Case study 012

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Question 1

Mr. D. is a 42-year-old business owner who has been diagnosed with type 2 diabetes mellitus about a year ago. Since diet and lifestyle changes were not sufficient to manage his blood sugar level, he started taking oral antidiabetic medication (metformin 500). Mr. D. was brought to the ER by his colleague, who found Mr. D. anxious and irritable in his office. His colleague said that Mr. D. was a hard worker and he skipped his breakfast in the morning because of an important business meeting. When arriving to the ER, Mr. D was confused, irritable and his speech was slow. Mr. D does not have a history of similar condition and is not known to have any other medical problems .

On examination:

Weight: 86 kg, Height: 175 cm, BMI: 28
BP: 135/88 mmHg, Temperature: 36.9 ⁰C, Heart rate: 133/min, Respiratory rate: 26/min, O₂SAT: 98%
Skin is pale, cold to touch and diaphoretic.
Random blood glucose check: 2.0 mmol/L

Which of the following hormones match correctly with the producing cells?

A	Amylin – F cells of pancreatic islets
B	Pancreatic polypeptide – pancreatic acinar cells
C	Somatostatin – alpha cells of pancreatic islets
D	Insulin – beta cells of pancreatic islets
E	Glucagon – delta cells of pancreatic islets

Question 1 Explanation:

Insulin is produced by the beta cells of the pancreas islets of Langerhans. Alpha cells produce glucagon, delta cells produce pancreas polypeptide.

Question 2

All of the followings are characteristics of insulin, EXCEPT:

A	Insulin is a polypeptide hormone, synthesized as preproinsulin.
B	Insulin is water-soluble and acts through an extracellular receptor.
C	Insulin primarily acts on muscle cells, liver cells, and adipocytes.
D	Insulin is one among many hormones that lower the blood sugar level.

Question 2 Explanation:

There are many hormones in the body to raise the blood sugar level, such as glucagon, corticosteroids, and thyroid hormones. However, insulin is the main hormone which lowers blood glucose level.

Question 3

Mr. D.’s laboratory examination showed:

Blood analysis:
- CBC:
  - RBCs: 3.9 x 10¹²/L, Hemoglobin: 133 g/L, Hematocrit: 0.39
  - MCV: 88 fL, MCH: 30 pg, RDW: 11.6%, Reticulocytes: 1.8 %, ESR: 9 mm/hour
  - WBC: 6.3 x 10⁹/L, (Neutrophils: 3.3.0 x 10⁹/L, Lymphocytes: 2.4 x 10⁹/L, Basophils: 0.05 x 10⁹/L, Eosinophils: 0.31 x 10⁹/L, Monocytes: 0.2 x 10⁹/L)
  - Platelet counts: 395 x 10⁹/L
- Na: 138 mmol/L, K: 3.9 mmol/L, Cl: 79 mmol/L
- Glucose: 2.2 mmol/L, Hgb A1C: 6.1 %, Creatinine: 99 µmol/L, Uric acid: 285 mmol/L
- Triglycerides: 1.8 mmol/L, Cholesterol: 4.3 mmol/L, HDL: 2.2 mmol/L, LDL: 1.2 mmol/L
- Bilirubin: 12 mmol/L, Albumin: 40 g / L,
- C peptide: 0.72 nmol/L
Urinalysis:
- Color: clear, pH: 5.2, Specific gravity: 1030, Osmolarity: 1040 mOsm/kg; Glucose, Ketones: negative, Albumin, Bilirubin, Urobilinogen: negative, WBCs: 8-10/HPF, RBCs: 0/HPF, Phosphate crystals: +, Yeast: ++, Bacteria: +, Squamous epithelial cells: 2-4/HPF

What is C-peptide?

A	It is a hormone synthesized by the beta cells that has a synergistic effect to insulin.
B	It is a hormone that is synthesized by the C cells in the pancreas in response of hypoglycemia.
C	It is an antibody that destroys the beta cells of the pancreas and thought to be the main cause of type 1 diabetes mellitus.
D	It is part of the structure of proinsulin which connects A and B chains.

Question 3 Explanation:

C peptide is a polypeptide chain that connects the alpha and beta chain together in proinsulin. C-peptide is released when proinsulin is activated to insulin. C-peptide level is elevated in insulin secreting tumor, impaired glucose tolerance, type 2 diabetes mellitus, and decreased in type 1 diabetes mellitus.

Question 4

Measuring the C-peptide levels can be useful in all of the following situations: (select all that apply)

A	To differentiate between type 1 and type 2 diabetes in a newly diagnosed patient
B	To rule out obstruction of the common bile duct
C	To determine pancreatic islet cell function when the patient is on insulin therapy
D	To determine if type 1 diabetes is well-controlled with insulin therapy
E	In cases of factitious hypoglycemia when insulin is administered in too high doses or unnecessarily

Question 4 Explanation:

Other than the situations above, research suggests that C-peptide level is elevated in insulin resistance, in type 2 diabetes, and associated with cardiovascular mortality and diabetic nephropathy. In type 1 diabetes, the C peptide level is low, since the pancreas does not produce insulin even if the blood sugar level is well controlled.

Question 5

What is the normal fasting blood glucose level?

A	3.8-6.1 nmol/L (70-110 mg/dL)
B	4.2-7.2 mmol/L (76-130 mg/dL)
C	3.0-6.1 mmol/L (54-110 mg/dL)
D	3.8-6.1 mmol/L (70-110 mg/dL)
E	3.5-5.1 nmol/L (63-92 mg/dL)

Question 6

What is the recommended dose of intravenous glucose to give if the patient is un-responsive?

A	50 ml of 5% Dextrose
B	10 ml of 10% Dextrose
C	50 ml of 50% Dextrose
D	25 ml of 10% Dextrose
E	5 ml of 50% Dextrose

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