Kasus Diabetes Melitus

A.B. is a retired 69-year-old man with a 5-year history of type 2 diabetes. He had fasting blood glucose records indicating values of 118127 mg/dl, which were described to him as indicative of borderline diabetes. He also remembered past episodes of noc turia associated with large pasta meals and Italian pastries. At the time of initial diagnosis, he was advised to lose weight (at least 10 lb.), but no further action was taken. Referred by his family physician to the diabetes specialty clinic, A.B. presents with recent weight gain, suboptimal diabetes control, and foot pain. He has been trying to lose weight and increase his exercise for the past 6 months without success. He had been started on glyburide (Diabeta), 2.5 mg every morning, but had stopped taking it because of dizziness, often accompanied by sweating and a feeling of mild agitation, in the late afternoon. A.B. also takes atorvastatin (Lipitor), 10 mg daily, for hypercholesterolemia (elevated LDL cholesterol, low HDL cholesterol, and elevated triglycerides). He has tolerated this medication and adheres to the daily schedule. During the past 6 months, he has also taken chromium picolinate, gymnema sylvestre, and a pancreas elixir in an attempt to improve his diabetes control. He stopped these supplements when he did not see any positive results. Although both his mother and father had type 2 diabetes, A.B. has limited knowledge regarding diabetes self-care management and states that he does not understand why he has diabetes since he never eats sugar. In the past, his wife has encouraged him to treat his diabetes with herbal remedies and weight-loss supplements, and she frequently scans the Internet for the latest diabetes remedies. During the past year, A.B. has gained 22 lb. Since retiring, he has been more physically active, playing golf once a week and gardening, but he has been unable to lose more than 2 3 lb. He has never seen a dietitian and has not been instructed in self-monitoring of blood glucose (SMBG). A.B.s diet history reveals excessive carbohydrate intake in the form of bread and pasta. His normal dinners consist of 2 cups of cooked pasta with homemade sauce and three to four slices of Italian bread. During the day, he often has a slice or two of bread with butter or olive oil. He also eats eight to ten pieces of fresh fruit per day at meals and as snacks. He prefers chicken and fish, but it is usually served with a tomato or cream sauce accompanied by pasta. His wife has offered to make him plain grilled meats, but he finds them tasteless. He drinks 8 oz. of red wine with dinner each evening. He stopped smoking more than 10 years ago, he reports, when the cost of cigarettes topped a buck -fifty. The medical documents that A.B. brings to this appointment indicate that his hemoglobin A1c (A1C) has never been <8%. His blood pressure has been measured at 150/70, 148/92, and 166/88 mmHg on separate occasions during the past year at the local senior center screening clinic. Although he was told that his blood pressure was up a little, he was not aware of the need to keep his blood pressure 130/80 mmHg for both cardiovascular and renal health.11 A.B. has never had a foot exam as part of his primary care exams, nor has he been instructed in preventive foot care. However, his medical records also indicate that he has had no surgeries or hospitalizations, his immunizations are up to date, and, in general, he has been remarkably healthy for many years. Physical Exam A physical examination reveals the following: Weight: 178 lb; height: 52; body mass index (BMI): 32.6 kg/m 2 Fasting capillary glucose: 166 mg/dl Blood pressure: lying, right arm 154/96 mmHg; sitting, right arm 140/90 mmHg Pulse: 88 bpm; respirations 20 per minute

Eyes: corrective lenses, pupils equal and reactive to light and accommodation, Fundi-clear, no arteriolovenous nicking, no retinopathy Thyroid: nonpalpable Lungs: clear to auscultation Heart: Rate and rhythm regular, no murmurs or gallops Vascular assessment: no carotid bruits; femoral, popliteal, and dorsalis pedis pulses 2+ bilaterally Neurological assessment: diminished vibratory sense to the forefoot, absent ankle reflexes, monofilament (5.07 Semmes-Weinstein) felt only above the ankle

Lab Results Results of laboratory tests (drawn 5 days before the office visit) are as follows: Glucose (fasting): 178 mg/dl (normal range: 65 109 mg/dl) Creatinine: 1.0 mg/dl (normal range: 0.5 1.4 mg/dl) Blood urea nitrogen: 18 mg/dl (normal range: 730 mg/dl) Sodium: 141 mg/dl (normal range: 135146 mg/dl) Potassium: 4.3 mg/dl (normal range: 3.5 5.3 mg/dl) Lipid panel Total cholesterol: 162 mg/dl (normal: <200 mg/dl) HDL cholesterol: 43 mg/dl (normal: 40 mg/dl) LDL cholesterol (calculated): 84 mg/dl (normal: <100 mg/dl) Triglycerides: 177 mg/dl (normal: <150 mg/dl) Cholesterol-to-HDL ratio: 3.8 (normal: <5.0) AST: 14 IU/l (normal: 040 IU/l) ALT: 19 IU/l (normal: 540 IU/l) Alkaline phosphotase: 56 IU/l (normal: 35125 IU/l) A1C: 8.1% (normal: 46%) Urine microalbumin: 45 mg (normal: <30 mg)

