d**o
发帖数: 618 | 1 Per HIPPA, some details are modified.
CC: MX is a 43yo female visiting a PCP for diabetes mellitus diagnosis.
HPI: Pt was checked at the PCP office annually. Last year she requested a test of HbA1c; result was 5.5. Pt has been measuring glucose by herself at home using OTC glucose meter, and reports orally that her glucose has been all over the range (60 to 400). Per her request, she had HbA1c and glucose tolerance tests before today's visit. Pt complains of debilitating fatigue and hand numbness, and intermittent dizziness. Pt suspects and worries about diabetes.
ROS: ROS of CVS, GI, pulm, urinary, muscle etc performed and all negative.
Med: simvastatin 20mg q.d.
Allergies: Gluten.
PMH: mild hypothyroidism and mild hyperlipidemia based on blood test last year.
FHx: Both mother and father had type 2 diabetes, and boths died of stroke.
SHx: Lives with husband and 2 children. No smoking or EtOH. Is not working b/o fatigue.
Lab (current, relevant results only):
HbA1c 5.0, 1-hour Glucose tolerance test with fasting: before: 64, after: 295.
TSH: 5.0, WBC: 3.0, Hb: 11. Fasting glucose on BMP: 96.
Random glucose in the clinic, at the moment of encounter, was 160. This was in the afternoon and pt had lunch.
PE: General: alert and oriented, not in acute distress.
Vitals: HR 60, BP 85/60, BMI 18 (Wt 100 lb, Ht 5ft3in, 12 lb loss compared to last year).
Eyes: conjunctiva and sclera normal, fundus normal.
Neck: supple. Thyroid of normal size. No bruit.
CVS: RRR with normal S1 and S2, no murmur.
Abdomen: Non-distended, soft, active bowel sounds, no organomegaly.
Feet: No edema, pedal pulses 2+ bilateral, no ulcer or discoloration. But does not feel monofilament or vibration at all.
What's your A&P as a PCP? | A*******s
发帖数: 9638 | 2 Questions:
1. What is her race?
2. What is the orthostatic BP?
3. How about DTRs? | d**o
发帖数: 618 | 3 For the purpose of this discussion:
Race: Chinese
No orthostatic hypotension
DTR normal | A*******s
发帖数: 9638 | 4 The reason I care about the race is that leukocytopenia at 3000 may not be a
big deal for AA but could be symptomatic(fatigue, lightheaded, etc) for
Chinese.
Orthostatic hypotension could be seen in DM autonomic neuropathy, same
applies to areflexia.
【在 d**o 的大作中提到】
: For the purpose of this discussion:
: Race: Chinese
: No orthostatic hypotension
: DTR normal
| d**o
发帖数: 618 | 5 Great reasoning. So based on all this info I told you, including her ethnicity, what'd you do?
a
【在 A*******s 的大作中提到】
: The reason I care about the race is that leukocytopenia at 3000 may not be a
: big deal for AA but could be symptomatic(fatigue, lightheaded, etc) for
: Chinese.
: Orthostatic hypotension could be seen in DM autonomic neuropathy, same
: applies to areflexia.
| b******a
发帖数: 704 | 6 more detail of the CBC, blood smear exam? BMP? blood vitamin B12 level?
any exam on the endocrine hormones, like ACTH level? just my wild guess. | d**o
发帖数: 618 | 7 CBC and BMP done a week before the visit were normal except for the results I listed. Fasting glucose on the BMP was 96. Random glucose in the clinic, at the moment of encounter, was 160. This was in the afternoon and pt had lunch.
Vit B12 and folic acid were not available at this encounter, but were measured later and found out normal. As for ACTH ... let me make it clear, this is an outpatient encounter, and you as PCP need to tell the pt something before you have all the fancy tests you want. This is a relatively simple case, I just wonder what your A&P would be at this moment?
【在 b******a 的大作中提到】
: more detail of the CBC, blood smear exam? BMP? blood vitamin B12 level?
: any exam on the endocrine hormones, like ACTH level? just my wild guess.
| b******a
发帖数: 704 | 8 Thank you for reminding my role as a PCP :-) It is not a simple case
for me as a Newbie. I feel 如梗在喉too.
