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Diabetes in Clinical Practice: Questions and Answers from Case Studies. Verified Answers

Diabetes in Clinical Practice: Questions and Answers from Case Studies CASE STUDY 1 A 72 years old woman with a 15 year history of Type 2 DM, treated with insulin NPH, 24 units in the morning and 14 units in the evening, presented for the first time in the Diabetes Clinic for evaluation. She reported that during the last six months she had been having ‘unexpectedly’ high blood sugar values in her SMBG measurements. Her weight has been steady (BMI: 29.5 kg/m 2 ). She reported no symptoms of any disease, neither polyuria nor polydipsia. Her last fundoscopic examination (two years before) had been normal. She also suffers from mild hypertension (and is receiving treatment with an ACE inhibitor). CASE STUDY 1 A 19 year old man was brought to the Emergency Department in the early morning hours, in a comatose state. He exhibited tonic-clonic contractions and was extremely agitated. His family members reported that he was suffering from Type 1 DM and that the previous evening he had attended a party; they did not know what he had eaten, but reportedly he had drunk quite a lot of alcohol. His mother got worried when she saw him sleeping very deeply and not responding to her efforts to wake him up. She tried to feed him because she thought he might be having a hypoglycaemic episode, but was unsuccessful (he had ‘sealed’ his mouth). The treating physician in the Emergency Room, after measuring a blood sugar level with a portable meter and finding it to be 25 mg/ dl (1.4 mmol/L), immediately ordered the intravenous administration of dextrose infusion. A 10 percent dextrose in water solution was started and the patient was given an intravenous injection of 5 ampoules 35 percent glucose (10 ml each). What is the diagnosis and cause of this acute situation? How much glucose must be administered? CASE STUDY 1 – DIABETIC KETOACIDOSIS A 25 year old young woman came to the hospital with fever and mild confusion. During the previous few weeks she had experienced polydipsia, polyphagia and polyuria, with significant weight loss (12 kg). She reported pain in her left flank area, with dysuria, for the previous 48 hours. Her mother reported that her daughter’s breath had a peculiar, uncommon smell, and that her breaths were more frequent. A physical exam was remarkable for evidence of dehydration. She had a low supine blood pressure (85/60 mmHg), with increased pulse rate (120 per min) and respiratory rate (32 breaths per min). Her breath had an acetone smell. There was mild clouding of sensorium, but without focal neurological signs. She had fever (37.9 C [100.2 F]) and tenderness on percussion of the left flank area (positive Giordano sign). A capillary blood glucose measurement showed a very high level: 484 mg/dl (26.9 mmol/L). At the same time, ketone bodies measured in the capillary blood with a portable meter (Medisense Xtra) were also very high: 4.5 mmol/L (note: these strips measure only b -hydroxybutyrate [b-HB] and not acetoacetate in the blood; levels > 3mmol/L are considered a sign of ketosis). Arterial blood gas analysis showed the following: pH 7.08 (7.35– 7.42); pCO 8 mmHg (35– 45); pO 120 mmHg (80– 100); and HCO À 2 2 3 6 mmol/L (24– 32). The diagnosis of diabetic ketoacidosis (DKA) was made. An ECG, a chest X-ray and further laboratory tests were done. The results were: Blood glucose: Sodium: Potassium: Chloride: 525 mg/dl (29.1 mmol/L) 124 mmol/L 3.8 mmol/L 88 mmol/L (75– 110 mg/dl [4.2– 6.1 mmol/L]) (132– 144) (3.4– 4.8) (93– 108) Urea: Creatinine: Urinalysis: CBC: 92 mg/dl (15.3 mmol/L) (18 – 36 mg/dl [3.0 – 6.0 mmol/L]) 3.2 mg/dl (282.9 m mol/L) (0.7 – 1.2 mg/dl [61.9 – 106.1 m mol/L]) Urine cloudy and foul smelling, glucose: þþþþ , ketone: þþþ , many WBCs, abundant microorganisms, many RBCs. Haematocrit: 44%, WBC: 22,000/ m l (polymorphonuclear 88%). What is diabetic ketoacidosis and what is the cause of DKA in this young woman? What are the therapeutic targets and our immediate priority? CASE STUDY 2 – HYPEROSMOLAR NON-KETOTIC HYPERGLYCAEMIC COMA (HNKHC) A 75 year old woman with a history of residual left hemiparesis due to a stroke, is transferred to the Emergency Room of the hospital. Recently, the patient has had intense polyuria and complained of profound thirst, the result of consuming of