Sunday, 8 May 2016

Adolescent health challenge - Type 1 DM

Dr.Smruti Mandar Nikumbh –Haval

About a young boy and his journey with diabetes mellitus type 1

One evening when I was busy in writing for my next publication my father in law called me when is my next OPD day.He was dealing with a young 17 year old boy who approached him for his complaints of weight loss (8 kg in 3 months),polyuria,polydypsia,hair fall,easy fatigue and vague abdominal discomfort.He advised relevant investigations and to his surprise his random blood glucose was on higher side 456 mg/dl. Now that was alarming as we were about to diagnose a type 1 DM patient who was a adolescent boy.

Adolescence or teen age its a age of weird ideas,dreams,ambition of career ,sports, unpredictable twists and turns .But this was a life changing twist.

 That high value of blood glucose alert us to investigate him for diabetic ketoacidosis though he was clinically stable.To our relief kidney function was normal but the fasting and post postprandial values were high and HbA1C was 14.2 with glycosuria. He was having UTI and urine ketones were 3 +.

 Now the next step was encounter with the family and most importantly patient himself.As expected the boy was anxious,irritated and nervous about the whole thing.The emotion was clear on his face Why me?

  He was also feeling sad that now he has to give up his favourite sports.But on other side parents were worried that why there son only got this.Both of them are not so far known diabetic neither any close family relatives were  diabetic.

 It was quite challenging for me to handle so many emotions at the same time as a young physician with little experience in this. I set my conversation priorities and told parents that let us thank God that in spite of such a hight sugar he is not in severe DKA. But now we know the root cause of his symptoms now its time for us to work as team and create a strong path for his dreams and a healthy life.

  Parents were feeling sorry that they did not stopped him from drinking excessive sugar cane juice or eating lots of sapata. I told them not to feel sorry as its not the food gave him this stage but its his genetic body that lacks insulin to maintain normal homoeostasis of blood glucose.We can achieve this now with insulin only as OHAs wont work in his case keeping a strong future for him in mind.Slowly as they were understanding the base of the disease and the way they are suppose to tackle  their anxiety was reducing.

Now the next step was fright of daily insulin therapy and pain associated with it.I gave them pen device advice but they chose conventional one.The boy was very anxious as he was feeling like a gunnie pig.Not to forget he was a science student.:P. But this problem to got solved with my Favourite finger rules.That demo reduced there fear of insulin therapy and now one more hurdle crossed.

  This entire process was easy as he was a science student and parents were really co operative and receptive.We gave him lifestyle modification,relevant pharmacological advice.
I know I should have admitted him but his exams were going on hence admission intracath would have increased his stress followed by sugars.So we took challenge and told them warning signs.If any of them appears  to contact us.

 I reviewed him after 5 days.As I always like my patient coming back to me with a big smile.He was from that cadre. Reports were fine,sugars were improving.Most importantly he was feeling much better and his symptoms has reduced .He was trying to learn the art of insulin administration. This was just a beginning. Long way to go. I know I should have done investigations like C peptide level, GAD Antibodies etc but I have some resource limitations. But will get them done soon.

  This case thought me a lot about adolescent patient's psychology, there challenges.
Thank you Almighty for helping us diagnosing him in time and save one life from falling in trap of intensive care.thank you.

Finger rule: 3 finger, 4 finger, 5 finger rule

While taking insulin over arm patient should keep 3 fingers over biceps and triceps, then remaining area is ideal for insulin administration. They can take it laterally when arm is put in supine position .This helped us to overcome the misconception of injection site-“for any injection is deltoid”. Over abdomen, we asked patient to leave 4 finger area from umbilicus. This leads to sparing of rectus sheath and facilitates administration of insulin more subcutaneously. So here patient can rotate sites easily. Over thigh we used 5 finger rule so patient spared quadriceps and hamstrings. Patient can take insulin over tenser fascia lata or adductor compartment. But here chances of absorption via intramuscular route are higher. Hence it’s not an ideal site.

This case thought me a lot about adolescent patient's psychology, there challenges.

Suggestions for strengthening rural healthcare.

To create database or educational materials which will help primary care physician in rural area all over the world in awareness of diabetes type 1 and its complications. Can arrange awareness and screening camps in schools and colleges.

Dr Smruti Mandar Haval  (Dr. Smruti Subhash Nikumbh)
 M.B.B.S.D.N.B. (Family Med),M.N.A.M.S.,P.G.D. Diabetology  & Geriatric Med.
Certified International Diabetic Educator by Project Hope & International Diabetes Federation (IDF) USA
Consulting Physician in Family medicine, Diabetology, Preventive Cardiology, Thyroid disorders  & Geriatric Medicine
C.E.O. Sukarmayogi Publishers, Sankeshwar Dist: Belgaum, Karnataka
Assistant Professor, Department Family Medicine, USM-KLE IMP,Belgaum

Area of practice- Sankeshwar, Dist – Belgaum ,Karnataka

Epidemiology of your area in brief:  It’s an semi rural area covering more than 50 km radius including many villages. Its USP is it’s an border area connecting borders of Maharashtra and Karnataka which makes it an multiethnic area. Common chronic health diseases are diabetes,hypertension,asthma ,hypothyroidism etc.

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