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Clinical case based discussion on DM .pdf
- 1. CLINICAL CASE DISCUSSION PRESENTER:Dr. AMANI MUTAKANI MODERATOR: Dr. GOLDY PATLE
- 2. HISTORY A 25 yearold male presented with complaints of - • Breathlessness since 1 day • Persistent nausea, vomiting, abdominal pain since 1-2 days • Weight loss and fatigue since 1 month • Increased frequency of urination since 2 months No H/O burning micturition, fever with chills No H/O cough with evening rise of temperature No H/O loose motions
- 3. Past History No H/OTB, asthma Personal History Diet- Veg Non smoker, non alcoholic Bladder habits – Increased urinary frequency Bowel habits- Normal Family History No significant family history
- 4. EXAMINATION ❑ General Examination Patientwas conscious and obeying commands. Thin built Signs of dehydration present No pallor, icterus, edema ❑ Vitals Temp- Afebrile SpO2- 96% Pulse- 120/min BMI- 17 kg/m2 RR- 25/min BP- 90/60 mmHg
- 5. ❑ Systemic Examination ➢CVS: S1,S2 heard, no murmur ➢ RS: Rapid, deep breathing ➢ P/A: Generalized tenderness ➢ CNS: Conscious, oriented
- 6. INVESTIGATIONS Parameters Value NormalRange WBC 10,000/cumm 4000- 11,000/cumm HCT 52 37-54 HB 14g/ dL 11-16g/dL MCV 87fL 80-100fL MCH 30pg 27-32pg MCHC 33.6g/dL 30-35g/dL RDW 12.6% 11.5-14.5% PLT 3,60,000/cumm 1,50,000- 4,50,00/cumm
- 7. ▪ Sugar Profile Randomblood sugar- 530mg/dL (70-100mg/dL) HbA1c- 9% (<5.7%)
- 8. Parameters Value Normal Range Total Protein 6.86-8g/ dL Albumin 3.2 2.5-4.5g/dl Total bilirubin 1 0.2- 1.2mg/dL Indirect bilirubin 0.6 0.2- 0.8mg/dL Direct bilirubin 0.4 0.1-0.4 mg/dL ALP 230 90-320U/L ALT 25 0-35U/L AST 32 0-40U/L Parameters Value Normal Range S. Urea 20 15- 40mg/dL S. Creatinine 0.7 0.2- 1.2mg/dL S. Uric acid 4.2 3-6mg/dL LFT KFT
- 9. ▪ Serum Electrolytes S.Sodium- 136mEq/L (135-145mEq/L) S. Potassium- 3.5mEq/L (3.5-5.5mEq/L)
- 10. ▪ Arterial BloodGas Analysis pH- 6.6 (7.35-7.45) Po2- 80 mm Hg (70-100 mm Hg) Pco2- 41 mm Hg (35-45 mm Hg) SaO2- 95% (93-98%) HCO3- 8 mmol/L (22-26mmol/L) Chloride -100mmol/ (98-109mmol/L)
- 11. URINE EXAMINATION Physical ExaminationChemical Examination Volume- 3000ml/24hr (600-2000ml/24hr) Protein- Nil Colour- Colourless Sugar-3+ Appearance- Clear Ketone- 2+ Odour- Fruity Sp. Gravity- 1.045 (1.003-1.030) pH- 4.5 (4.6-8)
- 12. Microscopic examination ofurine WBCs- occasional/hpf RBCs- Nil Epithelial cells- occasional/hpf Casts- Nil Crystals- Nil
- 13. DIAGNOSIS TYPE 1 DMWITH DIABETIC KETOACIDOSIS.
- 15. INVESTIGATIONS IN DM 1.Testsfor diagnosis of D M – Blood sugar HbA1c Glucose Tolerance Test 2.Tests for type or etiology of DM- Sr insulin C peptide Anti insulin Ab Anti GA D Ab etc
- 16. 3.Tests for monitoringdiabetes: HbA1c Glycated albumin Fructosamine SMB G (Self monitoring blood glucose) CGM System
- 17. 4.Screening tests forcomplications: Albuminuria Lipid profile Nerve conduction studies • 5.Tests for diagnosis of complications: Proteinuria Renal biopsy Fundoscopy etc
- 18. BLOOD PLASMA GLUCOSEESTIMATION • Critical to the diagnosis and management • Concentration differs according to the nature of blood specimen • Plasma is preferred since blood glucose is affected by concentration of proteins (especially Hb) & glycolysis • Glycolysis reduces glucose level in blood sample - 7 mg/dL/hour • NaF- 2.5mg/ml of blood • Not necessary if plasma is separated from whole blood within 1 hr
- 19. METHODS OF ESTIMATIONOF BLOOD / PLASMA GLUCOSE Chemical methods – 1. Orthotoluidine method 2. Blood glucose reduction methods using neocuproine, ferricyanide or copper Enzymatic method – 1. Glucose oxidase peroxidase method 2. Hexokinase method 3. Glucose dehydrogenase method
- 20. Normal Glucose Pre-diabetes Diabetes Mellitus Fasting Plasma Glucose < 100mg/dl 100 – 125 mg/dl >/=126 mg/dl 2 Hour Plasma Glucose <140 mg/dl 140 – 199 mg/dl >/=200 mg/dl
- 21. Oral Glucose ToleranceTest (OGTT) • GlucoseTolerance–Ability of the body to metabolise glucose. • A provocativetest to assess responseto glucose challenge in an individual PROCEDURE: • A fasting venous bloodsample is collected • Patient ingests 75 g anhydrousglucose in 250-300 ml of waterover 5 min • Children-1.75g/kgbody weight max 75 g • Time of starting glucose drinkis taken as zero hour • Single venous bloodsample is collected 2 hours after glucose load
- 22. Normal person Impaired fasting glucose Impaired glucose tolerance (IGT) Diabetes Mellitus Fasting 8 hrs <100 mg/dl100- 125mg/dl 100-125mg/dl >/= 126mg/dl 2 hr OGTT <140 mg/dl <140 mg/dl 140 - 199 mg/dl >/= 200 mg/dl
- 23. GDM ONE STEP APPROACH FASTING-92mg/dl 1 HOUR- 180mg/dl 2 HOUR- 153mg/dl TWO STEP APPROACH FASTING- 95mg/dl 1 HOUR- 180mg/dl 2 HOUR- 155mg/dl 3 HOUR- 140mg/dl
- 24. HbA1C(GLYCATED Hb) • Formednon-enzymatically and irreversibly • Index of average blood glucose level in past 2- 3 months. METHODS: • Immunoassay • Chromatography • Gel electrophoresis
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