CASE SCENARIO 1

Ahmed Elzahrany is a 15-year-old with a 7-year history of type 1 diabetes. He

presented to the emergency department with the following laboratory test
results:
Test Ahmed Reference Range
Plasma
Na (mEq/L) 136 136–145
K (mEq/L) 4.6 3.5–5.1
Cl (mEq/L) 90 98–107
CO2 (mEq/L) 10 23–29
Anion gap 41 10–20
Glucose (mg/dL) 315 74–100 (fasting)
Serum
Ketones 30 mg/dL (positive) Negative
Urine
Glucose 2+ Negative
Protein 1+ Negative
Ketones 3+ Negative

Ahmed appeared confused and disoriented; his blood pressure was 132/90 mm
Hg. Within the past year, Ahmed showed poor glucose control and was
admitted to the hospital for treatment of frank hypertension (144/90 mm Hg).
His parents were having a difficult time helping him comply with his treatment
plan, which included daily home monitoring of capillary glucose, insulin
therapy, and dietary recommendations.

Additional Laboratory Results

In addition to the immediate concern of ketoacidosis, the physician was also
concerned about development of nephropathy. Ahmed’s urea and creatinine
were analyzed a few hours later with the following results:
Test Ahmed Reference Range (Adolescent)
BUN (mg/dL) 25 6–20
Creatinine (mg/dL) 1.1 0.5–1.0
The blood urea nitrogen (BUN)/creatinine ratio was 25/1.1 or 23/1. An
increased ratio with a normal or near-normal creatinine is typical of prerenal
disorders. Ahmed’s creatinine was within normal limits, suggesting a prerenal
uremia, such as dehydration.

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Ahmed’s History
Ahmed’s mother noticed his first symptoms when he was 8 years old,
following an uneventful chickenpox infection. His symptoms appeared
suddenly. His mother noted that he urinated more frequently than usual, he had
increased thirst and appetite, and he had been losing weight. At the office of his
pediatrician, Ahmed was tested for glucose with a random blood glucose
concentration result of 560 mg/dL. Laboratory testing of his urine revealed
increased glucose and ketones. The pediatrician diagnosed type 1 diabetes
mellitus based on the glucose level of the random (or casual) blood draw,
which was above 200 mg/dL, and his classic symptoms of type 1 diabetes:
polydipsia, polyuria, and rapid weight loss. The diagnosis was confirmed with a
fasting glucose test of 255 mg/dL from blood drawn on another day. His
physician placed him on a strict course of therapy, including diet change.
Ahmed’s mother monitored his blood glucose at home to maintain it as close to
normal as possible.

Ahmed was seen periodically by the pediatrician to determine the control of his
glycemia. He was placed on carefully monitored insulin therapy.
Ahmed has shown poor glycemic control with episodes of postprandial
hyperglycemia and early-morning hypoglycemia by self-monitoring blood
glucose technique. His parents reported early difficulties in motivating Ahmed
to comply with daily home monitoring of blood glucose and his treatment
regimen. During Ahmed’s admission for treatment of hypertension in the
previous year, the following additional lab results were obtained:

Test Ahmed Reference Range

Serum creatinine (mg/dL) 0.5 0.5–1.0
Creatinine clearance (mL/min/1.73 m2) 183 93–131
Urine albumin excretion rate (µg/min) 240 <20
Hb A1c (%) 11.6 4–6
Blood pressure (mm Hg) 132/90 120/80

Follow-Up
During Ahmed’s next two routine clinic visits, his physician noted
hypertension and 2+ proteinuria. Ahmed’s physician is concerned that Ahmed
is not compliant with his home monitoring schedule and treatment regimen.
The physician referred Ahmed for diabetic education. Ahmed was also referred
to a kidney specialist for assessment of the renal complication of his disease.

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 CASE SCENARIO 2
Diabetes Mellitus Type 2: Mrs. Fatma and the Diabetes Center
Mrs. Fatma Khaton is an obese, 47-year-old woman who lives a sedentary life.
She had been experiencing fatigue, unusual thirst, and frequent urination for the
past few months. She got up several times during the night to urinate and was
thirsty at these times also. Lately, she noticed tingling and numbness in her
fingers and feet and noticed that she dropped items frequently. She also
reported that she lost weight recently, although she was not dieting. On the
advice of family members, she scheduled an appointment with Dr. Jad Eltaeib,
a family practice physician.

