Case Study 14.3 A 14-year old male student was seen by his physician. His chief complaints were fatigue; weight loss; and increase in appetite, thirst and frequency of urination. For the past 3 to 4 weeks, he had been excesively thirsty and had to urinate every few hours. He began to get up three to four times a night to urinate. The patient has a family history of diabetes milletus. 1. Based on the preceding information, can this patient be diagnosed with diabetes? - The patient can be diagnosed with diabetes based on his laboratory data, that shows his fasting plasma glucose is hi symptoms he is showing and family history of diabetes milletus. 2. What further tests might be performed to confirm the diagnosis? - Tests that are most commonly used are the fasting plasma glucose (FPG) test or the A1C test to diagnose diabetes. The FPG blood test measures your blood glucose level at a single point in time. For the most reliable results, it is best to have this test in the morning, after you fast for at least 8 hours. The A1C test is a blood test that provides your average levels of blood glucose over the past 3 months. Other names for the A1C test are hemoglobin A1C, HbA1C, glycated hemoglobin, and glycosylated hemoglobin test. You can eat and drink before this test. When it comes to using the A1C to diagnose diabetes, your doctor will consider factors such as your age and whether you have anemia or another problem with your blood. The A1C test is not accurate in people with anemia. 3. According to the American Diabetes Association, what criteria are required for the diagnosis of diabetes? Criteria for Diabetes Diagnosis: 4 options FPG ≥126 mg/dL (7.0 mmol/L)* Fasting is defined as no caloric intake for ≥8 hours 2-hr PG ≥200 mg/dL (11.1 mmol/L) during OGTT (75-g)* Using a glucose load containing the equivalent of 75g anhydrous glucose dissolved in water A1C ≥6.5% (48 mmol/mol)* Performed in a lab using NGSP-certified method and standardized to DCCT assay Random PG ≥200 mg/dL (11.1 mmol/L) In individuals with symptoms of hyperglycemia or hyperglycemic crisis No clear clinical diagnosis? Immediately repeat the same test using a new blood sample. Same test with same or similar results? Diagnosis confirmed. Different tests above diagnostic threshold? Diagnosis confirmed. Discordant results from two separate tests? Repeat the test with a result above diagnostic cut-point. *In absence of unequivocal hyperglycemia, result to be confirmed by repeat testing 4. Assuming the patient has diabetes, which type would be diagnosed? - The 14 year old patient may be diagnosed with Type 1 diabetes milletus. Case Study 14.4 A 13-year old girl collapsed on a playground at school. When her mother was contacted, she mentioned that her daughter had been losing weight and making frequent trips to the bathroom in the night. The emergency squad noticed a fruity breath. 1. Identify the patients most likely type of diabetes. - The patient is most likely to have type 1 diabetes 2. Based on your identification, name the common characteristics associated with that type of diabetes in the case study above. - Glucose 500 mg/dL; Ketones: Positive; BUN 6 mg/dL 3. What is the cause of the fruity breath? - When ketones rise to unsafe levels, the patient is at risk of a dangerous condition called diabetic ketoacidosis which causes the fruity breath. Case Study 14.5 A 28-year old woman delivered a 9.5-lb infant. The infant was above the 95th percentile for weight and length. The mother’s history was incomplete; she claimed to have had no medical care through her pregnancy. Shortly after birth, the infant became lethargic and flaccid. A whole blood glucose and ionized calcium were performed in the nursery. 1. Give the possible explantion for the infant’s large birth weight and size. - The mother was most likely a gestational diabetic. 2. If the mother was gestational diabetic, why was her baby hypoglycemic? - The baby was hypoglycemic because the oversupply of glucose from the mother was terminated when the umbical cord was severed. 3. Why was there discrepancy between the whole blood glucose concentration and the plasma glucose concentration? - The difference is that plasma numbers read about 10 12% higher than the older whole blood numbers. 4. If the mother had been monitored during pregnancy, what laboratory tests should have been performed and what criteria would have indicated that she had gestational diabetes? - Fasting blood sugar and OGTT. Kim Alysson Tan MT3B Case Study 14.1 An 18-year old male high school student who had a 4year history of diabetes milletus was brought to the emergency department because of excessive drowsiness, vomiting, and diarrhea. His diabetes had been well controlled with 40 units of NPH daily until several days ago when he developed excessive thirst and polyuria. For the past 3 days, he has also had headaches, myalgia and a low-grade fever. Diarrhea and vomiting began 1 day ago. 1. What is the probable diagnosis of this patient based on the data presented? - Diabetic Ketoacidosis 2. What laboratory tests should be performed to follow this patient and aid in adjusting insulin levels? - Blood test for glucose, serum electrolyte determination, Initial blood urea nitrogen (BUN), Initial arterial blood gas (ABG) 3. Why are the urine ketones positive? - Ketones build up when there is insufficient insulin to help fuel the body's cells. 4. What methods are used to quantitate urine ketones? Which ketones do they detect? - Ketone test / Urine ketones ; aceto-acetate and betahydroxybutyrate Case Study 14.2 A 58-year old man with frequent urination was seen by his primary care physician. The following laboratory work was performed. 1. What is the probable diagnosis of this patient? - The patient is most likely to be diagnosed with Type 2 diabetes. 2. What other tests should be performed to confirm this? Which is the preferred test? - A1c and urinalysis are the tests to be performed. 3. What values from #2 would confirm the diagnosis of diabetes? - A1c: 6.5 and above. - OGTT: 200 mg/dL 4. After diagnosis, what tests should be performed to monitor his condition? - Home glucose test, A1c and urinalysis tests are best to monitor his condition.