large quantities of juices. During the previous week she had experienced a decrease in her level of consciousness, with gradual clouding of sensorium, slowly deteriorating until she fell into a coma. Physical examination revealed signs of dehydration, with blood pressure of 110/80 mmHg and pulse rate of 110 per min. The patient was deeply comatose, with bilateral positive Babinski sign, unresponsive even to painful stimuli and with decreased deep tendon re fl exes. Initial impression was that she was suffering from a very severe stroke, probably in the medulla. A stat-computed tomography of the brain showed an ischaemic area of the right hemisphere, compatible with the history of left hemiparesis, but no signs of haemorrhage of recent thromboembolic lesion. The patient had a temperature of 36 C (96.8 F) (37.2 C [98.9 F] rectally). Laboratory results were: Na þ 138 mmol/L; K þ 3.6 mmol/L; Cl À 105.0 mmol/L; HCO À 3 30 mmol/L; urea 92 mg/dl (15.3 mmol/L); creatinine 2.2 mg/dl (194.5 l mol/L). Blood glucose was 1,235 mg/dl (68.5 mmol/L)!! Urinalysis showed 4 þ glucose and 1 þ ketones. 1. What is the diagnosis and where is it based? What are the circumstances during which HNKHC develops? What treatment will you offer to the patient? 1. Fluid administration and restoration of electrolyte disturbances. 2. Correction of hyperglycaemia with insulin administration (lower doses than needed in DKA 3. Management of underlying diseases 4. Prevention of thromboembolic episodes. 5. Close monitoring in an intensive care unit. CASE STUDY 3 – LACTIC ACIDOSIS A 74 year old woman presents to the hospital with complaints of recent high blood glucose levels and a feeling of progressively deteriorating fatigue. Her family members report episodes of lethargy and intense sleepiness, as well as confusion during the previous week. The patient suffers from DM (for 12 years), hypertension, coronary heart disease, dyslipidaemia, heart failure and atrial fi brillation. An echocardiogram done three months before showed left ventricular hypertrophy, mitral regurgitation and an ejection fraction of 35 percent. Her medications include: glimepiride, 6 mg/day; digoxin, 0.125 mg/day; ramipril, 10 mg/day; furosemide, 20 mg twice a day; aspirin, 325 mg/day; and for the last two months metformin, with a gradual increase of the dose to 1700 mg/day. She does not smoke or drink alcohol. Physical examination reveals a heart rate of 100/min, blood pressure of 168/ 72 mmHg, respiratory rate of 18/min and temperature of 36.8 C (98.2 F). An electrocardiogram shows presence of atrial fi brillation with a ventricular rate of 100 beats/min. Laboratory results are as follows: glucose 268 mg/dl (14.9 mmol/L); urea 48 mg/dl (8.0 mmol/L); creatinine 0.9 mg/dl (79.6 l mol/L); HbA 11.5 %; WBC 8600/ l l; Na þ 138 mEq/L; K þ 4.4 mEq/L; Cl À 1c 95 mEq/L. A chest X-ray is normal, without signs of cardiac overload or in fl ammatory in filtrates. Blood gas analysis shows pH 7.20 (7.35 – 7.42), pCO 2 28 mmHg (35 – 45), pO 105 mmHg (80 – 100) and HCO À 2 3 15 mmol/L (24 – 32). Anion gap is calculated at 32 mmol/L (increased). Ketone bodies (measured with the portable meter Medisense Xtra) are 1.6 mmol/L. Given the history of metformin ingestion and the presence of metabolic acidosis with a high anion gap, lactate levels are measured in the blood and found to be 6.1 mEq/L (normal values are 0.7 – 2.1 mEq/L). Metformin is discontinued and the patient started on insulin treatment with a twice a day injection of medium duration insulin. Twenty four hours later, lactate levels are 1.9 mEq/L. After a few days the patient returns home. CASE STUDY 1 A 54 year old man is referred to the urologist by his primary physician, because of intense dysuric symptoms during the last six months and three episodes of urinary tract infections. He was examined by the urologist and had an ultrasound examination of the kidneys, ureter and prostate. A significant hypertrophy of the prostate gland was found, accompanied by an appreciable amount of residual urine in the bladder after urination. A transurethral prostatectomy was suggested. The patient has been suffering from Type 2 DM for the previous six years, treated with metformin 850 mg tablets, twice a day and nateglinide 120 mg tablets, thrice a day, before meals. His glycaemic control is satisfactory, as depicted in his SMBG measurements and his HbA 1c level (6.7 