Case Studies

in
Diabetes
Mellitus
(Clinical Chemistry I)

Submitted By:
Erika C. Galimba
BMLS III-A

Submitted To:
Ma’am Erika Chiziri P. Martensen
CASE STUDY 14-1

An 18-year-old male high school student who had a 4-year history of

diabetes mellitus was brought to the emergency department because of
excessive drowsiness, vomiting, and diarrhea. His diabetes had been well
controlled with 40 units of NPH insulin daily until several days ago when he
developed excessive thirst and polyuria. For the past 3 days, he has also had
headaches, myalgia, and a low-grade fever. Diarrhea and vomiting began 1
day ago.

URINALYSIS RESULTS CHEMISTRY TEST RESULTS

Specific Gravity 1.012 Sodium 126 mmol/L

pH 5.0 Potassium 6.1 mmol/L

Glucose 4+ Chloride 87 mmol/L

Ketone Large Bicarbonate 6 mmol/L

Plasma
600 mg/dL
Glucose

BUN 48 mg/dL

Creatinine 2.0 mg/dL

Serum
4+
Ketones

Questions:

1. What is the probable diagnosis of this patient based on the data

presented?

- Large or high number of ketones are present in his body that

result in one of the two emergencies of diabetes, acidosis or
ketoacidosis.

2. What laboratory test(s) should be performed to follow this patient and

aid in adjusting insulin levels?
- Ketostix (or Ketodiastix with sugar check) is a urine testing
that is carefully timed within 15 seconds and is cheaper than
Ketodiastix but is good for 6 months only. Another method
that is available is Chemstrip K (or Chemstrip uGK with urine
glucose check) and the only difference from the Ketostix is in
the timing, this method must be timed for one minute.
Precision Xtra Meter is the only meter which allows testing for
blood beta ketones. Although this blood ketone strips are more
expensive, they do not have to be replaced (like Ketostix) every
6 months.
3. Why are the urine ketones positive?

- Most urine testing kits detect aceto-acetate, not the

predominant ketone beta-hydroxybutyrate. It is possible for
the test to be negative with high levels of beta-hydroxybutyrate
and then, as ketoacidosis improves and ketone levels fall, the
urine test becomes positive (to aceto-acetate).

4. What methods are used to quantitate urine ketones? Which ketone(s) do

they detect?

- Nitroprusside urine method produces a qualitative assessment

of ketosis and ketoacidosis by detecting both acetoacetate and
acetone and detects less than 25% of the ketones present in
ketosis. Another method is ß-Hydroxybutyrate that
demonstrates excellent stability, making it the most reliable
indicator of clinically relevant ketosis and ketoacidosis. It is
more precise than urine dipstick test too. Qualitative or
semi-quantitative tests are also available using visual methods
with spectrophotometric/enzymatic methods or gas
chromatography. Reagent strip test shows color change that
indicates the level of ketones. But this test has its advantage
and disadvantages. The advantages of reagent strip are easy to
use, portable and reasonably priced. On the other hand, the
disadvantages of this test is the results are not current; they
may lag by as many as three hours, color changes are
categorized as trace, small, medium, and large only and
dehydration can affect results
CASE STUDY 14-2

A 58-year-old obese man with frequent urination was seen by his

primary care physician. The following laboratory work was performed, and
the following results were obtained:

CASUAL PLASMA GLUCOSE 225 mg/dL

Urinalysis Results

Color and
Pale/Clear Blood Negative
Appearance

pH 6.0 Bilirubin Negative

Specific 1.025 Urobilinogen Negative

Glucose 2+ Nitrites Negative

Leukocyte
Ketones Negative Negative
Esterase

Questions:

1. What is the probable diagnosis of this patient?

- The probable diagnosis of this patient is a Type 2 diabetes.

2. What other test(s) should be performed to confirm this? Which is the

preferred test?

- Insulin testing may be used to help determine when a type 2

diabetic might need to start taking insulin to supplement oral
medications and suspected of having insulin resistance.