Kasus Diabetes Melitus

B.C. is a 51-year-old white man who was diagnosed with type 1 diabetes 21 years ago. He believes that his diabetes has been fairly well controlled during the past 20 years and that his insulin needs have increased. He was recently remarried, and his wife is now helping him care for his diabetes. His endocrinologist referred him to the RD for an urgent visit because 4 days ago he had a hypoglycemic event requiring treatment in the emergency room (ER). He has come to see the dietitian because his doctor and his wife insisted that he do so. B.C. has had chronic problems with asymptomatic hypoglycemia. His last doctors visit was 34 weeks ago, when areas of hypertrophy were found. His endocrinologist asked him to change his injection sites from his thigh to his abdomen after the ER incident. He does not think he needs any diabetes education but would like help in losing 10 lb. His body mass index is 25 kg/m2. His medications include pravastatin (Pravacol), 10 mg daily; NPH insulin, 34 units in the morning and 13 units at bedtime; and regular insulin at breakfast and dinner following a sliding-scale algorithm. He also takes lispro (Humalog) insulin as needed to correct high blood glucose. Before his ER visit, B.C. monitored his blood glucose only minimally, testing fasting and sometimes before dinner but not keeping records. Since his severe hypoglycemia 4 days ago, he has begun checking his blood glucose four times a day, before meals and bedtime. Lab Results B.C.s most recent laboratory testing results were as follows: A1C: 8.3% (normal 4.25.9%) Lipid panel Total cholesterol: 207 mg/dl (normal: 100200 mg/dl) HDL cholesterol: 46 mg/dl (normal: 3565 mg/dl) LDL cholesterol: 132 mg/dl (normal: Triglycerides: 144 mg/dl (normal: <100 mg/dl) <150 mg/dl)

Creatinine: 0.9 mg/dl (normal: 0.51.4 mg/dl) Microalbumin: 4 g (normal: 029 g)

Kasus Hipertiroid A 73-year-old, nulliparous, Caucasian woman had suffered a new onset of palpitations, tachycardia and a weight loss of 14 kg during the year before admission. Physical examination revealed a tender nodule 2 cm in size in the right thyroid lobe. Laboratory ndings were as follows: thyroid-stimulating hormone (TSH) , 0.01 mU/ml (0.1 4.0), free thyroxine (FT4) 2.7 ng/ml (0.7 2) and free triiodothyronine (FT3) 5 pg/ml (1.5 5.5), with thyroglobulin antibodies (AbTg), thyroperoxidase antibodies (AbTPO), TSH-receptor antibodies (TRAb), thyroglobulin and calcitonin in the normal range. A 13 8 15 mm cervical nodule at ultrasonography showed intense 123I uptake. Hypothyroidism was achieved 3 months later after 10 mCi 131I treatment However, the patient developed tachycardia and biochemically detected hyperthyroidism, prompting us to re-evaluate the thyroid prole without levothyroxine (TSH , 0.01 mU/ml, FT4 2.5 ng/ml, FT3 3 pg/ml, with AbTg, AbTPO and TRAb in the normal range) on the hypothesis of a residue of toxic adenoma, but a new RAI showed ,1% uptake in the cervical tract

Kasus hipotiroid
A 46-year-old woman was referred to the endocrine clinic for evaluation of suppressed thyrotropin level. The patient had been well until 4 months earlier, when she began to have fatigue and lethargy along with cold intolerance and dry skin. She denied any history of heat intolerance, weight loss, change in neck size, or eye or skin changes. Her primary physician obtained thyroid function tests, which yielded the following values: thyrotropin <0.05 mU/L (normal, 0.5 to 4.5 mU/L), thyroxine (T 4) 6.0 g/dL (4.5 to 11.5 g/dL), triiodothyronine (T3) 1.00 ng/mL (0.8 to 2.0 ng/mL), free T 4 index (FTI) 6.6 (4.5 to 11.5), and T4 uptake 1.1 (0.8 to 1.3). The patient was referred to our clinic for further workup. The patient denied any history of headaches, peripheral vision changes, or head trauma. Her medical history included unipolar depression, which was under excellent control. Total abdominal hysterectomy and bilateral salpingo-oophorectomy had been done 4 years earlier because of uterine fibroids. She was not receiving hormone replacement therapy. There was a family history of hyperthyroidism in an aunt and a niece. She denied any addictions, and her medications included sertraline, trazodone, and clonazepam. Physical examination revealed normal vital signs. Extraocular movements and the visual fields with direct confrontation were normal. The thyroid gland was normal in size, shape, and texture. Skin and hair were dry, and deep tendon reflexes were normal. Significant laboratory values were as follows: thyrotropin 0.11 mU/L, T3 0.74 ng/mL, T4 5.2 g/dL, FTI 5.2, T4 uptake 1.0, free T4 0.5 ng/dL (0.7 to 1.6 ng/dL), cortisol 19.9 g/dL, prolactin 6.9 ng/mL (normal, 0 to 18), corticotropin (ACTH) 21.7 pg/mL, luteinizing hormone (LH) 43.3 mIU/mL, follicle-stimulating hormone (FSH) 90.2 mIU/mL, and insulin-like growth factor I (IGF-I) 157 ng/mL. The serum cortisol level was measured at 8 AM. Magnetic resonance imaging (MRI) with gadolinium showed a normal pituitary gland with normal enhancement.

