Med-Peds Case Files
Last updated: December 2009
Introduction
• ‘Med-Peds Case Files’ are a compilation of cases that are
interesting to both internal medicine and pediatric
physicians.
• The purpose of the Case Files is:
a)
b)
c)
To provide a national venue for Med-Peds physicians to share
interesting Med-Peds cases.
To develop a public online library of Med-Peds cases for
educational and promotional purposes.
To provide Med-Peds physicians an opportunity to develop
case preparation and presentation skills.
• The Case Files will be freely available online under the AAP
Med-Peds Section website starting in Fall 2009
http://www.aap.org/sections/med-peds/default.cfm
Case Submissions
• Resident, fellow, or attending physicians are eligible to
submit a case.
• Medical students may submit a case with a resident or
faculty advisor.
• Individuals may be personally invited for case submission.
• Cases must be submitted in a structured power point
format (see specifications).
• Only peer-reviewed cases will be published online.
• Cases may include an adult problem in a pediatric patient
or progression of a childhood illness into adulthood.
• Cases will be accepted on an annual basis.
Slide Specifications
• Introduction slide (chief complaint and/or one line intro, your name and
affliated institution)
• Case presentation (H&P with pertinent positives/negatives)
• Labs and radiologic studies (include units and reference ranges for
uncommon labs)
• Management/treatment (include diagnosis/conclusion)
• Learning objectives slide (take-home points for the case)
• Case discussion (if possible, compare disease presentation and/or
treatment in adults vs children)
• References slide
• Slides for question and answer to reinforce your learning objectives.
Minimum of one, maximum of four questions. Do not use questions from
published board review material (ie PREP, MKSAP, MedStudy)
Slide Specifications
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Maximum number of slides is 30
Use Calibri font with size no smaller than 20
Use white background with black text
Use Power Point version 2003 or older
Use images, pictures, tables, and/or figures when possible
Use slide format with AAP logo
See Case example
• Focus more on the case discussion. Use bullets to highlight key points.
• Note: H&P in the case example is very short. You may elaborate more
if needed. Also, depending on whether you want to make the case a
mystery, you may decide to put your learning objective slide later in
the presentation (ie, before case discussion vs before case
presentation)
Questions?
• For questions about case submissions, please
contact Jacqueline Meeks at
Jacqueline.P.Meeks@uth.tmc.edu
Case example
Chief Complaint: Altered mental status
Jacqueline Meeks, M.D.
University of Texas at Houston Health Science
Center
Case Presentation
• 8 yo morbidly obese previously healthy AAF
• Three days prior to presentation she took high dose
prednisone for an asthma exacerbation.
• She then developed symptoms of polyuria, polydipsia.
• On presentation she was obtunded with hypovolemic
shock.
• Family history was significant for DM
• BMI >95th percentile (85.7 kg)
• Velvety hyperpigmentation over the posterior aspect
on her neck was seen on exam
Labs
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Initial serum glucose 2343 mg/dL
HgA1C 12.5% (CMBG 368 mg/dL)
Minimal serum ketones
Anion gap 24
Serum Osmolarity 393 mOsm/dL
Lactic acid 6.8
Islet cell Antibody neg
GAD-65 Antibody neg
LDL 179, HDL 33, TG 293
Total Cholesterol 271
Microalbuminuria (high)
Hospital Course
• Patient was treated with IV fluids and insulin
• Patient was diagnosed with type 2 diabetes
Learning Objectives
• Review diabetic ketoacidosis and
hyperosmolar hyperglycemia
• Review diagnostic criteria and screening
guidelines for type 2 diabetes in children
• Know that acanthosis nigricans is a marker for
insulin resistance
Case discussion
• Acute life-threatening consequences of uncontrolled
diabetes are hyperglycemia with ketoacidosis or the
nonketotic hyperosmolar syndrome. Pediatric patients
with nonketotic hyperosmolar hyperglycemia have a
high mortality rate with risks for multiple
complications.
• The increasing prevalence of type 2 diabetes in
children raises concerns for diabetic complication in
young adults.
• Diabetic education and screening can help prevent life
threatening complications of undiagnosed,
uncontrolled diabetes.
Diabetes Diagnostic Criteria
• Fasting (> 8 hrs) blood glucose >= 126 mg/dL*
• Symptoms of hyperglycemia and a casual plasma
glucose >= 200mg/dL. Casual meaning without
regard to last meal. Classic symptoms of
hyperglycemia including polyuria, polydipsia, and
unexplained weight loss.
• Two hour plasma glucose >= 200mg/dL during
OGTT as described by WHO using a glucose load
of 75 gm anhydrous glucose dissoled in water*
* In the absence of unequivocal hyperglycemia,
testing should be repeated on a different day.
Impaired Fasting Glucose
• Normal: Fasting plasma glucose (FPG) < 100
mg/dL
• Impaired fasting glucose (IFG) or “prediabetes”: FPG >= 100 mg/dL and < 126 mg/dL
or 2 hour values in the oral glucose tolerance
test of >= 140 mg/dL and < 200mg/dL.
• Two hour values in the OGTT < 140 mg/dL is
normal and >= 200mg/dL is diabetes
Acanthosis Nigricans
Case discussion
Diabetic ketoacidosis and hyperosmolar hyperglycemia represent a spectrum of
uncontrolled diabetes.
Diabetic Ketoacidosis
Hyperosmolar
Hyperglycemia
Serum glucose
>250
>600
Serum ketones
Moderate /high
Absent/Low
Anion gap
>12
Variable
Serum osmolarity
Variable
>320
Mental status
Mild – alert
Severe - coma
Stupor/coma
Mortality
<5%
~15%
Type 2 DM Screening
ADA/AAP recommends checking fasting serum
glucose at age 10 or earlier with puberty, every 2
years who meet criteria:
• BMI > 85th percentile for age and sex
• Any two of the following risk factors:
• Type 2 DM in 1st or 2nd degree relative
• African, Asian/Pacific Islander, Hispanic or Native
American Heritage
• Signs or conditions associated with insulin
resistance (i.e. acanthosis nigricans, PCOS, HTN,
dyslipidemia)
References:
• Stoner G: Hyperosmolar Hyperglycemic State
AFP 71(9):1723-29 2005 May 1
• Trachtenbarg D: Diabetic Ketoacidosis
AFP 71(9):1705-14 2005 May 1
• Behrman RE, et al: Nelson textbook of Pediatrics
• ADA Diabetes Care Journal
• www.ndep.nih.gov
• www.cdc.gov
• www.obesity.org
Question
• You are evaluating a 14 year-old boy who has
a BMI of 40kg/m2. His mother and 25 year-old
sister have type 2 diabetes. A fasting blood
glucose concentration for the boy is 110
mg/dL.
Question
• Of the following, the MOST appropriate next
step to screen for diabetes is to
A. measure glycosylated hemoglobin
B. measure serum insulin and C-peptide level
C. perform a 2 hour oral glucose tolerance test
D. measure blood glucose 1 hour after a high
carbohydrate breakfast
E. repeat a fasting blood glucose
Answer - C
• The boy in the vignette is at high risk for type 2
diabetes because of elevated BMI and strong family
history. His elevated fasting glucose is worrisome for
impaired fasting glucose but not diagnostic for
diabetes. A 2 hour glucose tolerance test should be
performed to determine whether he meets criteria for
diabetes.
• Glycosylated hemoglobin, insulin/C-peptide levels are
not diagnostic for diabetes.
• A high carbohydrate diet is poorly defined
• A repeat fasting glucose is likely to give an
indeterminate value.