Case study 005

Please wait while the activity loads.
If this activity does not load, try refreshing your browser. Also, this page requires javascript. Please visit using a browser with javascript enabled.

If loading fails, click here to try again

Start

You have completed Case Study 005. Your score is %%PERCENTAGE%%. %%RATING%%

Your answers are highlighted below.

Question 1

Mrs. A is 76-year-old lady with 21 years history of Type 2 Diabetes Mellitus. Her neighbour found her at her home being confused and agitated. Her clothes were soaked with urine, and she were only saying “I do not want to eat!” to any question. According to her neighbour, she lives alone and has been independent performing daily activities before. She was brought to the emergency department by ambulance. Metformin, gliclazide and captopril were found in her purse. Her Accu-Check showed 38 mmol/L and maintenance fluid (0.9% NaCl) was started by the paramedics.

On examination:

Height: 172 cm, Weight: 80.4 kg, BMI: 27.2
BP: 112/66 mmHg, Heart Rate: 122/min, Respiratory Rate: 26 /min, Temperature: 38.6C, OSAT: 94%
Patient is drowsy, disoriented to place, person, and time. Dry tongue and mucous membranes. Diminished skin turgor and tenting. Breathing is rapid and shallow.

What specific laboratory tests can be ordered for Mrs. A to determine the status of her diabetes?

A	Complete blood count
B	Serum glucose
C	Glucose tolerance test
D	Hemoglobin A1C
E	Arterial blood gas analysis
F	Urine and plasma osmolarity
G	Urinary ketone
H	Cholesterol and triglyceride
I	TSH, T3, T4
J	Plasma insulin level and C peptide
K	BUN and creatinine

Question 1 Explanation:

To determine the status of glucose metabolism in this case, serum glucose, hemoglobin A1c, urine and plasma osmolarity and urinary ketone bodies would be ordered. Glucose tolerance test is done to diagnose diabetes mellitus. Plasma insulin level and C peptide are more useful in determining the type of diabetes which is already known in Mrs. A’s condition. Other blood tests are not related to glucose metabolism status.

Question 2

Mrs. A's laboratory investigation showed:

Blood analysis:
- CBC:
  - RBCs: 4.0 x 10¹²/L, Hemoglobin: 129 g/L, Hematocrit: 0.41
  - MCV: 89 fL, MCH: 29 pg, RDW: 11.9%, Reticulocytes: 1.8%, ESR: 17 mm/hour
  - WBC: 13.8 x 10⁹/L, (Neutrophils: 9.2 x 10⁹/L, Lymphocytes: 3.8 x 10⁹/L, Basophils: 0.03 x 10⁹/L, Eosinophils: 0.32 x 10⁹/L, Monocytes: 0.43 x 10⁹/L)
  - Platelet counts: 206 x 10⁹/L
- Na: 135 mmol/L, K: 3.8 mmol/L, Cl: 105 mmol/L
- Glucose: 35 mmol/L, HbA1C: 10.4%, BUN: 14.3 mmol/L, Creatinine: 94.7 µmol/L, Uric acid: 389 mmol/L
- Triglycerides: 3.3 mmol/L, Cholesterol: 6.0 mmol/L, HDL: 0.9 mmol/L, LDL: 3.9 mmol/L
- Bilirubin: 8.0 mmol/L, Albumin: 41.7 g/L
- Serum osmolarity: 326 mmol/kg
Urinalysis:
- Color: light yellow, pH: 5.2, Specific gravity: 1043, Osmolarity: 1379 mOsm/kg, Glucose: ++++, Ketones: negative, Albumin, Bilirubin, Urobilinogen: negative, Nitrates: +++, WBCs: over 100/HPF, RBCs: nil, Phosphate crystals: ++, Yeast: ++, Bacteria: ++, Squamous epithelial cells: 6-8 cells/HPF
Arterial Blood Gases:
- pH: 7.35
- Oxygen saturation: 95%
- P_aO₂: 87 mmHg
- P_aco₂: 37 mmHg
- HCO3: 22 mmol/L
- Anion gap: 11.8 mmol/L

Select all the characteristics that have to be identified in order to determine the accurate diagnosis for Mrs. A. (select all that apply)

A	Leukocytosis
B	Hyperosmolarity
C	Hyperglycemia
D	Ketoacidosis
E	Dehydration
F	Hyperkalemia
G	Low plasma insulin level

Question 2 Explanation:

Hyperosmolar, hyperglycemic state (HHS) is characterized by severe hyperglycemia (usually above 30 mmol/L), hyperosmolarity, dehydration and the absence of ketoacidosis. Important laboratory findings to notice are the followings: extreme hyperglycemia, high serum, and urine osmolarity, high BUN. The blood gas analysis shows normal pH or mild metabolic acidosis with no ketonemia. Ketone bodies in urine are negative or very mild. Patients with type 2 diabetes usually have normal or even high plasma insulin levels.

