Carol, an 8-year-old girl in previously good health, has noticed that, in the pa
ID: 70004 • Letter: C
Question
Carol, an 8-year-old girl in previously good health, has noticed that, in the past month, she is increasingly thirsty. She gets up several times a night to urinate, and finds herself gulping down glasses of water. At the dinner table, she seems to be eating twice as much as she used to, yet she has lost 5 pounds in the past month. In the past three days, she has become nauseated, vomiting on three occasions, prompting a visit to her pediatrician.
At the doctor's office, she is breathing rapidly during her physical examination. Blood and urine samples are taken. The following lab results are noted:
Blood glucose level = 545 mg/dl
Blood pH level = 7.23
(normal = 50 - 170 mg/dl)
(normal = 7.35 - 7.45)
Urine = tested positive for glucose and for acetone / acetoacetate (i.e. ketone bodies) (normally urine is free of glucose and ketone bodies)
Following her visit to the pediatrician, Carol undergoes a diabetic care training program, learning how to self-inject insulin subcutaneously and check her blood-glucose level at home with chemstrips. In addition, she learns the importance of carrying candy and glucagon with her at all times as well as eating the right amounts of food at the right times each day. She is started on the following schedule of insulin dosing:
morning dose = 8 units of NPH insulin and 4 units of regular insulin
supper dose = 4 units of regular insulin
bedtime dose = 5 units of NPH insulin
total dose per day = 21 units
Note: regular insulin is a fast-acting insulin, while NPH insulin has a slower onset of action and a longer duration of action.
Three days later, she returns to the doctor's office for a review of her blood-glucose readings and a measurement of her fasting blood-glucose level, which is found to be 95 mg/dl. Most of her glucose readings during the day have been in the low- to mid-100 range. Her glucose levels before supper, however, are in the upper 200s. The dosage of insulin is adjusted. Carol returns to her pediatrician three months later for a re-check, and is found to have a glycosylated hemoglobin level (Hb A1C) of 9.5%.
1. Why is her glucose level elevated? What is the primary diagnosis and what are the key lab results that confirm it?
2. Why is her blood pH level decreased? Why are there ketone bodies in her urine?
3. Carol is breathing rapidly. What physiological purpose does this serve?
4. What is the name for frequent urination and why is it happening to Carol? What is osmotic diuresis and what causes it?
5. What is the name for constant hunger and why is it happening to Carol? Use the role of glucagon in your answer.
6. What are the concerns about Carol giving herself insulin on a daily basis? Why does she need to carry both candy and glucagon with her at all times?
7. How would you adjust Carol’s insulin-dosing schedule to bring her pre-supper glucose levels down?
8. What is glycolsylated hemoglobin? What is the normal range for glycosylated hemoglobin?
9. What does Carol's Hb A1C level indicate that a one-time direct measurement of blood glucose doesn't indicate?
10. What are the possible long-term complications of her disease?
Blood glucose level = 545 mg/dl
Blood pH level = 7.23
(normal = 50 - 170 mg/dl)
(normal = 7.35 - 7.45)
Urine = tested positive for glucose and for acetone / acetoacetate (i.e. ketone bodies) (normally urine is free of glucose and ketone bodies)
Explanation / Answer
1. She is suffering from diabetes
2. ph level has dropped due to incresed glucose and ketone levels because they affect ph of blood
3. It will provide more oxygen to haemoglobin.
4. Polyuria it occurs due incresed concentration of glucose in blood which in turn gains more water and increase in volume so large volumes of urine is formed. Osmotic diuresis means increased amount of urine due to change in osmotic concentration of blood.
5. Polyphagia. It happens due to non storage of glucose in cells as a source of energy
6. Insulin is given to store blood glucose for further use when body demands. She needs candy and glucagon to provide immediate glucose as she looses glucose in urine
8 . haemoglobin having increased level of plasma glucose linked to it. Normal level of glycosylated hb is 30-33mmol/mol
9. It means one time direct measurement of glucose in blood doesnt indicate the exact result and cannot be regarded as final and it may vary.
10. Possible long term effects may be neuropathy, blurred vision, impaired heeling capacity, uncinsciousness.