Case study 015

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Question 1

Mrs. L. is 50-year-old women. She came to the clinic for a check up because she had been experiencing fatigue, thirst, and frequent urination in the past few months. She mentioned that she had to get up several times during the night to go to the washroom and drink some water.. Lately she noticed tingling and numbness of her fingers and feet. She reports losing some weight recently without changing her diet. Her medical history includes hypertension and dyslipidemia. She takes enalapril, an ACE inhibitor, and a statin regularly.

On examination:

Weight: 86 kg, Height: 163 cm, BMI: 32.4
BP: 138/88 mmHg, Heart Rate: 82/min, Respiratory rate: 18/min, O₂ SAT: 98%
Dry tongue and mucous membranes. Review of system otherwise insignificant.

According to Mrs. L.’s clinical symptoms, what specific laboratory tests would be useful to further examine her condition? (select the top three)

A	Hemoglobin
B	White blood cell count and differential
C	Serum glucose
D	Hemoglobin A1C
E	TSH, free T3 and T4
F	Serum creatinine and GFR
G	Serum bilirubin
H	Urinary glucose and ketones

Question 2

Mrs. L's laboratory examination showed:

Blood analysis:
- CBC:
  - RBCs: 4.1 x 10¹²/L, Hemoglobin: 131 g/L, Hematocrit: 0.39
  - MCV: 81 fL, MCH: 28 pg, RDW: 11.7%, Reticulocytes: 1.8%, ESR: 11 mm/hour
  - WBC: 12.5 x 10⁹/L, (Neutrophils: 8.7 x 10⁹/L, Lymphocytes: 2.5 x 10⁹/L, Basophils: 0.02 x 10⁹/L, Eosinophils: 0.03 x 10⁹/L, Monocytes: 0.80 x 10⁹/L)
  - Platelet counts: 216 x 10⁹/L
- Na: 143 mmol/L, K: 4.2 mmol/L, Cl: 103 mmol/L
- Glucose: 21 mmol/L, HbA1C: 10.3%, BUN: 9.2 mmol/L, Creatinine: 97.2 µmol/L, Uric acid: 342 mmol/L
- Triglycerides: 2.5 mmol/L, Cholesterol: 6.3 mmol/L, HDL: 1.0 mmol/L, LDL: 3.4 mmol/L, (TC/HDL-C): 6.3
- Bilirubin: 12 mmol/L, Albumin: 39 g/L,
Urinalysis:
- Color: light yellow, pH: 5.2, Specific gravity: 1030, Osmolarity : 1040 mOsm/kg; Glucose: +++, Ketones: negative, Albumin, Bilirubin, Urobilinogen: negative, Nitrates:+, WBCs: 8-10/HPF, RBCs: 0/HPF, Phosphate crystals: +, Yeast: ++, Bacteria: +, Squamous epithelial cells: 2-4/HPF

What is the provisional diagnosis for Mrs. L's condition?

A	Impaired glucose tolerance
B	Diabetes mellitus type 1
C	Diabetes insipidus
D	Hypoglycemia
E	Diabetes mellitus type 2

Question 3

All of the followings are correct statements about the effect of insulin on metabolism, EXCEPT:

A	Insulin has an anabolic effect on the metabolism.
B	It stimulates glycogenesis and inhibits glycogenolysis.
C	Insulin also enhances the glucose uptake of muscle cells and adipocytes.
D	Insulin stimulates lipolysis so the cells can generate ATP from beta oxidation in the absence of glucose.

Question 3 Explanation:

Insulin inhibits lipolysis through inhibition of lipase enzyme. It has a lipogenic effect as it stimulates triglyceride synthesis in the adipocytes. All other statements are correct.

Question 4

Mrs. L's urine analysis showed:

Urinalysis:
- Color: light yellow, pH: 5.2, Specific gravity: 1030, Osmolarity : 1040 mOsm/kg; Glucose: +++, Ketones, Albumin, Bilirubin, Urobilinogen: negative, Nitrates:+, WBCs: 8-10/HPF, RBCs: 0/HPF, Phosphate crystals: +, Yeast: ++, Bacteria: +, Squamous epithelial cells: 2-4/HPF

What is the reason of glucosuria?

A	Glucose is filtered by the glomeruli and secreted in the proximal convoluted tubules if the blood sugar level is high.
B	All filtered glucose is excreted in urine because the renal tubules cannot reabsorb glucose.
C	If the serum glucose level is above the renal threshold, the renal tubules cannot reabsorb all the filtered amount, so glucose appears in the urine.
D	The kidneys are the main site of gluconeogenesis. Excessive gluconeogenesis results in glucosuria.

Question 4 Explanation:

Normally, all filtered glucose is reabsorbed in the proximal convoluted tubules. The renal threshold for glucose reabsorption is 10 mmol/L (180 mg/dL).. The liver is the main site of gluconeogenesis. The kidney contributes only by 10% of gluconeogenesis.

Question 5

Insulin and C peptide levels were measured:

Serum insulin level: 250 pmol/L
C peptide: 0.72 nmol/L

How do you interpret these results?

A	Both are normal.
B	Both are elevated, which reflects hyperinsulinism and insulin resistance.
C	Both are low, which is consistent with type 1 diabetes.
D	Insulin level is high and C peptide is low which is common in obese patients.

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