Case Studies Flashcards
An overweight 55-year-old woman presents for preventative care. She notes that her mother died of diabetes, but reports no polyuria, polydipsia, or weight loss. BP is 144/92 mmHg, fasting blood sugar 8.2 mmol/L (148 mg/dL), HbA1c 65 mmol/mol (8.1%), LDL-cholesterol 5.18 mmol/L (200 mg/dL), HDL-cholesterol 0.8 mmol/L (30 mg/dL), and triglycerides 6.53 mmol/L (252 mg/dL).
T2DM
A 12-year-old white girl is brought to the emergency department by her parents due to 12 hours of rapidly worsening nausea, vomiting, abdominal pain, and lethargy. Over the last week she has felt excessively thirsty and has been urinating a lot. Physical examination reveals a lean, dehydrated girl with deep rapid respirations, tachycardia, and no response to verbal commands.
T1DM
A 20-year-old man is brought to the accident and emergency department with abdominal pain, nausea, and vomiting with increasing polyuria, polydipsia, and drowsiness since the previous day. He was diagnosed with type 1 diabetes 2 years previously. He mentions that he ran out of insulin 2 days ago. Vital signs at admission are: BP 106/67 mmHg, heart rate 123 beats per minute, respiratory rate 32 breaths per minute, temperature 37.1°C (98.8°F). On mental status examination, he is drowsy. Physical examination reveals Kussmaul’s breathing (deep and rapid respiration due to ketoacidosis) with acetone odour and mild generalised abdominal tenderness without guarding and rebound tenderness. Initial laboratory data are: blood glucose 25.0 mmol/L (450 mg/dL), arterial pH 7.24, PCO2 25 mmHg, bicarbonate 12 mmol/L (12 mEq/L), WBC count 18.5 × 10⁹/L (18,500/microlitre), sodium 128 mmol/L (128 mEq/L), potassium 5.2 mmol/L (5.2 mEq/L), chloride 97 mmol/L (97 mEq/L), serum urea 11.4 mmol/L (32 mg/dL), creatinine 150.3 micromol/L (1.7 mg/dL), serum ketones strongly positive.
DKA
A 72-year-old man is brought to hospital from a nursing home for progressive lethargy. The patient has a history of hypertension complicated by a stroke 3 years previously. This has impaired his speech and rendered him wheelchair-bound. He also has schizophrenia for which he was started recently on clozapine. On presentation, he is disoriented to time and place and febrile, with a temperature of 38.3°C (101°F). Vital signs include a BP of 106/67 mmHg, heart rate of 106 beats per minute, and a respiratory rate of 32 breaths per minute. Initial laboratory work-up reveals a serum glucose of 52.7 mmol/L (950 mg/dL), a serum sodium of 127 mmol/L (127 mEq/L), a serum urea of 21.1 mmol/L (59 mg/dL), and a serum creatinine of 200 micromol/L (2.3 mg/dL). Serum osmolality is calculated as 338 mOsm/kg (338 mmol/kg). Urinalysis reveals numerous white blood cells and bacteria. Urine is positive for nitrates but negative for ketones. Serum is negative for beta-hydroxybutyrate.
HHS
A 45-year-old man with a history of type 2 diabetes is admitted directly from clinic for a serum glucose of 53.8 mmol/L (970 mg/dL). He was started recently on basal bolus insulin therapy after several years of treatment with oral hypoglycaemic agents. However, he reports not having followed his insulin prescription because he struggles to inject himself. For the past 2 weeks he has had polyuria and polydipsia, and has lost 5 kg in weight. He has also noted a progressively worsening cough for approximately 3 weeks that is productive of greenish-brown sputum. On examination, he is febrile, with a temperature of 38.5°C (101.3°F), tachypnoeic (respiratory rate of 24 breaths per minute), and normotensive. Urinalysis reveals trace ketones, but serum beta-hydroxybutyrate is not elevated. Serum bicarbonate is 17 mmol/L (17 mEq/L), and venous pH is 7.32.
HHS
A 38-year-old woman, who in the past had tried to lose weight without success, is happy to see that in the last 2 months she has lost about 11 kg (25 pounds). She also has difficulty sleeping at night. Her husband complains that she is keeping the house very cool. She recently consulted her ophthalmologist because of redness and watering of the eyes. Eye drops were not helpful. She consults her doctor for fatigue and anxiety, palpitations, and easy fatigability. On physical examination, her pulse rate is 100 bpm and her thyroid is slightly enlarged. Conjunctivae are red and she has a stare.
Graves Disease
