Case study 1

Case study

• A 12 year old boy is brought to the Emergency department of the hospital with recurrent vomiting and increasing drowsiness for the past few hours.

• Clinically he is found to have a fruity odour of his breath.

What are the chief presenting complaints ?

• Recurrent vomiting• Reduced consciousness• Fruity odour of the breath

How will you analyse the causes of the presenting complaints?

• Recurrent vomiting : GIT related or Non GIT related eg toxins in the blood ( elevated ketones, elevated urea or poisons etc)

• Reduced consciousness (Head injury, cerebral ischaemia (reduced blood flow to brain), metabolic derangements (eg electrolyte disturbances, high serum osmolality, acidosis etc)

• Fruity odour of the breath (elevated ketones in the blood, resulting from increased fat metabolism due to a shortage of insulin. Breakdown of acetoacetic acid produces acetone and carbon dioxide which are exhaled through the lungs)

Case study

• The mother has come with the child and mentions that the child has lost weight in the last 3 months; however the mother says that he has been eating and drinking even more than usual and has been complaining of thirst all the time.

• On further enquiring, it is noted that the child was passing a large amount of urine frequently and was getting up frequently at night to pass urine.

KEY POINTS

• The mother has come with the child and mentions that the child has lost weight in the last 3 months; however the mother says that he has been eating and drinking even more than usual and has been complaining of thirst all the time.

• On further enquiring, it is noted that the child was passing a large amount of urine frequently and was getting up frequently at night to pass urine.

What are the important points in the patient’s history?

• Weight loss• Excessive eating (polyphagia)• Excessive drinking water (polydipsia)• Passing excessive urine (polyuria)• Frequently passing urine at night (nocturia)

• The lab findings for the child are as follows; TLC: 11,400/mm3 DLC: normal

Sodium: 132mEq/L Chloride: 100 mEq/L BUN: 14mg/dL Creatinine: 1.2mg/dL Potassium: 4.9 mEq/L

Glucose: 320mg/dL Plasma ketones 1+ Urinary glucose 4+ Urinary ketones 2+ Plasma bicarbonate level 19 Blood pH 7.2 HbA1c 83 mmol/mol (10%) (Normal below 48 mmol/mol (6.5%) )

Case study

KEY POINTS

• The lab findings for the child are as follows; TLC: 11,400/mm3 DLC: normal

Sodium: 132mEq/L Chloride: 100 mEq/L BUN: 14mg/dL Creatinine: 1.2mg/dL Potassium: 4.9 mEq/L

Fasting plasma Glucose: 320 mg/dL Plasma ketones 1+ Urinary glucose 4+ Urinary ketones 2+ Plasma bicarbonate level 19 Blood pH 7.2 HbA1c 83 mmol/mol (10%) (Normal below 48 mmol/mol (6.5%) )

What arte the major abnormalities in the investigation results and what do these indicate ?

• The patient has very high blood glucose levels with elevated ketone levels in plasma and urine. This would indicate Diabetes mellitus and also Ketosis (excess ketone production) which is commonly seen with Type 1 Diabetes mellitus.

• Elevated HbA1c which further supports the diagnosis of Diabetes mellitus.

• Slightly low sodium levels could be due to recurrent vomiting and interference of high glucose levels with lab measurement of serum sodium levels

• Low Bicarbonate level with low pH indicates Metabolic acidosis

• The patient has high WBC count which may indicate an underlying infection or stress response to the metabolic abnormalities.

ANSWER THE FOLLOWING QUESTIONS

1. How did the insulin deficiency lead to an increase in plasma glucose & ketone concentration?

2. What are the types of DM ?

3. What is DKA(diabetic ketoacidosis)?

4. What is the most likely diagnosis of this patient?

5. What is the treatment of type 1 DM?

ANSWERS1. How did the insulin deficiency lead to an increase in plasma glucose & ketone conc.? Insulin is responsible for shifting glucose from blood to inside the cells. It also inhibits

glycogenolysis and neoglucogenesis. So insulin deficiency leads to hyperglycemia. Also in the absence of insulin lipolysis is increased leading to production of ketoacids.

2. What are the types of DM ? Type 1 DM, Type 2 DM, Gestational DM, Others like Genetic forms

3. What is DKA(diabetic ketoacidosis)? It is a life threatening complication of DM. In the absence of insulin increased level of fatty

acids are delivered where ketogenesis occurs this lowers the pH of blood. Presenting symptoms may include Kussmaul’s breathing, abdominal pain, dehydration, nausea vomiting. Patients may have sweet /fruity odour in their breath.

4. What is the most likely diagnosis of this patient? Type 1 DM presenting with DKA

5. What is the treatment of type 1 DM? Lifelong Insulin replacement for Type 1 DM Oral hypoglycemic agents alone are NOT the treatment for Type 1 DM

Case study 2

• A 38 year old lady, a bank manager, was referred to the Diabetes clinic. She was found to be obese with a Body mass index of 32 kg/m2

• She had been diagnosed to have diabetes about 2 months ago in the primary care clinic when she presented with undue fatigue and was found to have fasting hyperglycemia with an HbA1c of 83 mmol/mol (10 %). She did not have any history of ketoacidosis at any point of time.

