Diabetes mellitus 

30 years old man with DM was admitted to internal medicine department due to one year history of diarrhea.

History:

Grand mother of patient is treated since 62 years of age for DM. Patient was in age of 16 years old examined for slimming, thirst, frequent voiding and significant tiresomeness. DM was diagnosed and the insulin therapy in one daily dose was started immediately (Pur Insulin Interdep 24 U s.c. before breakfast).

During last year he observes intermittent (3-4 x night) watery stools, without tenesms (cramps) and any pathological admixtures, the body weight is not changing. Generally he feels well, once he overcome hypoglycemia associated with unconsciousness during increased physical activity, in the morning he feels sometimes thirst. During last week the voiding is more frequent, without any dysuric pains. He is regularly checked by diabetologist every two months; he does not perform self monitoring of glycemia.

Objective medical finding:

Height 175 cm, weight 73 kg, BP 110/70, HR 72/min, physical state appropriate to age.

Laboratory results:

Blood: daily glycemic profile (mmol/l): fasting 20,4; 1 hour after breakfast: 21,8; before lunch: 18,0; 1 hour after lunch: 12,5; before supper: 5,6; 1 hour after supper 14,3; before sleep: 12,0; At 2:00 AM 15,8; glycosylated hemoglobin 12,3%; glycosylated protein 3,2 mmol/l; C peptid < 0,02 pmol/l

Urine: ketonuria in the morning portion ++; glycosuria (grams of glucose): morning portion: 26, afternoon portion 7, night portion 50; quantitative proteinuria: 20 mg/24 hours

 

Questions:

Question No. 1: Symptoms, which preceded the DM diagnosis in our patient, are:

  1. Typical for DM type I.
  2. Typical for DM type II.
  3. More typical for urinary tract infection

Question No. 2: Our patient is treated with Pur Insulin Interdep – one daily dose. Taking into consideration the results of daily glycemic profile, glycosuria and ketonuria:

  1. we change the therapy
  2. we will continue with the same therapy

Question No. 3: Morning hyperglycemia and feeling the thirst in the morning are symptoms of: 

  1. Somogyi phenomenon
  2. insufficient effect of insulin
  3. „dawn phenomenon“

Question No. 4: Are there any other signs of incorrect compensation of DM (except of hyperglycemia, glycosuria and ketonuria) in history, objective finding or laboratory results?

  1. Yes.
  2.  No.

Question No. 5: The concentration of C-peptid in the blood of our patient is almost zero. It means:   

  1. that the secreting ability of B-cells completely disappeared.
  2. that there is probably no for of acute inflammation. Higher values of this parameter (normal 70 - 80 pmol/l) are non-specific markers of inflammation.

Question No. 6: DM type I. is characteristic by the fact, that:

  1. Patient is vitally dependent on exogenous insulin
  2. Insulin therapy can be replaced in most of the patients with peroral antidiabetics.

In our patients it is DM type I, which is insufficiently compensated with Pur Insulin Interdep. Self monitoring of glycemia is not used.

Question No. 7: „Self monitoring“ of glycemia means:

  1. monitoring (repeated evaluation) of glycemia 3 x day.
  2. evaluation of glycemia by patient himself, according to necessity or physicians recommendation.
  3. evaluation of glycemia regularly 1 x week.

Question No. 8: Pur Insulin Interdep is:

  1. mono-component (MC) long acting insulin
  2. chromatographically purified (Pur) short acting insulin
  3. mixture of intermediate and long acting chromatographically purified insulin

Question No. 9:Pur Insulin Interdep is insulin suitable for:

  1. Mantanining the basal level of insulin during a day
  2. Flexible decrease of post-prandial glycemia

Question No. 10: For reaching optimal glycemic profile in our patient the best solution is:

  1. to increase the dose of Pur Insulin Interdep, or to apply it in two doses
  2. to replace Pur Insulin Interdep with mono-component animal or human insulin and to introduce intensified insulin regimen.