percent). The urologist refers the patient back to his primary physician, so that pre-operative instructions for optimal control of his blood glucose before surgery are given. Can the patient be directly operated on, and if yes, should he be admitted to the hospital before the surgery? Why should hyperglycaemia be avoided in the surgical diabetic patient? Metabolic: Cardiovascular: CASE STUDY 2 A 42 year old man comes to the hospital because of fever and intense abdominal pain. He has an increased WBC count of 18,000/ l l and a toxic clinical picture (he has the face of a sick person, tachycardia, hypotension and high fever). Hydrops of the gallbladder is detected from radiological examinations. A decision was made to take the patient immediately to surgery. He is suffering from Type 1 DM, being treated with an intensive insulin regimen, with 10 – 12 units of rapid-acting insulin before meals and 36 units of basal insulin (glargine) before bedtime. His blood glucose level is 283 mg/dl (15.7 mmol/L), and electrolytes, urea, and creatinine concentrations are within normal limits. How can this patient be managed so that urgent surgery can be performed? Were this patient (with Type 1 DM) to undergo a minor surgical procedure, how should he be managed? CASE STUDY 1 A 30 year old man with Type 1 DM is under treatment with isophane insulin (NPH), 10 units in the morning and 14 units in the evening, as well as insulin Aspart before each meal (at a dose determined based on the carbohydrate content of the meal and the pre-prandial blood glucose level). The usual daily dose of insulin Aspart is 20– 24 units). His glycaemic control is very good (recent HbA 1c : 6.9 percent). The patient called his primary physician in the morning because during the previous night he had four episodes of vomiting, abdominal pains and three episodes of diarrhoea. His blood glucose level in the morning was 320 mg/dl (17.8 mmol/L). He continued to feel intense nausea and when attempting to drink water, he vomited again. CASE STUDY 2 A 70 year old woman with Type 2 DM for 10 years, smoker, with mild chronic obstructive pulmonary disease (COPD), is being treated with oral antidiabetic medicines (glibenclamide 15 mg daily and metformin 850 mg daily). Her glycaemic control is moderate (last HbA 1c : 7.9 percent). She urgently called her treating physician because 24 hours ago she developed fever (up to 38.6 C [101.5 F]), cough and a moderate degree of dyspnoea, which did not improved despite use of inhaled bronchodilators. Her blood glucose levels were persistently higher than 400 mg/dl (22.2 mmol/L) for the previous 12 hours, despite the fact that she ‘ does not eat nearly anything ’ and despite the fact that she took the initiative to take one extra pill of glibenclamide 5 mg and one of metformin 850 mg. She has a dry mouth, intense polydipsia and polyuria. She is asking for help with management of the high blood glucose levels. CASES STUDY 1 A 37 year old man with Type 1 DM since the age of 14, comes to the diabetes clinic for a routine visit. He is treated with an intensive insulin regimen, consisting of three injections of rapid-acting insulin analogue before main meals (dose based on pre-prandial glucose measurements and carbohydrate food counting) and one injection of long-acting insulin glargine at bedtime. He consumes three main meals and 2– 3 snacks daily. His glycaemic control has generally been quite good for many years (fasting blood glucose: 80– 110 mg/dl [4.4– 6.1 mmol/L], postprandial < 140 mg/dl [7.8 mmol/L], HbA 1c : 5.7 percent), with relatively few hypoglycaemic episodes, of which he is always aware. During the last month the patient has started participating in an exercise programme with some friends, playing tennis three times a week, late in the afternoon (7– 8 p.m.). He observed that on the days of tennis playing he had severe hypoglycaemic episodes during the following night. Indicative measurements of the last five days are shown in Table 9.4 (the units of rapidacting insulin analogue administered are in parenthesis). CASE STUDY 2 A 34 year old man with well controlled diabetes receives six units rapid-acting (regular) insulin and six units isophane insulin before breakfast (9 a.m.), four units rapid-acting insulin before lunch (1 p.m.) and four units rapid-acting insulin with six units isophane insulin before dinner (8 p.m.). He exercises daily (walks