Patient Assessment 2 I.

History [Page: 1\3]

Hospital Location: MCH Setting: Ward.

Date of Assessment: 10\4\2022. File number: 816610.

Contents
Patient’s Name: Nawaf Abdullah. Age: 9-Year-old.
Gender: Male. Diagnosis: DKA.
✿ Source of information:
History was obtained from the patient and his mother, and both are

Assessment 1
reliable. Additionally, patient's file was used in gathering information.

Patient
✿ Personal Data:
Nawaf Abdullah, A 9 years old, Saudi, male patient, Student, born and
living in Medina, known case of type1 diabetes for 2 years.
✿ Chief Complain:

Assessment 2
He is complaining of abdominal pain and vomiting for 1 day.

Patient
✿ History of Present Illness:
He presented to the emergency department with his parents complaining of
abdominal pain and vomiting for 1 day. One week before, he was visiting
primary health care because of lower respiratory tract infection, which is
managed by antibiotic and resolved completely. Initially, the abdominal

patient
Log of
pain was started suddenly. It was progressive, continue all over the day, and
diffuse in nature. Non-radiating, not aggravating or relieving by anything’s
even with vomiting. The pain was moderate scaled 8 out of 10. After that,
he developed vomiting. It started suddenly, twice episodes in an interrupted
pattern, non-projectile, watery and yellowish in color without food or blood

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content. Large in an amount approximately one cup each episode, not
related to meals, without a specific time, exacerbate or relief factors,
associated with nausea. The mother’s mentions that his son complies with
insulin therapy as his doctor advised without missing any doses. She inject
the doses by herself, rotates their injection sites, calculates his total caloric Lab 2
intake and level of physical activity. Monitoring for his blood glucose after Skill
meals and in the morning. He follows the endocrine clinic every three
months and the last Hgb A1c result not sure but remember it was above 7%.
He only noticed that he feels excessive thirst and needs to drink a lot of
water. In addition, the patient had polyuria, nocturia. There is no similar
condition before, or any hospital\ICU admission related to diabetes in this
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year. But multiple episodes of hypo\hyper glycemia since school started

with two ER visits in the last three months. There were no symptoms of
diabetic complications such as proteinuria, cardiovascular disease, vision
problem, numbness or loss of sensation in his extremities. No history of
contact with sick patients, surgery, recent trauma, weight loss, change in
appetite, fever, rigor, night sweat or any gastrointestinal symptoms.
Patient Assessment 2 I. History [Page: 2\3]

✿ Idea, Concern, Expectation, and Effect on life:

Contents
His mother thought that these symptoms are something related to food
poisoning. She wasn't concerned, but the symptoms were affecting his
son school attendance and study performance. Expect anything that
makes him get better

Assessment 1
✿ Review of systems:

Patient
General: No altered mental state, weight or appetite change.
Cardiovascular system: No chest pain, tachycardia, or loss of conscious.
Respiratory system: No cough, SOB, wheezing, cyanosis or hemoptysis.
Gastrointestinal system: Mentioned in HPI.

Assessment 2
Genitourinary system: No hematuria, or flank pain.

Patient
Nervous system: No headache, dizziness, vertigo, seizures, numbness
weakness or any visual\smell\taste\ hearing\ or speech problem.
Musculoskeletal system: No presence of joint\muscle pain or stiffness.
Endocrine: No hot\cold intolerance, insomnia\hyper insomnia.
Dermatology: No rashes, swelling, pigmentations or visible scars.

patient
Log of
Hematology: No ecchymosis, bruising, or body orifice bleeding.
✿ Covid-19 and vaccines History:
He didn't get a coronavirus infection yet. Received two doses of
vaccine without the third booster. Both were Pfizer, not documenting
any abnormal side effects or complications. No contact with anyone

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confirmed with Covid-19 in the last two weeks or other symptoms
suspicious of Covid-19. No other regular vaccine.
✿ Prenatal, natal, postnatal history:
Uneventful pregnancy, full-term, Normal Spontaneous Vaginal
Delivery [NSVD], birth weight was normal, no congenital anomalies,
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discharged after 1 day, no NICU admission.
✿ Nutritional and allergies history:
Postnatal was breastfeeding, weaning after 9 months, no vitamin
supplements. He eats home food [3 meals with snacks on school]. The
mother counts the calories related to insulin doses as she learned from
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his doctor. No known allergies [food, animals, drugs] and not

following any herbal remedies.
✿ Developmental history:
He had normal development. Including gross motor, fine motor, vision,
hearing, speaking, and social skills.
Patient Assessment 2 I. History [Page: 3\3]

✿ Immunization history:

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Completed vaccination. No unwanted reactions to any vaccine.
✿ Past Medical and Surgical History :
He was diagnosed with T1DM 2 years ago, was diagnosed incidentally
during the school screening, uncontrolled, uncomplicated by any
chronic complications such as retinopathy, nephropathy and neuropathy.