Question No. 11: Which of the following mono-component insulin preparations is suitable for covering the whole day consumption of insulin?

  1. Actrapid MC
  2. HM Actrapid Penfill 100
  3. Ultralente MC
  4. HM Ultratard

Question No.12: Do you suppose that proposed replacement of insulin form will be sufficient for optimizing of glycemic profile in our patient?

  1. Yes.
  2. No, it is important to substitute increased necessity of insulin associated with main courses.

Question No. 13: Intensified insulin regimen means:

  1. increased number of insulin doses during a day
  2. two daily doses of long acting insulin
  3. administration of human insulin

Question No. 14: For optimal compensation of DM in our patient we select following way of insulinotherapy:

  1. Insulin Ultratard HM as a basal dose before sleep + Actraphane HM Penfill before main courses as a bolus
  2. Continual subcutaneous infusion of mono-component animal or human insulin
  3. Insulin Ultratard HM as a balas dose and glipizid tab á 5 mg /Minidiab/ with main courses

Question No. 15: In case we use the transportable infusion insulin pump (CSII), we use following insulin:

  1. Insulin Actrapid MC
  2. Insulin Semilente MC
  3. Pur Insulin Superdep

Question No. 16: In every patient treated for DM it is important to calculate with risk of hypoglycemia. Therefore, it is necessary to inform relatives what to do in this situation. Let`s say our diabetic patient is working whole afternoon in the garden. He has eaten only small lunch and has forgotten to take some snack in the afternoon. At 5.00 PM he is getting worse, sick, he sweats and gets unconscious. What is to be done by relatives?

  1. To get some sweet tea into his mouth.
  2. To call the emergency, who administers 50 ml of 40% glucose solution i.v.
  3. To administer glucagone 1/mg i.m. and after several minutes (when the patients arises) give some sweet drink.

Except of information about intermittent night watery stools without cramps and pathological admixtures) and findings pointing at bad compensation of DM there are results of following tests:
Xylose test: blood 2 hours after administration – 4.0 mmol/l, urine 5 hours after administration – 52.5 mmol/l
Blood: vitamin A – 2.2 µmol/l, vitamin E – 34.8 µmol/l
Urine: PABA test: 54 %
Stool: without residua; cultivation – negative
Rtg: passage through thin intestine – non-homogeneity of mucosal relief, irregular motility, significant dilatation and elongation of stomach with food residua.
Gastroendoscopy: significant duodeno-gastric reflux

Question No. 17: The mentioned results suggest that the diarrhea:

  1. has probably neurotic origin
  2. is a symptom of malabsorption syndrome
  3. is a result of failure in excretory pancreas function
  4. is a symptom of diabetic visceral neuropathy
  5. has infectious origin

Question No. 18: To the complex of test made for diagnosis of malabsorption syndrome belongs glycemic curve, too. This examination was in our patient:

  1. incorrectly missed and should be completed.
  2. not done, as this test is in current conditions unsuitable.

Question No. 19: The examination of stomach shows diabetic gastropathy, which is often one of symptoms of diabetic neuropathy. Therapeutically, metoclopramid (CERUCAL) 5mg 3x day is suitable together with optimal compensation of DM. Do you agree with this consideration?

  1. Yes.
  2. No, as it is enough to optimize the insulin therapy for influencing gastroparesis.

Question No. 20: During hospitalization the physician asked for ophthalmologic examination. Ophthalmologist found preproliferative diabetic retinopathy on both eyes with numerous hemorrhages, predominantly right side. How would you consider this finding?

  1. It is a typical benign complication of DM. For therapy is appropriate calcium dobesilate (Danium) in dose of 1 tab every 2nd day during several months.
  2. You would repeat the consultation with ophthalmologist, as this finding is not usual before 40 years age.
  3. It is serious complication of DM; the only effective therapy is laser-coagulation.

Question No.  21: Do you think that:

  1. hospitalization was for this patient an optimal solution?
  2. problem could be solved in out-patient form (ambulatory)?  

 

Source: http://lfhk.cuni.cz

 

Solution