14 M Downs with type 1 DM and Addisons (APStype 2)

 14 YR MALE PRESENTED WITH HISTORY OF PASSING BLOOD IN STOOLS AND URINE FOR 2 DAYS (2 EPISODES)


CHIEF C/O 
LETHARGY FROM 1 WEEK

14 /M BORN OUT OF CONSANGINOUS MARRIAGE , 4TH CHILD TO HIS PARENTS, 3 ELDER SIBLINGS, 2 SISTERS AND 1 BROTHER
CONGENITAL DOWNS SYNDROME

PT WAS A/A 6 YRS BACK WHEN HE DEVELOPED SUDDEN GENERALISED WEAKNESS AND WAS TAKEN TO A HOSPITAL IN AN ALTERED MENTAL STATE ,FOUND TO HAVE HYPERGLYCEMIA(?DKA).
PT WAS EVALUATED AND FOUND TO HAVE TYPE 1 DM AND WAS ADVISED INSULIN SINCE THEN 3 YRS BACK PT AGAIN DEVELOPED SIMILAR COMPLAINTS FOR WHICH INSULIN DOSE WAS INCREASED , 1 MONTH BACK DEVELOPED SUDDEN INVOLUNTARY MOVEMENTS IN HANDS
AND FEET , FOUND TO HAVE HYPOGLYCEMIA
PT ALSO FOUND TO HAVE LOW HB,WBC,RBC,PLT(?PANCYTOPENIA)
PT WAS MANAGED CONSERVATIVELY AND DISCHARGED AFTWER WHICH HE DEVELOPED CURRENT SYMPTOMS WITH IN 2 DAYS

PAST HISTORY: K/C/O DM SINCE 6 YRS
NO H/O HTN,ASTHMA,TB
PERSONAL HISTORY:
APPETITE REDUCED FROM PAST 2 MONTHS
MIXED DIET
REGULAR BOWEL AND BLADDER MOVEMENTS
NO ADDICTIONS

FAMILY HISTORY : NOT SIGNIFICANT

ON EXAMINATION :
PT IS C/C/C
AFEBRILE
BP: 120/80 MM HG
PR 70 BPM
CVS: S1 S2 HEARD
RS: NVBS +
CNS: NO FAD





























Day 1
Dermatology referral taken in view of hyperpigmentation of hands and peri oral region. A diagnosis of Addison's pigmentation and acanthosis nigricans was made.

S
No c/o black colored stools, blood
stools.
O
Pallor +
Clubbing -
PR - 91 bpm
BP - 100/70mmhg
Afebrile
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
Autoimmune Polyglandular Syndrome?Down's SyndromeK/C/O Type 1 DM since 8 years
P
1. VIT
B12 inj 1000 micrograms IV OD
2. IVF 1 unit NS at 75ml/hr
3. Inj HAI 6-6-6 (8am 2pm 8am)
4. Inj NPH 5-x-5 (8am 8pm)
5. GRBS monitoring
6. Strict I/O charting

DAY 2
Cardiology referral taken with 2d echo.
No abnormality detected. ENT opinion taken. Ciproflox ear drops added. Review after 1 week.
Endocrinology opinion take. Adviced 8 am serum cortisol, iron profile, free T3 and free T4 adviced.
Samples sent awaiting reports.


S
No c/o black colored stools, blood stools or lethargy.
O
Pallor +
Clubbing -
PR - 91 bpm
BP - 100/70mmhg
Afebrile
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
Autoimmune
Polyglandular Syndrome?Down's SyndromeK/C/O Type 1 DM since 8 years
P
1. VIT B12 inj 1000 micrograms IV OD
2. IVF 1 unit NS at 75ml/hr
3. Inj HAI 6-6-6 (8am 2pm 8am)
4. Inj NPH 5-x-5 (8am 8pm)
5. ZYTEE gel for L/A on oral mucosa before food
6. CIPROFLOX D ear drops
7. GRBS
monitoring
8. Strict I/O charting

DAY 3
S
No c/o black colored stools, blood stools or lethargy. Surgery
cross consultation with PR examination and proctoscopy for H/o blood in stools. Fissure in ano diagnosed. Oint Anobliss, high fibre diet and sitz bath adviced.

