Case Study 14.

A 14-year old male student was seen by his physician. His

chief complaints were fatigue; weight loss; and increase in
appetite, thirst and frequency of urination. For the past 3 to 4
weeks, he had been excesively thirsty and had to urinate every
few hours. He began to get up three to four times a night to
urinate. The patient has a family history of diabetes milletus.

1. Based on the preceding information, can this patient be

diagnosed with diabetes?

- The patient can be diagnosed with diabetes based on

his laboratory data, that shows his fasting plasma
glucose is hi symptoms he is showing and family
history of diabetes milletus.

2. What further tests might be performed to confirm the

diagnosis?

- Tests that are most commonly used are the fasting

plasma glucose (FPG) test or the A1C test to diagnose
diabetes. The FPG blood test measures your blood
glucose level at a single point in time. For the most
reliable results, it is best to have this test in the
morning, after you fast for at least 8 hours. The A1C
test is a blood test that provides your average levels of
blood glucose over the past 3 months. Other names for
the A1C test are hemoglobin A1C, HbA1C, glycated
hemoglobin, and glycosylated hemoglobin test. You
can eat and drink before this test. When it comes to
using the A1C to diagnose diabetes, your doctor will
consider factors such as your age and whether you
 have anemia or another problem with your blood. The
A1C test is not accurate in people with anemia.

3. According to the American Diabetes Association, what

criteria are required for the diagnosis of diabetes?

Criteria for Diabetes Diagnosis: 4 options

FPG 126 mg/dL (7.0 mmol/L)*
Fasting is defined as no caloric intake for 8 hours
2-hr PG 200 mg/dL (11.1 mmol/L) during OGTT (75-g)*
Using a glucose load containing the equivalent of 75g anhydrous glucose dissolved in water
A1C 6.5% (48 mmol/mol)*
Performed in a lab using NGSP-certified method and standardized to DCCT assay
Random PG 200 mg/dL (11.1 mmol/L)
In individuals with symptoms of hyperglycemia or hyperglycemic crisis
No clear clinical diagnosis? Immediately repeat the same test using a new
blood sample.
Same test with same or similar results? Diagnosis confirmed.
Different tests above diagnostic threshold? Diagnosis confirmed.
Discordant results from two separate tests? Repeat the test with a result above
diagnostic cut-point.

*In absence of unequivocal hyperglycemia, result to be confirmed by repeat testing

4. Assuming the patient has diabetes, which type would be

diagnosed?

- The 14 year old patient may be diagnosed with Type 1

diabetes milletus.
Case Study 14.4

A 13-year old girl collapsed on a playground at school.

When her mother was contacted, she mentioned that her
daughter had been losing weight and making frequent trips to
the bathroom in the night. The emergency squad noticed a
fruity breath.

1. Identify the patients most likely type of diabetes.

- The patient is most likely to have type 1 diabetes

2. Based on your identification, name the common

characteristics associated with that type of diabetes in the
case study above.

- Glucose 500 mg/dL; Ketones: Positive; BUN 6 mg/dL

3. What is the cause of the fruity breath?

- When ketones rise to unsafe levels, the patient is at risk

of a dangerous condition called diabetic ketoacidosis
which causes the fruity breath.
Case Study 14.5

A 28-year old woman delivered a 9.5-lb infant. The infant

was above the 95th percentile for weight and length. The
mothers history was incomplete; she claimed to have had no
medical care through her pregnancy. Shortly after birth, the
infant became lethargic and flaccid. A whole blood glucose and
ionized calcium were performed in the nursery.

1. Give the possible explantion for the infants large birth

weight and size.

- The mother was most likely a gestational diabetic.

2. If the mother was gestational diabetic, why was her baby

hypoglycemic?

- The baby was hypoglycemic because the oversupply of

glucose from the mother was terminated when the
umbical cord was severed.

3. Why was there discrepancy between the whole blood

glucose concentration and the plasma glucose
concentration?

- The difference is that plasma numbers read about 10 -

12% higher than the older whole blood numbers.

4. If the mother had been monitored during pregnancy,

what laboratory tests should have been performed and
what criteria would have indicated that she had
gestational diabetes?

- Fasting blood sugar and OGTT.

Kim Alysson Tan
MT3B
Case Study 14.1

An 18-year old male high school student who had a 4-

year history of diabetes milletus was brought to the emergency
department because of excessive drowsiness, vomiting, and
diarrhea. His diabetes had been well controlled with 40 units
of NPH daily until several days ago when he developed
excessive thirst and polyuria. For the past 3 days, he has also
had headaches, myalgia and a low-grade fever. Diarrhea and
vomiting began 1 day ago.

1. What is the probable diagnosis of this patient based on

the data presented?

- Diabetic Ketoacidosis

2. What laboratory tests should be performed to follow this

patient and aid in adjusting insulin levels?

- Blood test for glucose, serum electrolyte determination,

Initial blood urea nitrogen (BUN), Initial arterial blood
gas (ABG)

3. Why are the urine ketones positive?

- Ketones build up when there is insufficient insulin to

help fuel the body's cells.

4. What methods are used to quantitate urine ketones?

Which ketones do they detect?
- Ketone test / Urine ketones ; aceto-acetate and beta-
hydroxybutyrate
Case Study 14.2

A 58-year old man with frequent urination was seen by his

primary care physician. The following laboratory work was
performed.

1. What is the probable diagnosis of this patient?

- The patient is most likely to be diagnosed with Type 2

diabetes.

2. What other tests should be performed to confirm this?

Which is the preferred test?

- A1c and urinalysis are the tests to be performed.

3. What values from #2 would confirm the diagnosis of

diabetes?

- A1c: 6.5 and above.

- OGTT: 200 mg/dL

4. After diagnosis, what tests should be performed to

monitor his condition?

- Home glucose test, A1c and urinalysis tests are best to

monitor his condition.