3. What values from #2 would confirm the diagnosis of diabetes?

- The patient’s weight because the more fatty tissue he has, the
more resistant his cells become to insulin and his age because
the risk increases as he gets older. This may be because he
tends to exercise less, lose muscle mass and gain weight as he
ages.

4. After diagnosis, what test(s) should be performed to monitor his

condition?

- He must be screen if his blood pressure is higher than 135/80 or

if he takes medicine for high blood pressure to monitor his
condition. May also recommend for dietary changes, increased
physical activity, and the oral diabetes drug metformin. If these
measures fail to lower blood glucose levels, the doctor may
order a diabetes-related autoantibody test to check whether
Type 2 diabetes may have been the wrong diagnosis.
CASE STUDY 14-3

A 14-year-old male student was seen by his physician. His chief

complaints were fatigue; weight loss; and increases in appetite, thirst, and
frequency of urination. For the past 3 to 4 weeks, he had been excessively
thirsty and had to urinate every few hours. He began to get up three to four
times a night to urinate. The patient has a family history of diabetes
mellitus.

LABORATORY DATA

Fasting Plasma Glucose 160 mg/dL

Specific Gravity 1.040

Urinalysis Glucose 4+

Ketones Moderate

Questions:

1. Based on the preceding information, can this patient be diagnosed with

diabetes?

- Yes, he’s suspected of having a Type 1 diabetes.

2. What further tests might be performed to confirm the diagnosis?

- Insulin assays test may be performed and should be analyzed

by the same laboratory to ensure consistency. He may also have
insulin and C-peptide tests if insulinoma is present and then
order the tests periodically to monitor for recurrence.

3. According to the American Diabetes Association, what criteria are

required for the diagnosis of diabetes?

- Fasting Plasma Glucose

4. Assuming this patient has diabetes, which type would be diagnosed?

- He will be diagnosed and be suspected of having a Type 1

diabetes, due to his signs and symptoms that is prior to Type 1
diabetes.
CASE STUDY 14-4

A 13-year-old girl collapsed on a playground at school. When her

mother was contacted, she mentioned that her daughter had been losing
weight and making frequent trips to the bathroom in the night. The
emergency squad noticed a fruity breath. On entrance to the emergency
department, her vital signs were as follows:

Blood Pressure 98/50 mm Hg

Respirations Rapid

Temperature 99°F

Stat lab results include:

RANDOM URINE SERUM CHEMISTRIES

pH 5.5 Glucose 500 mg/dL

Protein Negative Ketones Positive

Glucose 4+ BUN 6 mg/dL

Ketones Moderate Creatinine 0.4 mg/dL

Blood Negative

Questions:

1. Identify this patient’s most likely type of diabetes.

- The patient will be most likely to have a Type 1 diabetes.

2. Based on your identification, circle the common characteristics

associated with that type of diabetes in the case study above.

- This includes (as mentioned in the case study above and have
been circled) loss weight, frequent urination at night, and
fruity breath due to the presence of ketones in moderate level.

3. What is the cause of the fruity breath?

- A fruity odor to the breath is a sign of ketoacidosis. Diabetic

ketoacidosis is a problem when the body cannot use glucose as
a fuel source because there is no insulin or not enough insulin.
Fat is used for fuel instead. As fats are broken down, acids
called ketones build up in the blood and urine. Ketones are
poisonous in high levels. This condition is called ketoacidosis.
CASE STUDY 14-5

A 28-year-old woman delivered a 9.5-lb infant. The infant was above

the 95th percentile for weight and length. The mother’s history was
incomplete; she claimed to have had no medical care through her
pregnancy. Shortly after birth, the infant became lethargic and flaccid. A
whole blood glucose and ionized calcium were performed in the nursery
with the following results:

Whole Blood Glucose 25 mg/dL

Ionized Calcium 4.9 mg/dL

Plasma glucose was drawn and analyzed in the main laboratory to

confirm the whole blood findings.

Plasma Glucose 33 mg/dL

An intravenous glucose solution was started and whole blood glucose

was measured hourly.