O
Pallor +
Clubbing -
PR - 91 bpm
BP -
100/70mmhg
Afebrile
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per
Abdomen - Soft, non-tender, Bowel sounds +
Urea - 118mg/dl
Creatinine - 2.8mg/dl
Na - 137meq
K -
43meq
Cl - 104meq
Sr Iron 81.2mcg
A
Autoimmune Polyglandular Syndrome?Down's SyndromeK/C/O
Type 1 DM since 8 years
P
1. VIT B12 inj 1000 micrograms IV OD
2. IVF 1 unit NS at 75ml/hr
3. Inj HAI 6-6-6 (8am 2pm 8am)
4. Inj NPH 5-x-5 (8am 8pm)
5. ZYTEE gel for L/A on
oral mucosa before food
6. CIPROFLOX D ear drops
7. GRBS monitoring
8. Strict I/O charting

DAY 4
S
No c/o black colored stools, blood stools
O
Pallor +
Clubbing -
PR - 90 bpm
BP - 100/70mmhg
Afebrile
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
Autoimmune Polyglandular Syndrome?Down's
SyndromeK/C/O Type 1 DM since 8 years
P
1. VIT B12 inj 1000 micrograms IV OD
2. IVF 1 unit NS at 75ml/hr
3. Inj HAI 6-6-6 (8am 2pm 8am)
4. Inj NPH 5-x-5 (8am 8pm)
5. ZYTEE gel for L/A on oral mucosa before food
6. CIPROFLOX D ear drops
7. Oint ANOBLISS for l/a
8. GRBS monitoring
9. Strict I/O charting

DAY 5
S
No c/o black colored stools, blood stools
O
Pallor +
Clubbing -
PR - 97 bpm
BP - 100/60mmhg
Afebrile
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
Serum Cortisol 11.63mcg/dl
Free T4 0.99ng/dl
Iron 35mcg/dl
TIBC 387mcg/dl
Transferritin saturation 26.5%

A
Autoimmune Polyglandular Syndrome?Down's SyndromeK/C/O Type 1 DM since 8 years
P
1. VIT B12 inj 1000 micrograms IV OD
2. IVF 1 unit NS at 75ml/hr
3. Inj HAI 6-6-6 (8am 2pm 8am)
4. Inj NPH 5-x-5 (8am 8pm)
5. ZYTEE gel for L/A on oral mucosa before food
6. CIPROFLOX D ear drops
7. Oint ANOBLISS for l/a
8. GRBS monitoring
9. Strict I/O charting

DAY 6
The patient was taken for Dermatology referral as there is a hypopigmented patch over the undersurface of scrotum a/w itching.

S
No c/o black colored stools, blood stools
O
Pallor +
Clubbing -
PR - 97 bpm
BP - 100/60mmhg
Afebrile
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
Autoimmune Polyglandular Syndrome?Down's Syndrome K/C/O Type 1 DM since 8 years
P
1. VIT B12 inj 1000 micrograms IV OD
2. IVF 1 unit NS at 75ml/hr
3. Inj HAI 6-6-6 (8am 2pm 8am)
4. Inj NPH 5-x-5 (8am 8pm)
5. ZYTEE gel for L/A on oral mucosa before food
6. CIPROFLOX D ear drops
7. Oint ANOBLISS for l/a
8. GRBS monitoring
9. Strict I/O charting

Day 7
S
No c/o black colored stools, blood stools
O
Pallor +
Clubbing -
PR - 97 bpm
BP - 100/60mmhg
Afebrile
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
?Down's Syndrome K/C/O Type 1 DM since 8 years with Addison's disease, Pancytopenia secondary to B12 defeciency with b/l CSOM with Fissure in ano with Generalised xerosis with Intertrigo (on scrotum)
P
1. VIT B12 inj 1000 micrograms IV OD
2. IVF 1 unit NS at 75ml/hr
3. Inj HAI 6-6-6 (8am 2pm 8am)
4. Inj NPH 5-x-5 (8am 8pm)
5. ZYTEE gel for L/A on oral mucosa before food
6. CIPROFLOX D ear drops
7. Oint ANOBLISS for l/a
8. CANDID cream for l/a bd
9. LIQUID PARAFFIN all over the body bd
10. Tab TECZINE 5mg od
11. GRBS monitoring
12. Strict I/O charting

