Diabetes Exam Question

Kieran Kitchener

Question 1

• Amritpal, a 10 year old boy, has developed a flu-like illness over the last few months according to his parents. He has found that playing sports tires him out more than it used to, he has to go to the toilet far more often and passes more urine than he used to.

• His parents bring him in for a consultation with you.

• What questions would you ask him? (3)• What exams would you perform? (3)

• Questions:– Have you lost any weight– Has your intake of fluid dramatically increased?– Do you feel the need to urinate in the night?

• Examinations– Look at appearance in general.– Pulse and respiration– Smell his breath.

• The exam finds the presence of glucose and ketones in his urine. His blood shows an elevated level of glucose and a lowered pH value.

• What do you think his diagnosis is? (1)• Why? (3)

• Type I diabetes mellitus with ketoacidosis.

• The lack of control of type I diabetes from insulin deficiency means there is no storage of glucose as glycogen in the liver. When the body is in the fasted state it starts to use up fatty acids to provide energy. This creates ketones which cause acidity.

• Supporting signs are polyuria, polydipsia, weight loss, fatigue, hyperglycaemia and ketoacidosis.

• What will happen if Amritpal is not given rapid treatment? (1)

• Diabetic ketoacidosis can lead to a ketoacidotic coma and death if it is not treated.

• Mechanism for this - the condition leads to electrolyte and fluid loss, hyperosmolar plasma and acidosis.

• How, in general, would you expect his treatment to proceed? (3)

• Slow IV infusion of insulin• Fluid replacement• Possible bicarbonate to raise pH (tricky to

calculate, in control of the specialist. Leave this to be your last possible answer in exams)

• When glucose is under control – insulin injections.

• What long-term problems may Amritpal face? (6)

• Normal diabetic complications:– Vascular disease – blindness, kidney failure, nerve

damage, stroke, heart disease, – Coma

• Problems with diabetic control:– Problems with hyperglycaemia, control of diet– Problems when factoring exercise.

• Problems with treatment– Allergies to insulin, dosage problems, site of

injection

Question 2

• Brenda, a 55 year old lorry driver, has recently felt tired and irritable. She has decided to come for a check-up and you have found the following on questioning and examination:

• Questions:– Recently undergone menopause– Recurring vaginal candidiasis– Increased lethargy– Recently lost weight but still has a BMI of 33.– Has polyuria and polydipsia

• Examination:– Normal pulse– BP – 150/95– Weight loss– Urine – high glucose, no nitrates, no protein, no

ketones.

• What are polyuria and polydipsia

• What do these results indicate?

• Is this as urgent a case as in the previous question?

• Polyuria – excessive or abnormally large production of urine with increase of urinary frequency.

• Polydipsia – excessive thirst

• Results indicate Type II Diabetes Mellitus

• Not as urgent as not ketoacidotic – no progression into coma.

• Hopefully you said she has TIIDM. What is your reasoning for this?

• Age of onset• High BMI• Vaginal candidiasis• Recent loss of weight• Lack of ketones in urine (not always present

but if they do it would indicate Type I)• Normal diabetic symptoms

• What blood test could you perform to see how well Brenda’s diabetes is controlled?

• HbA1c

• This is a protein in blood cells that glucose binds to, causing glycosylation. The levels of glycosylation depend on the amount of glucose that has been in the blood over time.

• Good for looking at long term diabetes control as patients often start taking medicine again just before a check-up, shifting glucose tolerance test results.

• What would you expect the basics of her treatment to be?

• Initially more control of diet is needed.• Add an exercise regime in.• Oral hypoglycaemia agents• May eventually require insulin.