Questions:

1. Give the possible explanation for the infant’s large birth weight and size.

- Some babies are large because their parents are large. Taller,
heavier parents tend to have larger babies. Birthweight may
also be related to the amount of weight a mother gains during
pregnancy. But by far, maternal diabetes is the most common
cause of LGA (Large for Gestational Age) babies. Babies born to
an obese mother have greatly increased chances of LGA.
Diabetes during pregnancy cause the mother’s increased blood
glucose to circulate to the baby. In response, the baby’s body
makes insulin. All the extra glucose and extra insulin
production can lead to excessive growth and deposits of fats
resulting to a large baby.
2. If the mother was a gestational diabetic, why was her baby hypoglycemic?

- Sometimes babies of mothers with gestational diabetes develop

hypoglycemia shortly after birth and during first few days of
life because their own insulin production is high. Right after
the baby is born, the blood glucose level may drop very low
(hypoglycemia) because they have so much insulin in their
bodies. The extra glucose in mother’s body actually stimulates
the baby’s body to make more insulin, so when the baby is out
the womb, the extra insulin can cause problems. Hypoglycemia
in babies is easily treated by giving the baby a glucose solution
to quickly raise the blood glucose level. Feeding the baby
should also raise the blood glucose level.
3. Why was there a discrepancy between the whole blood glucose
concentration and the plasma glucose concentration?

- The difference between plasma glucose (which is what blood

labwork reports) and whole blood glucose (which is what most
home testing fingerstick meters report) is blood labwork are
always high compared to home fingerstick measurements. And
home meter was always 8 to 10 points too low when compared
to the plasma glucose readings. A home fingerstick meter
measures Whole Blood Glucose. While blood-sample
bloodwork labs measure Plasma Glucose. Plasma Glucose is
typically 11% to 15% higher than whole Blood Glucose. So the
whole fasting glucose measurement of < 100 is a Plasma
Glucose number. While the home meter, which measures
Whole Blood Glucose, needs to read < 90.

4. If the mother had been monitored during pregnancy, what laboratory

tests should have been performed and what criteria would have indicated
that she had gestational diabetes?

- Genetic screening can help diagnose the potential for certain

genetic disorders before birth. First trimester screening is a
combination of fetal ultrasound and maternal blood testing.
This screening process can help determine the risk of the fetus
having certain birth defects. Second trimester prenatal
screening may include several blood tests called multiple
markers. These markers provide information about the risk of
having a baby with certain genetic conditions or birth defects.
You may have ultrasounds performed at different times in
pregnancy to check for fetal growth, estimate your due date
and look for any structural abnormalities in the baby.
Additional testing during pregnancy may
include amniocentesis, chorionic villus sampling (CVS), fetal
monitoring, glucose testing and Group B strep culture.
CASE STUDY 14-6

Laboratory tests were performed on a 50-yesr-old lean white woman

during an annual physical examination. She had no family history of
diabetes or any history of elevated glucose levels during pregnancy.

LABORATORY RESULTS

Fasting Blood Glucose 90 mg/dL

Cholesterol 140 mg/dL

HDL 40 mg/dL

Triglycerides 90 mg/dL

Questions:

1. What is the probable diagnosis of this patient?

- Elevated risk for Cardiovascular Disease (CVD) due to her

improper lipid condition. And may also develop a Type 2
diabetes.

2. Describe the proper follow-up for this patient?

- Must lower the LDL cholesterol, raising HDL cholesterol, and

lowering triglycerides to reduce the threat of macrovascular
disease and mortality to this patient and also in patients with
type 2 diabetes, particularly those who have had prior
cardiovascular events.

3. What are the appropriate screening tests for diabetes in nonpregnant

adults?

- The recommended screening test for nonpregnant adults is the

FPG or the Fasting Plasma Glucose.