Question 3

What differentiates Mrs. A’s condition from diabetic ketoacidosis (DKA)? (select all that apply)

A	The normal plasma pH
B	The lack of ketone bodies in the serum and urine
C	The lack of insulin secretion from the pancreas
D	The extreme high value of serum glucose

Question 3 Explanation:

Both HHS and DKA are severe complications of diabetes mellitus. However, HHS is more common in elderly patients with type 2 diabetes. The main feature that differentiates HHS from DKA is the lack of accumulation of keto acids in the blood and consequently the absence of ketone bodies in the urine. The patient typically does not present with the fruity odor of acetone or Kussmaul breathing.

Question 4

Which of the following statements is correct to explain why ketone bodies do not accumulate in HHS?

A	Insulin inhibits the breakdown of proteins, which would be the main source of keto acids.
B	Insulin stimulates glycogenesis so keto acids are used up from the blood by the liver cells.
C	Insulin inhibits lipogenesis which prevents the formulation of keto acids.
D	Insulin inhibits lipolysis which prevents the formation of keto acids.

Question 4 Explanation:

In type 2 diabetes, there is some level of insulin production by the pancreas which prevents the accumulation of keto acids in the body. In the complete absence of insulin, the cells (mainly liver) are breaking down fatty acids to produce energy in the absence of glucose, and this results in formation of keto acids. These keto acids cannot be metabolized by the liver cells, instead they are released to the blood. In type 2 diabetes, insulin is still able to stimulates lipogenesis. This prevents lipid breakdown which is enough to prevent ketosis.

Question 5

Have another look at the description of the case and laboratory results before you answer the following question. Mrs. A is 76-year-old lady with 21 years history of Type 2 Diabetes Mellitus. Her neighbour found her at her home being confused and agitated. Her clothes were soaked with urine, and she were only saying “I do not want to eat!” to any question. According to her neighbour, she lives alone and has been independent performing daily activities before. She was brought to the emergency department by ambulance. Metformin, gliclazide and captopril were found in her purse. Her Accu-Check showed 38 mmol/L and maintenance fluid (0.9% NaCl) was started by the paramedics. On examination:

Weight: 80.4 kg, Height: 172 cm, BMI: 27.2
BP: 112/66 mmHg, Heart Rate: 122/min, Respiratory rate: 26/min, Temperature: 38.6 ⁰C, O₂SAT: 94%

Blood analysis:

- CBC:
  - RBCs: 4.0 x 10¹²/L, Hemoglobin: 129 g/L, Hematocrit: 0.41
  - MCV: 89 fL, MCH: 29 pg, RDW: 11.9%, Reticulocytes: 1.8%, ESR: 17 mm/hour
  - WBC: 13.8 x 10⁹/L, (Neutrophils: 9.2 x 10⁹/L, Lymphocytes: 3.8 x 10⁹/L, Basophils: 0.03 x 10⁹/L, Eosinophils: 0.32 x 10⁹/L, Monocytes: 0.43 x 10⁹/L)
  - Platelet counts: 206 x 10⁹/L
- Na: 135 mmol/L, K: 3.8 mmol/L, Cl: 105 mmol/L
- Glucose: 35 mmol/L, HbA1C: 10.4%, BUN: 14.3 mmol/L, Creatinine: 94.7 µmol/L, Uric acid: 389 mmol/L
- Triglycerides: 3.3 mmol/L, Cholesterol: 6.0 mmol/L, HDL: 0.9 mmol/L, LDL: 3.9 mmol/L,
- Bilirubin: 8.0 mmol/L, Albumin: 41.7 g / L,
- Serum osmolarity: 326 mmol/kg

Urinalysis:

- Color: light yellow, pH: 5.2, Specific gravity: 1043, Osmolarity: 1379 mOsm/kg, Glucose: ++++, Ketones: negative, Albumin, Bilirubin, Urobilinogen: negative, Nitrates: +++, WBCs: over 100/HPF, RBCs: nil, Phosphate crystals: ++, Yeast: ++, Bacteria: ++, Squamous epithelial cells: 6-8 cells/HPF

What could have been the most probable precipitating factor in the development of Mrs. A’s condition?

A	Progressive diabetic nephropathy
B	A sudden decline of her cognitive function and memory impairment
C	Urinary tract infection
D	Insufficient water intake
E	Not eating enough

Question 5 Explanation:

Mrs. A has fever and leukocytosis, which suggests an infection. The urinalysis shows nitrates, white blood cells and significant bacteriuria. These findings indicate urinary tract infection, which is one of the most common precipitating factors in the development of hyperglycemic, hyperosmolar state in diabetic patients.

Question 6

Which of the following measures is number one priority for the management of Mrs. A? (choose only one)

A	Bolus intravenous insulin therapy
B	Fluid and electrolyte replacement
C	Broad spectrum antibiotic
D	Intravenous bicarbonate

Question 6 Explanation:

In HHS, the patient is severely dehydrated. Fluid and electrolyte replacement is priority to correct dehydration. Intravenous fluid replacement with 0.9% NaCl solution, also, improves renal perfusion, lowers the serum glucose level, and decreases hyperosmolarity. After fluid has been started, the patient would be given intravenous insulin as well, and the dose should be titrated according to the blood glucose level. A broad-spectrum antibiotic should be started empirically while waiting for the urine culture.

Once you are finished, click the button below. Any items you have not completed will be marked incorrect. Get Results

There are 6 questions to complete.

←

List

→

Return

Shaded items are complete.

1	2	3	4	5
6	End

Return