Kasus Cushing Syndrome A twenty four-year-old unmarried female presented with a seven-month history of puffiness of the face that progressed to generalized swelling of the body. She had noticed striae over the lower limbs, abdomen and lower back at the same time. Besides, she had complaints of amenorrhoea, progressively increasing weakness of the proximal muscles, frontal headaches, polyuria and poor performance in school over the past six months. On examination, the patient had moon facies, truncal obesity, puffiness of the face and eyes, purple striae over breasts, abdomen and thighs, and non-pitting pedal edema. Her b l o o d p r e s s u r e wa s 1 6 0 / 1 0 0 mmHg . Ab d omi n a l examination revealed a lump in the right upper abdomen extending to the right flank of size 10 x 8 cms. An ultrasound of the abdomen showed a large heterogenous mass 13 x 12 x 7.6 cms anterolateral to the upper pole of r ight kidney, abut t ing the r ight lobe of l ive r and compressing the inferior vena cava. A contrast enhanced computed tomography (CECT) scan of the abdomen revealed a 20cm x 18 cm sized soft tissue mass with mixed densities in the right suprarenal region. This mass was displacing the right lobe of liver superiorly and the right kidney inferiorly. Areas of necrosis and calcification were seen in the mass. The findings were suggestive of a right adrenal gland malignancy. Urine free cortisol concentrations measured as cortisol/creatinine ratios on two successive 24-hour urine collections were raised at 80 and 169 nmol/mmol r e s p e c t i v e l y ( r e f e r e n c e r a n g e 5 - 5 5 ) . H i g h d o s e d e x a m e t h a s o n e s u p p r e s s i o n t e s t w a s d o n e (dexamethasone 2 mg orally every six hours for 48 hours). Basal serum cortisol was 530 nmol/l and failed to suppress after 48 hours, remaining raised at 525 nmol/ l. This was suggestive of primary adrenal disease as cortisol levels normally suppress to less than 50% of basal levels in pituitary driven Cushings disease. Serum testosterone and urinary catecholamine levels were n o r m a l . C u s h i n g s s y n d r o m e d u e t o a n a d r e n a l malignancy was suspected.

Kasus Addison disease A 63-year-ol woman presented with increasing darkening of the skin, dizziness, and easy fatigability, nausea with occasional vomiting and progressive weight loss over eight months prior to presentation. There were no headaches, blurred vision, and neither loss of consciousness nor change in her bowel habit. The medical history and systemic review revealed no abnormality and were not significant as to the likely cause of her disease state. Physical examination revealed an elderly lady, pale, asthenic with generalized hyperpigmentation especially on the face, oral mucosa, palmar creases and knuckles. No features of malnutrition or hypovitaminosis. There was no significant peripheral lymphadenopathy. Main findings in the systemic examination were a pulse of 106 bpm, regular and small; blood pressure 100/60 mmHg supine and 70/40mmHg sitting. She could not stand on account of severe postural dizziness. The apex beat was normal. Fundoscopy revealed a normal fundus. All other systems were essentially normal. A clinical assessment of Addisons disease to exclude paraneoplastic syndrome was made. Laboratory investigations and results are shown in Table 1. Plasma cortisol was undetectable at 0 and 30 minutes of cosyntropin administration (0.25 mg). Plasma rennin and aldosterone activity could not be estimated. HIV screening was negative (HIV 1 & II) Radiological diagnostic tests included an abdominal ultrasound, which was reported as showing normal liver, spleen, pancreas and pelvic organs. However, the left kidney was not outlined. A computerised tomography scan (CT) of the abdomen showed a non-enhancing oval shaped left suprarenal mass with calcification and an ipsilateral hypoplastic but functional left kidney. There was neither ascites nor significant abdominal lymph nodes. The conclusion was a suprarenal tumour-adenoma or adrenocortical carcinoma to exclude tuberculous adrenalitis. A CT brain scan was normal. In view of the CT abdominal findings suggestive of adrenal tuberculosis, and ESR 58mm/hr, she was commenced on anti-tuberculous drugs.