4. What are the risk factors that would indicate a potential of this patient’s
developing diabetes?

- Increased prevalence of lipid abnormalities that contributes to

higher rates of Cardiovascular Disease is prior to Patients with
type 2 diabetes.
CASE STUDY 14-7

For three consecutive quarters, a fasting glucose and glycosylated

hemoglobin were performed on a patient. The results are as follows:

QUARTER QUARTER QUARTER

1 2 3

Plasma 280 mg/dL 85 mg/dL 91 mg/dL

Glucose
Fasting

Glycosylated 7.8% 15.3% 8.5%

Hemoglobin

Questions:

1. In which quarter was the patient’s glucose best controlled? The least
controlled?

- In Quarter 3 was the best controlled and in Quarter 1 was the

least controlled.

2. Do the fasting plasma glucose and glycosylated hemoglobin match? Why

or why not?

- No, fasting plasma glucose and glycosylated hemoglobin don’t

match. The diagnostic criteria for diabetes for fasting plasma
glucose is ≥126 mg/𝑑𝐿 while in glycosylated hemoglobin is
≥6.5%. So all the Quarter results in glycosylated hemoglobin is
not in normal level but the plasma glucose fasting in Quarter 2
and Quarter 3 is normal fasting glucose.

3. What methods are used to measure glycosylated hemoglobin?

- Methods used to measure glycosylated hemoglobin are

High-performance liquid chromatography (HPLC),
Immunoassay, Enzymatic, Capillary electrophoresis and
Boronate affinity chromatography.

4. What potential conditions might cause erroneous results?

- Any condition that shortens erythrocyte survival or decreases

mean erythrocyte age like for example recovery from acute
blood loss, hemolytic anemia will falsely lower HbA1c test
results regardless of the assay method used.
CASE STUDY 14-8

A 25-year-old healthy female patient complained of dizziness and

shaking 1 hour after eating a large, heavy-carbohydrate meal. The result of a
random glucose test performed via fingerstick was 60 mg/dL.

Questions:

1. Identify the characteristics of hypoglycemia in this case study.

- The characteristics of hypoglycemia in this case study are

dizziness and shaking and may also include polyphagia because
the patient ate a large, heavy-carbohydrate meal and decreased
plasma glucose.

2. What test(s) should be performed next to determine this young woman’s

problem?

- Suppression test, a 72-hour fast, usually supervised in a hospital

setting, can be done to see if insulin levels fail to suppress,
which is a strong indicator of the presence of an
insulin-secreting tumor. During the test, the patient may have
calorie-free and caffeine-free liquids. Capillary blood glucose is
measured every 4 hours using a reflectance meter, until values
< 60 mg/dL (3.3 mmol/L) are obtained. Then, the frequency of
blood glucose measurement is increased to every hour until
values are < 49 mg/dL (2.7 mmol/L). At that point, or when the
patient has symptoms of hypoglycemia, a blood test is drawn
for serum glucose, insulin, proinsulin, and C-peptide levels.
The fast is then stopped at that point, and the hypoglycemia
treated with intravenous dextrose or carbohydrate-containing
food or drink.

3. To which category of hypoglycemia would this individual belong.

- The patient will be categorized in Documented Symptomatic

Hypoglycemia.

4. What criteria would be used to diagnose a potential insulinoma?

- The following blood tests that are needed to diagnose

insulinoma are glucose, insulin, C-peptide, and if
a proinsulin level is available, it might be useful as well.
CASE STUDY 14-9

A nurse caring for patients with diabetes performed a fingerstick

glucose test on the Accu-Chek glucose monitor and obtained a value of 200
mg/dL. A plasma sample, collected at the same time by a phlebotomist and
performed by the laboratory, resulted in a glucose value of 225 mg/dL.

Questions:

1. Are these two results significantly different?

- yes

2. Explain.

- The difference between plasma glucose (which is what blood

labwork reports) and whole blood glucose (which is what most
home testing fingerstick meters report) is blood labwork are
always high compared to home fingerstick measurements. And
home meter was always 8 to 10 points too low when compared
to the plasma glucose readings. A home fingerstick meter
measures Whole Blood Glucose. While blood-sample
bloodwork labs measure Plasma Glucose. Plasma Glucose is
typically 11% to 15% higher than whole Blood Glucose. So the
whole fasting glucose measurement of < 100 is a Plasma
Glucose number. While the home meter, which measures
Whole Blood Glucose, needs to read < 90.