CABRAL, RUTHER HARVEY I.

Ateneo de Zamboanga
University
20 March 2020 School of
Medicine

CASE PRESENTATION AND DISCUSSION ON

DIABETES MELLITUS

GENERAL DATA

This is a case of H.P., a 45-year old married female, from Sinunuc, Zamboanga City, a

housewife and a practicing Roman Catholic.

CHIEF COMPLAINT

Polyuria

HISTORY OF PRESENT ILLNESS

The patient was apparently well, until…

One month prior to consult, the patient had an onset of polyuria, at six to eight voiding episodes

per day with approximately 200 mL of voided urine per episode, associated with nocturia, at two

to three episodes per night, polydipsia, with the patient drinking approximately three to four

liters of water daily, and polyphagia. No nausea, vomiting, difficulty of breathing, abdominal

pain or decreased sensorium was noted. No management or consult was done.

Few hours prior to consult, persistence of symptoms prompted patient to consult at Emergency

and Trauma Center of the Zamboanga City Medical Center.

PAST MEDICAL HISTORY

Patient has no previous admissions or surgeries. She has no known comorbid illnesses and is not

taking any maintenance medications. She has no known allergies to food or drugs.

Patient is a G2P2 (2002), with both deliveries (2002, 2005) NSVD, with no known

complications. Her menstruation is regular, every 28-30 days, and she consumes two pads per

day. She had a tubal ligation after her second delivery.

FAMILY HISTORY

The patient has a strong family history diabetes mellitus on both paternal and maternal sides. No

other heredofamilial history of hypertension, bronchial asthma or cancer was noted.

PERSONAL AND SOCIAL HISTORY

The patient is currently living with her family and is a housewife. Her usual diet consists of rice,

fish and vegetables, but she notes that she is fond of candies and chocolates, and drinks

sweetened carbonated drinks daily. She denies any other vices.

REVIEW OF SYSTEMS

General (+) 12% weight loss (-) body malaise

HEENT (-) blurring of vision (-) eye pain (-) excessive tearing (-) ear discharge

(-) epistaxis (-) frequent colds (-) toothache (-) frequent sore throat

Respiratory (-) cough (-) hemoptysis

Cardiovascular (-) chest pain (-) palpitations

Gastrointestinal (-) hematemesis (-) loose bowel movements (-) constipation (-) melena

(-) hematochezia

Urinary (-) dysuria (-) frothy urine

PHYSICAL EXAMINATION

General The patient was seen conscious, alert and coherent, oriented to three

spheres, and not in respiratory distress.

Vital Signs Temperature: 37.0°C O2 saturation: 99% via room air

Pulse rate: 74 beats/minute Height: 1.48 meters

Respiratory rate: 16 breaths/minute Weight: 61 kilograms

Blood pressure: 110 mm Hg/60 mm Hg

Capillary blood glucose: 247 mg/dL

HEENT Atraumatic, normocephalic with good hair distribution

 Anicteric sclerae, pink palpebral conjunctivae, pupils 3 mm equally round

and reactive to light and accommodation

No discharges or lesions, no tenderness noted

Septum midline, no discharges or lesions, no paranasal tenderness noted

Moist buccal mucosa, no tonsillopharyngeal injection noted

Neck Trachea midline, no masses or lesions, no lymphadenopathies noted

Chest & Lungs No scars or lesions, equal chest expansion, clear breath sounds

Cardiovascular Adynamic precordium, PMI at 5th intercostal space, left midclavicular line,

no heaves or thrills, normal rate, regular rhythm, no murmurs or extra

heart sounds noted

Abdomen Flat, no scars or lesions, normoactive bowel sounds at 18 clicks/minute,

soft, nontender abdomen. No hepatosplenomegaly noted.

Extremities No lesions or edema noted, good and equal pulses, CRT <2s

CLINICAL DIAGNOSIS

Primary clinical diagnosis: Diabetes mellitus type 2, uncontrolled

For this case, the primary clinical diagnosis is diabetes mellitus type 2, uncontrolled. This is

based on the patient’s risk factors, history and symptoms, and physical examination. For the risk

factors, the patient has a strong family history of diabetes mellitus and has a diet that highly

consists of sweet products. The patient is also exhibiting the 3P’s of diabetes mellitus: polyuria,

polydipsia and polyphagia. These symptoms were also associated with nocturia and weight loss,
which are also cardinal symptoms of diabetes mellitus. The physical examination is generally

unremarkable, other than a body mass index of 27.8, which categorizes the patient as Obese I

under the Asia-Pacific criteria, and a capillary blood glucose of 247 mg/dL.

For type 2 diabetes mellitus, insulin resistance and abnormal insulin secretion are key to the

pathogenesis. There is also strong evidence that it has a strong genetic component, with studies

demonstrating concordance in identical twins from 70 to 90%. Other metabolic abnormalities

seen in type 2 diabetes mellitus include excessive hepatic glucose production, abnormal fat

metabolism and systemic low-grade inflammation (Kasper et al, 2018).