Assessment 1
and follows up regularly at pediatric endocrinology clinic.

Patient
No history of any autoimmune disease or other chronic diseases such as
asthma. No history of prior surgery or blood transfusion
✿ Medication and Allergies History:
On insulin Basal\bolus regimen:

Assessment 2
No complaint about any side effects of insulin therapy.

Patient
No over-the-counter (OTC) drugs such as NSAID.
No other medications or any herbal remedies that interact with insulin.
No known allergies of food or drugs.
✿ Recent Travel History:

patient
Log of
No history of travel in the past 2 months.
✿ Family History:
Both parents and 2 brothers are healthy. No consanguinity between his
parents. No other chronic illness or inherited disease in his family.
✿ Family Pedigree:

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Nawaf
9

✿ Socioeconomic State:
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An elementary school student, nonsmoker, non-alcoholic, lived in

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Medina with parents and two brothers, the oldest is 13 years old and the
youngest is 5 years old, with an average socioeconomic state. Good
physical activity and school performance. Not doing regular exercise
only playing football in school twice weekly.
Patient Assessment 2 II. Assessment [Page: 1\5]

Hospital Location: MCH Setting: Ward.

Date of Assessment: 10\4\2022. File number: 816610.

Contents
Patient’s Name: Nawaf Abdullah. Age: 9-Year-old.
Gender: Male.
Patient demographics and Background:
A 9 years old, Saudi, male patient, Student, born and

Assessment 1
living in Medina, known case of type 1 diabetes for 2 years.

Patient
Problem representation [one sentences introduction to the case]:
Presented to the emergency department complaining of abdominal pain
and vomiting for 1 day.

Assessment 2
Initial working diagnosis:

Patient
[possible diagnostic approaches e.g: VITAMIN CDEF approach] with key and
decimation features you would look for in each.
✿ Diabetic Ketoacidosis [DKA].

✿ Gastroenteritis.

patient
Log of
✿ Peptic Ulcer Disease [PUD].

✿ Acute cholecystitis.
History key features.

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Define, describe and justify the significant of each.
Key Point 1:
The point: The patient known case of T1DM.
Detailed description: [Known case of T1DM 2 years ago, The
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Symptoms proceeds by RTI].
Significance: This goes more with DKA as infection may trigger it.
Key Point 2:
The point: Analysis of complain
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Detailed description: [ The pain started sudden progressive and

continue all over the day. Its diffuse in nature. Non-radiating,
aggravating or relieving by anything’s even with vomiting. The patient
only noticed that he feels excessive thirst and needs to drink a lot of
water. In addition, the patient had polyuria, nocturia. He developed
vomiting. It started suddenly, twice episodes in an interrupted pattern,
Patient Assessment 2 II. Assessment [Page: 2\5]

non-projectile, watery and yellowish in color without food or blood

Contents
content. Large in an amount, not related to meals, without a specific
time, exacerbate or relief factors, associated with nausea].
Significant: This presentation in patient known case of T1DM makes
DKA on top of my deferential. Also, could be gastroenteritis.

Assessment 1
Key Point 3:

Patient
The point: Risk factors
Detailed description: [The patient denies fever, recent trauma,
jaundice. He completed his vaccine, no recent travel, contact with sick
patient, and no history of change in bowel habits [diarrhea\

Assessment 2
constipation], heartburn melena, or hematochezia or other

Patient
gastrointestinal symptoms. Moreover, short duration of complain, not
related to anything, uncontrolled DM, multiple episodes of hypo\hyper
glycemia since school started with two ER visits in the last three
months].

patient
Log of
Significance: This makes PUD, gastroenteritis, and acute cholecystitis
less likely].
Examination Findings:
Key findings in this patient that help to confirm or refuse a diagnosis.
Relevant positive finding and how to interpret each:

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General:
- Patient conscious, oriented, looks pale and in pain.
Local:
- Conjunctival pallor, dry mucus membrane, and delayed capillary Lab 2
refill. [Correlate with dehydration]. Skill
[Offer to assess body mass index]

Relevant negative finding and how to interpret each:

General:
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- [Hemodynamically stable]: Vital signs HR, BP, RR, Temp. [Afebrile]

, and O2 sat. were normal. Not altered mental state. There is no
dysmorphic feature, special decubitus, cyanosis or jaundice.
Local:
- [Abdomen]: Soft and lax, no masses, or organomegaly.
Patient Assessment 2 II. Assessment [Page: 3\5]

Diagnostic plan [investigations]:

Contents
Appropriate stepwise investigational that help to confirm or refuse a diagnosis.
Investigations already done [interpret its result]:

Parameter Result Interpretation

PH [7.33] LOW

Assessment 1
HCO3 [14mEq\L] LOW

Patient
pCO2 [35 mmHg] NORMAL
Serum Ketones [3.20 mmo;\L] HIGH
RBG [450 mg\dL] HIGH
Na [125 mEq\L] LOW

Assessment 2
K+ [3.2 mEq\L] LOW

Patient
WBC [17.6 x 103 /uL] HIGH

- Urine analysis: Positive for ketones and and glucose.

- Coagulations profile and Renal functions: Normal.

patient
Investigations suggested and why:

Log of
- HBA1C : [To assess diabetic control].
Differential Diagnoses [Most likely and important to exclude]:
Differential Diagnosis 1: DKA.

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With: Known case of T1DM, triggered by LRTI, associated
with abdominal pain, vomiting and multiple hypo\hyper glycemic
episodes with two ER visits.
Against: Regular and rotate insulin injections and calculate calories
intake.
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What is needed to support or refuse? ABG, RBG, Urine analysis, and
electrolyte.

Differential Diagnosis 2: Gastroenteritis.

Lab 3

With: History of abdominal pain and vomiting.

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Against: Afebrile, Known case of T1DM, the pain not related with
food, no similar events with other brothers, no other gastrointestinal
symptoms such as diarrhea and precedes by LRTI,.
What is needed to support or refuse? Stool analysis and culture.
Patient Assessment 2 II. Assessment [Page: 4\5]

Differential Diagnosis 3: PUD.

Contents
With: Abdominal pain and nausea.
Against: No water brush, diarrhea, heartburn, known case of T1DM,
and the pain not related to meal.
What is needed to support or refuse? Urea-breath test and
endoscopy.

Assessment 1
Red Flags [related to diabetes].

Patient
- Altered mental state.
- Loss of consciousness.
- Unresponsive to fluid therapy.
- Decreased urine output

Assessment 2
Patient
Therapeutic management:
Initial [emergency or urgency] management step
ABC Approach
- Airway: ensure is patent.

patient
Log of
- Breathing: ensure good ventilation. [consider Oxygen if indicated].
- Circulation: IV fluid - place 2 large bores cannula.
- Ensure the patient is hemodynamically stable.
- Call the senior.
- Order Investigations.

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- Monitoring vital, ABG, electrolytes, and admission if indicated.
List Patient Problems; for each mention

Problem 1:
- Dehydration:
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IV fluid [15-20mg/kg/hour - Normal Saline].

Problem 2:
- Hyperglycemia, low potassium, and metabolic acidosis:
Insulin infusion : 0.1units/kg/ h.
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Add K+ with caution.

Problem 3:
- Prevent recurrent:
Patient and family must know and educate about precepting
factors to avoid it. Maintain hydration, and complies to insulin
Patient Assessment 2 II. Assessment [Page: 5\5]

Referral and follow up:

Contents
Referred for pediatric endocrinology for follow up.
Health promotion, patient education and disease prevention:
- Educate the patient and his family for periodic follow up to:
Thyroid function test and growth.

Assessment 1
Ophthalmologist and Nephrologist

Patient
- Promote the patient to continue compliance to his medications and
doing exercise.
- Encourage the patient to follow up regular until achieve target HbA1C
- Maintain healthy lifestyles and calculate calories intake.

Assessment 2
Patient
Any Additional discussion: Management options
- None.

patient
Log of
Tutor’s name: ……………..……..…… | Signature: ……..…………….…

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