• The patient mentioned that her father had developed DM at the age of 45 years and was currently on tablets

• The patient was taking a healthy diet but was sedentary most of the time.

• On further questioning the patient gave a history of having developed high blood glucose during pregnancy last year which had resolved after delivery.

• Her physician had been concerned because the patient’s HbA1c ( 10 %) was high and the patient may develop complications especially renal complications.

A patient with DM

Keywords

• A 38 year old lady, a bank manager, was referred to the Diabetes clinic. She was found to be obese with a Body mass index of 32 kg/m2

• She had been diagnosed to have diabetes about 2 months ago in the primary care clinic when she presented with undue fatigue and was found to have fasting hyperglycemia with an HbA1c of 83 mmol/mol (10 %). She did not have any history of ketoacidosis at any point of time.

• The patient mentioned that her father had developed DM at the age of 45 years and was currently on tablets

• The patient was taking a healthy diet but was sedentary most of the time.

• On further questioning the patient gave a history of having developed high blood glucose during pregnancy (Gestational Diabetes Mellitus) last year which had resolved after delivery.

• Her physician had been concerned because the patient’s HbA1c ( 10 %) was high and the patient may develop complications especially renal complications.

HbA1c (Glycosylated Hb)

Diagnosis and Assessing the Control of Diabetes mellitus with HbA1c

HbA1c > 6.5 % is one of the diagnostic criteria for

diabetes mellitus

ANSWER THE FOLLOWING QUESTIONS

1. What type of Diabetes do you think the patient has ?

2. What are the indicators that favour your diagnosis of this kind of diabetes ?

3. Why are renal functions closely monitored in DM?

4. What are the major renal complication of Type 2 DM?

ANSWERS

1. The patient probably has Type 2 Diabetes mellitus.

2. The indicators of the type of Diabetes mellitus in this patient include the age of the patient, presence of obesity and sedentary lifestyle, history of type 2 diabetes mellitus affecting her father, No history of ketoacidosis at any point of time.

3.Why the renal functions are closely monitored in DM? For early detection and prevention of development of diabetic nephropathy, albuminuria and

kidney functions have to be monitored.

4.What are the major renal complications of Type 2 DM? Diabetic nephropathy, Albuminuria , Renal failure

ANSWER THE FOLLOWING QUESTIONS

5. What is the treatment of Microalbuminuria?

6. What are the other major complications of type 2 DM?

7. What is the treatment of type 2 DM?

8. What are the differences between Type 1 and Type 2 DM ?

9. What is the treatment of Gestational Diabetes Mellitus (GDM) ?

ANSWERS

5. What is the treatment of Microalbuminuria? Control Blood pressure ControlBlood glucose ACE Inhibitors like Lisinopril or Angiotensin receptor blockers like Losartan

6. What are the other major complications of type 2 DM? Acute complication like hypoglycemia , hyperosmolar hyperglycemic state (HHS) Chronic complications like: Microvascular disease ( Nephropathy, Retinopathy, Neuropathy) Macrovascular disease ( Increased chance of Ischemic heart disease, CerebroVascularAccident (neurological stroke), Peripheral vascular disease)

ANSWERS

7. What is the treatment of type 2 DM?

1) Lifestyle interventions eg proper diet and regular appropriate exercise.

2) Maintaining blood glucose levels in the normal range by using medications such as: A) Metformin ( Suppresses hepatic glucose production and increases insulin sensitivity) B) Sulfonylureas eg Gliclazide, Glibenclamide, Glyburide ( increase insulin secretion from pancreatic beta cells) C) Exogenous Insulin may be required in patients in whom beta cells are no longer able to secrete insulin eg in late stages of Type 2 DM

3) Lowering other cardiac and vascular risk factors eg blood pressure control, stop smoking, normalize high cholesterol levels

4) Regular screening for complications like opthalmology screening, screening for microalbuminuria etc

ANSWERS8. What are the differences between Type 1 and Type 2 DM

Characteristic Type 1 DM Type 2 DM

Onset Juvenile Adult

Primary defect Immune or viral destruction of beta cells

Increased resistance to insulin

Genetic predisposition Weak polygenic Strong polygenic

HLA association Yes ( HLA-DR3 and DR4) No

Glucose intolerance Severe Mild to moderate

Ketoacidosis Common Rare

Beta cells in the pancreatic islets

Decrease Variable

Serum insulin level Decreased Variable

Classic symptoms Polyuria, thirst, polydipsia, weight loss

common

Variable

Insulin treatment ALWAYS necessary May be required

ANSWERS9. What is the treatment of Gestational Diabetes Mellitus (GDM) ?

• Diabetes Education to the patients• Diabetic Diet for pregnant women• Regular simple exercises appropriate for pregnant women• Short acting insulin ( Human Regular Insulin) given premeals mainly to

control the post-prandial Blood Glucose• Intermediate acting insulin ( NPH insulin) mainly to control fasting and

premeal blood glucose levels• Regular monitoring and adjustment of insulin doses as the pregnancy

progresses• Prevent hypoglycemias by adjusting the dose of insulin, proper diet advice

and snacks between meals