On the basis of her history, he ordered laboratory tests, which returned the
following results:
Test Mrs. Fatma Reference Range Serum (Fasting)
Glucose (mg/dL) 365 74–100
Total cholesterol (mg/dL) 243 148–268
HDL cholesterol (mg/dL) 20 34–87
Triglycerides (mg/dL) 416 44–223

Whole Blood Hb A1c(%) 10.4 4–6

Urine
Glucose 4+ Negative
Ketones Negative Negative
Protein Negative Negative

When Dr. Jad showed the laboratory results to Mrs. Fatma, he explained that he
believed that she has type 2 diabetes. The physician explained that she had an
insulin problem; her body was making enough insulin but her body cells could
not use the insulin properly. Although she had plenty of glucose in her blood,
her body could not use the glucose for energy because glucose could not enter
her body cells. Instead, her blood glucose was eliminated in her urine.
Dr. Jad explained that the disease was more frequent in women of her age,
sedentary lifestyle, and race. He stated that many diabetics had family members
with diabetes, but Mrs. Fatma could not recall family members who had
diabetes. The physician explained that diabetes increases the risk for
developing kidney disease, cardiovascular disease, and blindness. Mrs. Fatma
was understandably upset. Her physician told her that type 2 diabetes is usually
much more easily managed than type 1 diabetes. She may be able to control the
disease by exercise, diet change, and weight loss. Dr. Jad performed a foot
examination to check for microvascular and neuropathic problems. The
examination was normal except for some callus formation.

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Dr. Jad asked the office staff to make appointments for Mrs. Fatma at the
diabetes center, where she could attend classes for self-monitoring her blood
glucose and receive nutritional counseling. He prescribed an oral diabetes agent
to increase cellular sensitivity to insulin and decrease the release of glucose by
the liver. He also scheduled a second appointment for Mrs. Fatma to have a
fasting blood glucose test to confirm his diagnosis. There are many identified
risk factors for the development of type 2 diabetes mellitus.

Dr. Jad made his diagnosis on the basis of her elevated random glucose above
200 mg/dL and the presence of symptoms. Mrs. Fatma had some of the classic
symptoms of diabetes: polyuria, polydipsia, and unexplained weight loss;
symptoms of fatigue, blurred vision, and numbness and tingling in the
extremities are also common symptoms of diabetes. The criteria that are used to
diagnose type 1 diabetes are also used to diagnose type 2 diabetes. ADA
Clinical Practice Guidelines for monitoring type 1 diabetes mellitus are also
recommended for type 2 diabetes. In contrast to type 1 diabetes, type 2 diabetes
is not usually controlled through insulin treatment. However, insulin treatment
in the later stages of the disease may be prescribed. Although long term
complications are associated with type 2 diabetes, ketoacidosis is seldom seen.

Mrs. Fatma was seen at the diabetes center a few days after her visit to the
doctor. Such facilities focus on preventive care and offer programs that help the
patient slow or stop progression of disease. At the center, she saw the diabetes
educator, who was a registered nurse, and the dietitian. The diabetes educator
taught her how to use her glucose monitor.

She learned to wash her hands before the procedure, take a capillary blood
sample, use the glucose monitor, and record her glucose levels. The diabetes
educator suggested that Mrs. Fatma test her blood every morning to monitor
her fasting level, and before and after a meal to monitor her response to
glucose. Her target levels were set at 80 to 120 mg/dL for her fasting level and
below 140 mg/dl 2 hours after a meal. Her goal was to meet her target levels
for at least 50% of her tests.

The diabetes educator explained to Mrs. Fatma that her Hb A1c would be
tested at the diabetes Center at least every 6 months to determine the average of
her blood glucose levels over the previous 3- to 4-month period. Studies have
shown a correlation between mean plasma glucose concentration and Hb A1c .

Mrs. Fatma also attended a nutrition class. She and the dietician discussed
changes in eating habits that would help Mrs. Fatma meet her blood glucose

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goals. She learned to record her meals so that she and the dietician could
continue to monitor her carbohydrate intake. Finally, Mrs. Fatma joined the
exercise group and planned activities that she could do at home.

Diabetes centers provide point-of-care testing (POCT) for consistent Six

months after her first visit to the diabetes center, Mrs. Fatma had met her goals.
Seventy percent of her home blood glucose tests were in the target range. Her
symptoms were diminishing and her Hb A1c was 8.0%.
She continued to attend nutrition sessions and exercise regularly.

