Trabalho de Inglês - Caso Clínico

Clinical case presentation
Names: Fabriti Rivelto Sokolowski

Gustavo Beilke
João Matheus Pimentel dos Santos
Teacher: Athany Gutierres
Opener
C.A.S., male, 14 years old, has been presenting for about 3 months polyuria, polydipsia and
weight loss. The mother, A.A., scheduled an appointment at the Basic Health Unit Vila
Formosa for him due to the clinical manifestations that are affecting him.
History of present illness

Patient reports polyuria, polydipsia and weight loss of about 8 kg in the last 3 months. The
mother reports that the symptoms appeared suddenly – the patient was a healthy teenager
before the current condition; almost did not seek care at the UBS. She noticed that her son
was drinking much more water than he was used to ingesting on a daily basis, in addition to
observing his more frequent trips to the bathroom. The mother also reports a marked weight
loss in the patient, which is not associated with inappetence – in fact, she reports that the child
was eating excessively (polyphagia).
In addition, the mother noticed that her son has become more lethargic, which worried her due
to the drop in school performance. In addition, the patient reports a lack of motivation to
perform physical activities, which contrasts with the high willingness he had to perform them
before the onset of symptoms. Patient ratifies the mother's reports. Both deny the presence of
febrile symptoms in the patient.
Review of systems
Integumentary system: without any type of lesion that calls attention, the crease sign
disappears a little slower than normal.
Head and neck: no adenomegaly and palpable thyroid, with normal size and without nodules
on palpation.
Respiratory system: tachypneic patient. Pulmonary auscultation, percussion, expansibility and
thoraco-vocal thrill were unaltered.
Cardiovascular system: cardiac auscultation with normophonetic and regular heart sounds in
two beats, without murmurs.
Gastrointestinal system: inspection, palpation and percussion without alterations. On
auscultation, normal airborne sounds.
Locomotor system: upper and lower limbs without pain on palpation and with normal and
painless movements as well.
Neurological system: gait and superficial and deep reflexes without alterations.
Past medical history and family history

He denies previous occurrences of measles, mumps, whooping cough, rubella and parasites.
She reported an episode of chickenpox when she was 10 years old, but it resolved well with
proper treatment at the time. He denies previous surgeries and hospitalizations. She denies
comorbidities and allergies. Vaccination book up to date.
She was born at term by normal delivery, without complications. She was breastfed until the
age of two. He had normal neuropsychomotor development and growth - his growth curves
from the vaccination record are within normal limits. Patient reports inactive sex life. He
denies the use of alcohol, cigarettes and other drugs.
According to her mother, C.A.S. he was always a smart, intelligent and healthy child, played
football at least once a week and always got excellent grades in school. The mother reports
that she and the father always offered all educational, emotional and financial support so that
the son could dedicate himself to his studies and maintain good life habits.
The patient lives in a brick house with basic sanitation and access to treated water in the urban
area of the city, with his two parents and his 10-year-old sister. Mother and son report
harmonious family dynamics.
Regarding family history, the mother and father are alive and have systemic arterial
hypertension. Your sister does not have any morbidity. His maternal and paternal
grandmothers have type 2 diabetes mellitus. His paternal grandfather is deceased and did not
have any chronic disease in life. Her maternal grandfather had type 1 diabetes mellitus and
died at age 68.
Physical exam
Weight: 50 kg; Height: 165 cm; Body Mass Index: 18.37 kg/m² ; Axillary temperature:
36.0°C.
Blood pressure: 110×70 mmHg; Heart rate: 95 bpm; Respiratory rate: 18 bpm.
On general examination, the patient was in a regular general condition, lucid and oriented in
space-time, anicteric, acyanotic, with pale conjunctival mucosa +/4+ and slightly dry oral
mucosa and tongue. Capillary filling of upper and lower limbs is normal.
Results of lab test, imaging and other diagnostics

Fecal parasitological screening was negative, the blood count was normal and the following
blood glucose results were obtained: fasting glucose – 143 mg/dl, serum glucose after 2 h of
the oral glucose tolerance test – 1.75 g/kg of dextrosol 250 mg/dl and a glycated hemoglobin
(HbA1C) – 8.0%
Assessment and plan

Thus, associating the symptoms presented by the patient together with laboratory findings and
family history, it was possible to confirm the diagnosis of type 1B diabetes mellitus, as it was
an idiopathic and nonspecific condition. The classification in 1B was due to the fact that the
patient was young, healthy, had a normal BMI for his age (18.37 kg/m²) and had cases of the
disease in his family. With this, the possibility of being type 2 diabetes mellitus was ruled out,
as this form normally affects adults, the elderly and obese patients.
According to the Diabetes Mellitus Type 1 Clinical Protocol and Therapeutic Guidelines
(BRASIL, 2019), the treatment of people with type 1 diabetes mellitus consists of five main
components: diabetes education, insulin therapy, glycemic self-monitoring, nutritional
guidance and monitored practice of physical exercise.

Trabalho de Inglês - Caso Clínico

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Trabalho de Inglês - Caso Clínico

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Clinical case presentation

Names: Fabriti Rivelto Sokolowski

History of present illness

Past medical history and family history

Results of lab test, imaging and other diagnostics

Assessment and plan

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