10. Temperature (T) :101.2 F ; BP:98/64 mm Hg P 130/min ; respiratory rate (RR): 28/min.
He is lethargic. Physical examination shows no jugular venous distension , equally
round and reactive pupils , and clear lungs.
Heart : RRR. tachycardic : and abdomen is benign. Neurologic examination shows
no obvious focal deficits.
A 19-year-old man comes to the emergency department with increasing weakness,
and with lethargy for 2 days. He has been complaining of being thirsty and going to
the bathroom to urinate constantly.
Diabetes Mellitus : Case 1
11. Diabetes Mellitus : Case1 Labs:
- Glucose : 426 mg/dL
● Blood Cultures P
- K : 6.1 mg/dL
- BUN 51 : creatinine 1.5 mg/dL
- HCO3: 12 mEq/L
- Na: 130 mg/dL
- Cl: 100 mg/dL
● Chest x-ray P
● UA P
12. Diabetes Mellitus : Case 1 (cont’d)
● Admit: intensive care unit (ICU)
● Aggressive IVF : 0.9 normal saline
● Confirm Ketones in the blood or urine
● Blood and urine cultures, ect.
● In patients with “normal” serum K on admission with DKA: give KCI !
● Insulin: Intravenous, then subcutaneous
13. He appears very lethargic. He is arousable responds incoherently to questions. He
only orients to his name.
A 62-year-old man is brought to the emergency department by his family because he
is confused. His wife had not noticed any fever, Chills, nausea, or vomiting.
Diabetes Mellitus : Case 2
T:98.9 F; BP; 102/62 mm Hg; P: 122/ min with orthostasis; RR 18/min
His lung examination is normal. His heart has RRR. There are no focal neurologic
signs. The rest of his physical examination is unremarkable.
14. Diabetes Mellitus : Case2 Labs:
- Ketones negative
● Chest x-ray P
- K : 4.8 mg/dL
- BUN : 61 : creatinine: 1.5 mg/dL
- HCO3 : 24 mEq/L
- Na : 130 mg/dL
- Cl : 100 mg/dL
● Labs:
● Blood cultures P
● ECG: no ischemic changes
- Glucose : 1,118 mg/dL
● UA P
15. Diabetes Mellitus : Case 2 (cont’d)
- Admit : ICU
- Aggressive IVF : 0.9 normal saline
- Insulin : intravenous, then subcutaneous
- ECG
- Blood and urine cultures, ect.
17. Diabetes Mellitus : (cont’d)
Follow – up:
- Foot exam: yearly
- Type 1: eye exam 5 years after the diagnosis, then yearly
- Type 2: yearly eye exam by ophthalmologist
21. Differential Diagnosis of Insulinoma and Factitious Hyperinsulinism
Test Insulinoma Exogenous
Insulin
Sulfonylureas
1.Plasma insulin
High(usually less
than 200µU/ml)
Very high
(usually>1.000µU/ml)
High
2.Proinsulin Increased Normal or low Normal
22. Differential Diagnosis of Insulinoma and Factitious Hyperinsulinism(cont’d.)
Test Insulinoma Exogenous
Insulin
Sulfonylureas
3. C peptide.
(Insulin connective peptide)
1:1
Increased Normal or low Increased
4. Insulin antibodies Absent +/- Present Absent
5. Plasma of urine
sulfonylurea
Absent Absent Persent
