Clinical case based discussion on DM .pdf

Case based discussion on diabetes mellitus

1. CLINICAL CASE DISCUSSION
PRESENTER: Dr. AMANI MUTAKANI
MODERATOR: Dr. GOLDY PATLE

2. HISTORY
A 25 year old 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/O TB, 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
Patient was 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 Normal Range
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
Random blood sugar-530mg/dL (70-100mg/dL)
HbA1c-9% (<5.7%)

8. Parameters Value Normal
Range
Total
Protein
6.8 6-8g/ 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 Blood Gas 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 Examination Chemical 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 of urine
WBCs- occasional/hpf
RBCs- Nil
Epithelial cells- occasional/hpf
Casts- Nil
Crystals- Nil

13. DIAGNOSIS
TYPE 1 DM WITH DIABETIC KETOACIDOSIS.

15. INVESTIGATIONS IN DM
1.Tests for diagnosis of DM –
Blood sugar
HbA1c
Glucose Tolerance Test
2.Tests for type or etiology of DM-
Sr insulin
C peptide
Anti insulin Ab
Anti GAD Ab etc

16. 3.Tests for monitoring diabetes:
HbA1c
Glycated albumin
Fructosamine
SMBG (Self monitoring blood glucose)
CGM System

17. 4.Screeningtestsforcomplications:
Albuminuria
Lipidprofile
Nerveconductionstudies
•5.Tests for diagnosis of complications:
Proteinuria
Renal biopsy
Fundoscopy etc

18. BLOOD PLASMA GLUCOSE ESTIMATION
•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 ESTIMATION OF 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-diabetesDiabetes
Mellitus
Fasting
Plasma
Glucose
<100mg/dl100–125
mg/dl
>/=126
mg/dl
2Hour
Plasma
Glucose
<140mg/dl140–199
mg/dl
>/=200
mg/dl

21. Oral Glucose Tolerance Test (OGTT)
•Glucose Tolerance –Ability of the body to metabolise glucose.
•A provocative test to assess response to glucose challenge in an individual
PROCEDURE:
•A fasting venous blood sample is collected
•Patient ingests 75 g anhydrous glucose in 250-300 ml of water over 5 min
•Children-1.75 g/kg body weight max 75 g
•Time of starting glucose drink is taken as zero hour
•Single venous blood sample is collected 2 hours after glucose load

22. Normal
person
Impaired
fasting
glucose
Impaired
glucose
tolerance
(IGT)
Diabetes
Mellitus
Fasting8
hrs
<100mg/dl100-
125mg/dl
100-125mg/dl>/=126mg/dl
2 hr
OGTT
<140mg/dl<140mg/dl140-199
mg/dl
>/=200mg/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)
•Formed non-enzymatically and irreversibly
•Index of average blood glucose level in past 2- 3 months.
METHODS:
•Immunoassay
•Chromatography
•Gel electrophoresis

25. SFBG

26. CGM Device

27. THANK YOU