around 5 km [3.1 miles] every morning before breakfast). For the previous two days he felt a bit sick, with mild fever and cough, but decided not to abandon his daily exercise programme. He woke in the morning (8 a.m.) with blood glucose level 298 mg/dl (16.5 mmol/L) and decided to take his usual walk and administer his morning insulin afterwards, before breakfast. He noticed he was much more tired today after walking and was surprised to see his blood glucose level had climbed up to 355 mg/dl (19.7 mmol/L) after walking. Urine ketones were positive. CASE STUDY 1 A 35 year old healthy woman, with a history of an unexplained miscarriage six months ago, wishes to become pregnant again. Is there a chance that this woman will develop gestational diabetes and how will the diagnosis be made?. CASE STUDY 3 – MANAGEMENT OF A WOMAN WITH GESTATIONAL DIABETES A pregnant woman in the 25th week of gestation is subjected to a three-hour oral glucose tolerance test with 100 g glucose. The following results are obtained: fasting plasma glucose: 90 mg/dl (5.0 mmol/L); one hour 198 mg/dl (11.00 mmol/L); two hours 160 mg/dl (8.9 mmol/L); and three hours 115 mg/dl (6.4 mmol/L). What advice should she be given and how should she be monitored during pregnancy after these results? CASE STUDY 1 A 12 year old boy has lost 6 kg (13.2 lb) over the last six months. At the same time he exhibited intense polydipsia and polyuria. His paediatrician ordered some laboratory tests and found that he was suffering from Type 1 DM. Information about the disease brought up many queries for the child and his parents. The child was not initially receptive to talking about the problem or getting trained for insulin injections and self monitoring of blood glucose. Is this anticipated? What is the reaction of a young person and his or her family to the onset of Type 1 DM? CASE STUDY 2 A 15 year old girl is suffering from Type 1 DM. She is treated with four injections of insulin per day. During the last two days she had vomiting and intense polyuria and polydipsia. She was admitted to the hospital with diabetic ketoacidosis. The cause, as the patient herself admitted, was that she had neglected her injections lately, in an attempt to lose weight. Is this frequent? What are appetite disturbances in young persons with DM? CASE STUDY 3 Mrs Anna is 38 years old and is the mother of a 16 year old girl who suffers from Type 1 DM. During the last two years, the daughter has had very poor glycaemic control and continues to be extremely disobedient. The mother wants to discuss the problem with the physician and look for solutions. CASE STUDY 4 A 7 year old boy is suffering from Type 1 DM. His parents are anxious and want to ask the physician and the treating health care team what they should know themselves and what the child should know. CASE STUDY 5 A 16 year old boy is suffering from Type 1 DM. His glycaemic control is poor and his parents are worried because he eats lots of sweets and has started smoking. Is there reason for worry? Can the problem be dealt with? CASE STUDY 1 An 85 year old man with Type 2 DM for 20 years, hypertension and dyslipidaemia, presents with a stroke, that causes left hemiparesis and severe restriction in his mobility (he can transfer from the bed to the chair only with help, he can dress with help, he can eat alone but cannot walk alone). His DM is treated with a combination of oral antidiabetic medicines (metformin at noon) and two doses of a mixture of insulin (70 percent isophane and 30 percent rapid-acting) in the morning and night before meals. His glycaemic control prior to the stroke was moderate (HbA 1c 7.5 percent, fasting blood glucose 150– 200 mg/dl [8.3– 11.1 mmol/L], though very rarely did he measure post-prandial blood glucose levels, usually > 200 mg/dl [11.1 mmol/L]). Before the stroke he lived alone, but now he lives with his daughter, who works during the day and has hired a helper to care for her father during her absence. The daughter reports that her father has become more insular since the stroke and ‘seems to have declined: he frequently doesn’t eat his food, shows no interest in anything and sleeps all the time’. She is worried about his glycaemic control, whether it could lead to a second stroke. She also has difficulties with insulin injections (in the morning she leaves for work early, before her father eats his breakfast; the