CASE SCENARIO 3
Gestational Diabetes Mellitus: The Prenatal Clinic
Jamila husein is a 32-year-old woman who is in her 26th week of pregnancy.
During her first prenatal visit, Mrs. Jamila’s urine was tested for glucose and
protein; both tests were negative. At her last prenatal visit, the results of her
urine test for protein and glucose were
Test Mrs. Jamila Reference Range
Protein Negative Negative
Glucose Positive Negative

Mrs. Jamila is overweight and has a family history of diabetes. Her age, family
history, and weight put her at risk for gestational diabetes mellitus. Mrs.
Jamila’s physician uses the recommendations of the National Diabetes
Association for laboratory testing for diagnosis of gestational diabetes.

In the National Diabetes Group protocol for diagnosis of gestational diabetes,

the physician first orders a 50-g glucose challenge to screen for diabetes. For
this screening test, the patient need not be fasting. Blood is drawn 1 hour after
the glucose solution is consumed.

Mrs. Jamila’s results are shown below:

Test Mrs. Jamila Reference Range
1-hour glucose (50 g) 210 mg/dL < 140 mg/dL

Because the screening test is positive, the physician asks Mrs. Jamila to return
to the laboratory after an 8-hour fast. Mrs. Jamila is instructed to refrain from
eating or drinking fluids, other than water, overnight for 10 to 16 hours before

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the test. She is cautioned not to smoke or take medications on the morning of
the test. During the testing period, she will be allowed only water.

A fasting sample is drawn and she is given a 100-g glucose solution. Mrs.
Jamila’s blood is drawn every hour for 3 hours with the following results:
Test Mrs. Jamila Reference Range
Fasting 144 mg/dL < 95 mg/dL
1 hour 155 mg/dL <180 mg/dL
2 hour 210 mg/dL <155 mg/dL
3 hour 152 mg/dL <140 mg/dL

The results of Mrs. Jamila’s laboratory tests confirmed her physician’s

diagnosis of gestational diabetes. Since gestational diabetes increases the risk to
both mother and child for harm, the physician referred her for diabetes
education immediately.

The goal of treatment for gestational diabetes is the goal of all diabetics,
glycemic control. Mrs. Jamila was taught to monitor her blood glucose and
was given nutritional counseling to include caloric reduction for weight loss
and moderate physical exercise. Her physician asked her to schedule regular
appointments to verify blood glucose levels. If she is not able to control her
glycemia through self-monitoring, diet change, and exercise, insulin therapy
will be considered.

Mrs. Jamila is also at risk for developing hypertension and pre-eclampsia and
may require a cesarean delivery. The fact that she has developed gestational
diabetes mellitus puts her at risk for developing other types of diabetes
mellitus, usually type 2, in the future.

Mrs. Jamila delivered a healthy, normal-sized infant. She continued her diet
and exercise plan and lost weight. These basic lifestyle changes will help her
avoid developing gestational diabetes with future pregnancies and other types
of diabetes after pregnancy.

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 CASE SCENARIO 4
Transient Neonatal Hypoglycemia: The Big Baby
“He is a big baby, isn’t he?” his mother asked. Baby Morgana was delivered at
Medical Center to a 33-year-old mother who had no prenatal history. Baby
Morgana was indeed larger than normal. The nurses in the nursery noticed that
Baby Morgana seemed lethargic and unresponsive. A whole blood glucose
done in the nursery was 23 mg/dL. Although neonatal blood glucose levels are
usually lower than adult blood glucose levels, Baby Morgana’s glucose level
worried the nurses. Hypoglycemia in neonates may be caused by prematurity,
maternal diabetes, and maternal toxemia.

Upon questioning the mother, the physician learned that Mrs. Morgana had a
history of delivering big babies and having sugar problems during pregnancy.

Mrs. Morgana probably had developed gestational diabetes. The fetus of a

mother with gestational diabetes over secretes insulin. When the neonate is
born, fetal hyperglycemia is ended. Since the fetal pancreas is accustomed to
over secretion of insulin, the neonate goes into severe hypoglycemia. This
hypoglycemia is usually transient.

Baby Morgana’s hypoglycemia was indeed transient. As revealed by capillary

blood glucose monitoring several times a day for 3 days, his glucose levels
returned to the normal reference range for his age group. As the effects of
maternal hyperglycemia dissipated, the neonatal pancreas responded properly
to Baby Morgana’s first nutrients. Mrs. Morgana was referred to the diabetes
educator for nutritional counseling and exercise classes to control her weight.

She also received information about gestational diabetes, which included

warnings about the dangers of hyperglycemia during pregnancy for both mother
and child.