ward, he was seen in diabetic clinic with diabetic diary which he should check his blood sugar pre-meals with dietary recall on respective day. Mother claimed he was compliant to medication as the mother supervised him everyday. His insulin dosage has been decreased to actrapid 6 unit TDS and insulatard 6 unit ON as he has few episodes of symptomatic hypoglycaemia at home.

Throughout year of 2005, MH has fairly good blood sugar control at the beginning. Reaching end of the year, his blood sugar noted widely range. According to mother, MH started to miss the injection and not being truthful with diabetic diary. Though he had sugar control less than 10.0 mmol/l, his HbA1c noted more than 9.0%.

He has multiple admissions for blood sugar stabilization as his diabetic diary was poorly controlled. Most of the reasons of uncontrolled sugar are not adherence to medication and poor dietary profile. He is either presented with hypoglycaemic symptoms or diabetic ketoacidosis.

In March 2006, he was admitted for second time for diabetic ketoacidosis as he presented with severe abdominal pain and vomiting. Mother claimed that MH refused to inject himself. He did not check his blood sugar very often as his family could not afford to buy the glucose strips. As far as mother can remember, during presentation to casualty at that time, MH was still alert and conscious. His blood sugar was noted ‘HI’ reading. His urine had significant ketonuria. He was stabilized in casualty then stayed in the ward for couples of days for sugar monitoring.

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He was changed to mixtard as he was not compliant to 4 doses of insulin per day. He was discharged with s/c mixtard 25 unit OM and 15 unit ON.

Since discharged from ward, he was happy with new regime of insulin. He used to inject himself at thigh. However his mother used to inject his son at buttock as his son complaint of thigh pain due to injection. MH also used to adjust the dose himself according to frequency and amount of food intake for the day. Thus, his sugar controls was not so good in early 2007 because of wrong technique and site of injection and not adhere to correct dosage as prescribed earlier. Mother has been counseled that MH might need to change to actrapid and insulatard if control remains poor. She also has been educated and advised on dietary control.

End of 2007 mother claimed that MH only injected himself once a day, either morning or the evening. Mother was unable to control his diet. MH behaviour started to change. He became hot temper, easily get angry and used to scold his mother if she tried to remind him about his medicine and food intake. His medication was increased slowly throughout the year as his blood sugar was badly control. MH has been advised for admission to assess his diabetic control but his parents refused as they have other school going children and a newborn baby. He was referred to social welfare officer for financial support.

In April 2009 he was admitted electively for insulin dosage adjustment as he claimed that he had few episodes of symptomatic hypoglycaemia at home for 3 months. His insulin dosage was adjusted and he was discharged with s/c mixtard 15 unit OM and 6 unit ON.

However upon reviewing him in clinic 3 weeks after being discharged, his blood sugar control was poorly controlled. Home blood sugar monitoring showed reflo ranging 2.7 to ‘HI’. At that point, his father was explained that s/c actrapid is better to control the sugar. Therefore father agreed to change to humulin R 6 unit TDS and s/c humulin N 6 unit ON.

MH seemed to have difficultness in order to understand the importance of good glycaemic control. He had very poor compliant. He only injected himself twice daily.
On top of that, he did not have proper meal time. He self-omitted the pre-lunch and pre-bed dosage.

Due to poor compliance to multiple dose regime and infrequent home sugar monitoring, MH agreed to be more compliant if his medication switched back to BD regime. Thus, he was given mixtard 15 unit OM and 6 unit ON. According to mother then, MH showed good compliant to medication but had poor compliance to the diet. He was not listening to his mother despite has been advised. At sometimes, mother has been giving him extra dose of mixtard 10 unit in the afternoon as she feels MH eat a lot and hence high sugar. Pre-bed insulin was taken erratically as late as 1 am.

In early May 2010, he was admitted for hypoglycaemic attack due to insulin overdose. He was found unresponsive at 6.30am, the day of presentation. According to mother, MH took extra 10unit that night. Prior to that, MH had a big quarrel with his father. His father had slapped him hence he locked himself in his room and injecting extra 10unit of insulin. In view of poor sugar control, his medication has been switched back to short acting insulin, s/c actrapid 8 unit TDS and long acting s/c insulatard 10 unit ON.

Mid of June 2010, he was admitted electively for dosage adjustment. Since he always get early morning hypoglycaemia, he was prescribed with s/c Lantus 10 unit ON as been advised by endocrinologist.

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