Day 8
S
No c/o black colored stools, blood
stools
O
Pallor +
Clubbing -
PR - 97 bpm
BP - 100/60mmhg
Afebrile
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
?Down's Syndrome K/C/O Type 1 DM since 8 years with Addison's disease, Pancytopenia
secondary to B12 defeciency with b/l CSOM with Fissure in ano with Generalised xerosis with Intertrigo (on scrotum)
P
1. VIT B12 inj 1000 micrograms IV OD
2. IVF 1 unit NS at 75ml/hr
3. Inj HAI 6-6-6 (8am 2pm 8am)
4. Inj NPH 5-x-5 (8am 8pm)
5. ZYTEE gel for L/A on oral mucosa before food
6. CIPROFLOX D ear drops
7. Oint ANOBLISS for l/a
8. CANDID cream for l/a bd
9. LIQUID PARAFFIN
all over the body bd
10. Tab TECZINE 5mg od
11. GRBS monitoring
12. Strict I/O charting

Day 9
S
No c/o black colored stools, blood stools
O
Pallor +
Clubbing -
PR - 97 bpm
BP - 100/60mmhg
Afebrile
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
?Down's Syndrome K/C/O Type 1 DM since 8 years with Addison's disease, Pancytopenia secondary to B12 defeciency with b/l CSOM with Fissure in ano with Generalised xerosis with Intertrigo (on scrotum)
P
1. IVF 1 unit NS at 75ml/hr
2. Inj HAI 6-6-6 (8am 2pm 8am)
3. Inj NPH 5-x-5 (8am 8pm)
4. ZYTEE gel for L/A on oral mucosa before food
5. CIPROFLOX D ear drops
6. Oint ANOBLISS for l/a
7. CANDID cream for l/a bd
8. LIQUID PARAFFIN all over the body bd
9. Tab TECZINE 5mg od
10. GRBS monitoring
11.Strict I/O charting

Day 10
Patient was taken for ENT review. Aural toilet was done. Adviced to continue
CIPROFLOX ear drops for 5 more days and was told to keep the ear dry.
S
No c/o black colored stools, blood stools
O
Pallor +
Clubbing -
PR - 97 bpm
BP - 100/60mmhg
Afebrile
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel
sounds +
A
?Down's Syndrome K/C/O Type 1 DM since 8 years with Addison's disease, Pancytopenia
secondary to B12 defeciency with b/l CSOM with Fissure in ano with Generalised xerosis with Intertrigo (on scrotum)
P
1. IVF 1 unit NS at 75ml/hr
2. Inj HAI 6-6-6 (8am 2pm 8am)
3. Inj NPH 5-x-5 (8am 8pm)
4. ZYTEE gel for L/A on oral mucosa before food
5. CIPROFLOX D ear drops
6. Oint ANOBLISS for l/a
7. CANDID cream for l/a bd
8. LIQUID PARAFFIN all over the body bd
9. Tab TECZINE 5mg od
10. GRBS monitoring
11.Strict I/O charting

Day 11
S
No c/o black colored stools, blood stools
O
Pallor +
Clubbing -
PR - 97 bpm
BP - 100/60mmhg
Afebrile
Spo2- at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
?Down's Syndrome K/C/O Type 1 DM since 8 years with Addison's disease, Pancytopenia secondary to B12 defeciency with b/l CSOM with Fissure in ano with Generalised xerosis with Intertrigo (on scrotum)
P
1. IVF 1 unit NS at 75ml/hr
2. Inj HAI 6-6-6 (8am 2pm 8am)
3. Inj NPH 5-x-5 (8am 8pm)
4. ZYTEE gel for L/A on oral mucosa before food
5. CIPROFLOX D ear drops
6. Oint ANOBLISS for l/a
7. CANDID cream for l/a bd
8. LIQUID PARAFFIN all over the body bd
9. Tab TECZINE 5mg od
10. GRBS monitoring
11.Strict I/O charting

Day 12
S
No c/o black colored stools, blood stools
O
Pallor +
Clubbing -
PR - 97 bpm
BP - 100/60mmhg
Afebrile
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2+
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
?Down's Syndrome K/C/O Type 1 DM since 8 years with Addison's disease, Pancytopenia secondary to B12 defeciency with b/l CSOM with Fissure in ano with Generalised xerosis with Intertrigo (on scrotum)
P
1. IVF 1 unit NS at 75ml/hr
2. Inj HAI 6-6-6 (8am 2pm 8am)
3. Inj NPH 5-x-5 (8am 8pm)
4. ZYTEE gel for L/A on oral mucosa before food
5. CIPROFLOX D ear drops
6. Oint ANOBLISS for l/a
7. CANDID cream for l/a bd
8. LIQUID PARAFFIN all over the body bd
9. Tab TECZINE 5mg od
10. GRBS monitoring
11.Strict I/O charting


Discharge summary

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