helper comes later). She is asking for the doctor’s advice. CASE STUDY 2 A 76 year old woman with Type 2 DM for 15 years comes to the diabetic clinic for a routine visit. She is treated with maximal doses of sulfonylureas and metformin. Her blood pressure is 130/80 mmHg and her weight 82 kg (180.8 lb, BMI: 27 kg/m 2 ). She occasionally measures her blood sugar at home (3 – 4 times per week, usually in the morning or more rarely at noon after lunch – she says that ’ s how her doctor instructed her). Her measurements are usually high (in the morning 180 – 220 mg/dl [10.0 – 12.2 mmol/L], postprandially at noon always > 200 mg/dl [11.1 mmol/L]). Her HbA 1c is 8.2 percent. She also receives a statin every night and an ACE inhibitor/ thiazide diuretic combination antihypertensive tablet. She has no complaints except for nocturia (once or twice a night) and is generally very active. She has mild benign retinopathy (the ophthalmologist has recommended quarterly follow-ups for the time being) and no microalbuminuria. What is the proper further management of this patient? CASE STUDY 3 A 78 year old man with Type 2 DM for 30 years, and a history of coronary heart disease (myocardial infarction and coronary artery bypass surgery eight years ago), hypertension and dyslipidaemia, comes to the diabetic clinic for a routine follow-up. He uses a mixture of 70/30 insulin, 28 units in the morning and 18 units in the evening before meals and occasionally rapid-acting insulin before lunch (usually 5 – 6 units before meals) subcutaneously. He says he measures his blood sugar regularly (always twice and sometimes three times a day) and is unhappy that his glucose control is not very good (morning blood sugar levels 120 – 220 mg/dl [6.7 – 12.2 mmol/L], evening 180 – 240 mg/dl [10.0 – 13.3 mmol/L], noon 200 – 340 mg/dl [11.1 – 18.9 mmol/L]). The patient is in very good general health, walks daily for at least 30 – 45 minutes without any problems and is generally very active (he is a retired civil servant and likes to work in his garden). He reports very frequent hypoglycaemias, usually around noon. His HbA 1c is 8.4 percent, his weight 92 kg (202.9 lb, BMI: 30.1 kg/m 2 ) and his blood pressure under good control. CASE STUDY 1 A 68 year old woman, with poorly controlled DM of 25 years duration, comes to the diabetes clinic for follow-up. Her fasting blood glucose is around 256 mg/dl (14.2 mmol/L) and her HbA 1c is 11.2 percent. The patient complains of pricking pains, burning sensation and numbness in her lower extremities, as well as frequent cramps. Furthermore, she reports deterioration of her vision lately with decrease in her visual acuity and blurred vision. She has a history of operated cataract in the left eye. Physical examination is remarkable only for: BP 170/90 mmHg, a systolic murmur in the apex and abolition of Achilles tendon re fl exes bilaterally. Her antidiabetic regimen includes: glibenclamide tablets 5 mg, 1 Â 3, and metformin tablets 850 mg, 1 Â 3 daily. Fundoscopy reveals diabetic maculopathy bilaterally, without obvious lesions in the rest of the retina. What would you recommend for this patient? CASE STUDY 1 A 64 year old woman without previous history of DM presents at the outpatient clinic with mild xerostomia, polyuria and polydipsia. She reports having dyslipidaemia and hypertension for a year, treated with cilazapril 5 mg and amlodipine 10 mg daily. She is a smoker, has a moderate alcohol consumption, is obese (weight: 80 kg [176.4 lb], height: 1.62 m [5 ft, 4 in], BMI: 31 kg/m 2 ), and has arterial pressure 170/80 mmHg; otherwise her physical condition is unremarkable. Laboratory fi ndings: fasting blood glucose 112 mg/ dl (6.2 mmol/L); urinalysis abundant WBCs and urine protein ( þþþ ). What would you initially recommend for the patient? CASE STUDY 1 A 67 year old woman, with a 15 year history of Type 2 DM, comes to the clinic for a routine visit. She is treated with a mixture of shortand long-acting insulin in the morning and evening and also rapid-acting insulin before lunch. DM control is very good (recent HbA 1c : 6.9 percent). The patient reports burning pains in the soles for the last year, aggravated at night. Sometimes the discomfort is so intense that she has to get up and walk around or insert her feet in cold water to get some relief. How are her symptoms explained?

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