Insulin resistance usually results from a combination of genetic susceptibility and obesity. This

leads to impaired glucose utilization by insulin-sensitive tissues and increases hepatic glucose

output, contributing to the hyperglycemia of the patient. On the other hand, it is quite unclear as

to how impaired insulin secretion develops. It is often assumed that there may be a second

genetic defect that leads to decreased beta cell function or that chronic hyperglycemia may

impair islet function paradoxically. This hyperglycemia leads to the classic symptoms of diabetes

mellitus. The excess glucose is excreted through the kidneys and into the urine. However, since

glucose is an osmotic substance, it leads to an increased water excretion, thus leading to polyuria.

The increased excretion of water lowers the serum osmolarity, thus leading to polydipsia.

Because of the insulin resistance, there is a chronic lack of glucose within the cells of the body,

which the body tries to adapt to by increasing food intake, leading to polyphagia (Kasper et al,

2018).
Secondary clinical diagnosis: Primary polydipsia

Like diabetes mellitus, primary polydipsia presents will polyuria and polydipsia. This is due to

an abnormality in cognition of thirst, which causes an excessive intake of fluids, and thus

decreasing the plasma osmolarity. The decrease is plasma osmolarity causes the increased water

excretion and increased urine output to stabilize the plasma osmolarity within normal levels.

However, given that the patient also presents with polyphagia and weight loss, with an increased

capillary blood glucose level, this impression can be deemed least likely (Kasper et al, 2018).

PARACLINICAL DIAGNOSTIC PROCEDURES

For this case, we are primarily considering diabetes mellitus type 2, uncontrolled as the clinical

impression. Based on the patient’s age, risk factors, signs and symptoms, we are 95% certain that

the patient only has symptomatic type 2 diabetes mellitus, which can be easily treated by the use

of oral hypoglycemic agents and lifestyle modification. On the other hand, we are also

considering primary polydipsia probably bleed as a secondary clinical diagnosis. However, there

is only low clinical suspicion for this disease entity, due to the presence of other symptoms, such

as weight loss and polyphagia, and the increased capillary blood glucose upon examination, with

a 30% certainty.

To totally rule out primary polydipsia, urine and serum sodium (PhP 200.00 for urine and serum

sodium in the Zamboanga City Medical Centerf) and osmolarity can be determined. If the values
are below normal, we may consider primary polydipsia as the cause of the patient’s polyuria and

polydipsia. However, if the values are within normal limits, we can rule out primary polydipsia.

In the case of this patient, primary polydipsia was ruled out on the basis of the patient’s history

and physical examination and no other paraclinical diagnostics were used to rule primary

polydipsia out. However, other diagnostics were done to confirm diabetes mellitus and to aid the

management and monitoring of the patient’s type 2 diabetes mellitus. Urinalysis (PhP 130.00 in

Zamboanga City Medical Center) was done to confirm presence of glucose in the urine and to

see if there is any concomitant urinary tract infection, in which the patient has a high risk for due

to the presence of glucose in the urine. The patient’s level of glycosylated hemoglobin (HbA 1C,

PhP 650.00 in Zamboanga City Medical Center) was also determined as baseline for treatment

monitoring. The patient’s urine protein (Php 200.00 in Zamboanga City Medical Center) was

also determined to see if there are already complications involving the patient’s kidneys. The

patient’s lipid profile (PhP 510.00 in Zamboanga City Medical Center) was also determined for

monitoring (Kasper et al, 2018).

TREATMENT

For this patient, the goal is for glycemic control, which involves various strategies, including

medical management and lifestyle modification. The patient was prescribed with metformin 500

mg to be taken once daily. For monitoring, the patient was advised to do weekly monitoring of

her blood glucose in her home or in any nearby barangay health station with a glucometer. The

patient was also referred to the Tzu Chi Eye Center for proper eye examination and formal
fundoscopy to determine if there are already ophthalmological complications. The patient was

also advised on lifestyle management and frequent follow-ups for monitoring (Kasper et al,

2018).

PREVENTION AND HEALTH PROMOTION

Lifestyle management is just as crucial as pharmacological management in the treatment of

diabetes. This includes nutrition therapy and physical activity, which would help in the overall

goal of glycemic control. It was emphasized to the patient that she should lower her body-mass

index to normal levels, with the help of a good diet and exercise regimen. The patient was

educated on the diabetic diet, which consists of vegetable, fruits, whole grains and low-fat dairy

products, focusing on food that are higher in fiber and lower in glycemic content. She was also

advised on having moderate aerobic physical activity averaging 150 minutes per week, with no

gaps longer than 2 days, with particular focus on resistance exercises, flexibility and balance

training, and reduced sedentary behavior.

REFERENCES

Kasper, D. L., Fauci, A. S., Hauser, S. L., Longo, D. L., Jameson, J. L., & Loscalzo, J.

(2018). Harrison's Principles of Internal Medicine, (Vol. 1 & Vol. 2). McGraw Hill

Professional.