The disease in my mind first is hypothyroidism, next DM with complication of
neuropathy, Vitamin B12 deficiency. Why did she lose BW?
Plan is to check total T4, free T4/T3, anti TPO Ab, insulin levels and C-
peptide, lipid profile again and refer to specialist Dr. againstwind.
This is a relatively simple case, I just wonder what your A&P would be at
this moment?
【在 d**o 的大作中提到】
: CBC and BMP done a week before the visit were normal except for the results I listed. Fasting glucose on the BMP was 96. Random glucose in the clinic, at the moment of encounter, was 160. This was in the afternoon and pt had lunch.
: Vit B12 and folic acid were not available at this encounter, but were measured later and found out normal. As for ACTH ... let me make it clear, this is an outpatient encounter, and you as PCP need to tell the pt something before you have all the fancy tests you want. This is a relatively simple case, I just wonder what your A&P would be at this moment?
| d**o
发帖数: 618 | 9 Actually, I have not got to the 如梗在喉 part yet :P
Your plan is great. Two questions:
1, Pt asked you at that moment "Do I have diabetes"? How'd you answer?
2, What's your reason for requesting endocrine consult?
of
【在 b******a 的大作中提到】
: Thank you for reminding my role as a PCP :-) It is not a simple case
: for me as a Newbie. I feel 如梗在喉too.
: The disease in my mind first is hypothyroidism, next DM with complication of
: neuropathy, Vitamin B12 deficiency. Why did she lose BW?
: Plan is to check total T4, free T4/T3, anti TPO Ab, insulin levels and C-
: peptide, lipid profile again and refer to specialist Dr. againstwind.
:
: This is a relatively simple case, I just wonder what your A&P would be at
: this moment?
| b******a
发帖数: 704 | 10 1. most likely, yes. Her glucose tolerance test after glucose intake: 1 hour
295, how about 2hr??? if two hours after a 75 g oral glucose>200mg/dl,
supporting this diagnosis if I am not wrong. this may explain her BW lose.
However, I am not sure such a short term of DM could lead to complications
such as neuropathy.
2. In exam, I would prefer to get the opinion from an expert to avoid losing
any point, lol. I am not sure what cause her neurological symptoms. her TSH looks normal. HbA1c is normal. | | | d**o
发帖数: 618 | 11 Thanks for the good discussion. I wish to hear others' inputs before
revealing the 如梗在喉 part.
【在 b******a 的大作中提到】
: 1. most likely, yes. Her glucose tolerance test after glucose intake: 1 hour
: 295, how about 2hr??? if two hours after a 75 g oral glucose>200mg/dl,
: supporting this diagnosis if I am not wrong. this may explain her BW lose.
: However, I am not sure such a short term of DM could lead to complications
: such as neuropathy.
: 2. In exam, I would prefer to get the opinion from an expert to avoid losing
: any point, lol. I am not sure what cause her neurological symptoms. her TSH looks normal. HbA1c is normal.
| R*******t
发帖数: 367 | | d**o
发帖数: 618 | 13 Great point. Suppose you were the PCP and asked the pt about her diet. Pt
reported that she was not eating much both because she wanted to lose weight
and because she did not have much appetite anyway. She reported eating
mainly soup, and a few nuts per day. So?
【在 R*******t 的大作中提到】
: 病人有没有因为血脂高而故意减肥？
| R*******t
发帖数: 367 | 14 那她的fatigue跟减肥一定会有关系，她的glucose tolerance test pre只有64，有点
低啊。营养不良，维生素不足，电解质失衡什么的。查查蛋白albumin什么的了吗？不过没有水肿，蛋白估计还可
以。
她吃维生素吗？有借助药物减肥吗？
weight
【在 d**o 的大作中提到】
: Great point. Suppose you were the PCP and asked the pt about her diet. Pt
: reported that she was not eating much both because she wanted to lose weight
: and because she did not have much appetite anyway. She reported eating
: mainly soup, and a few nuts per day. So?
| s*******w
发帖数: 1879 | 15 偷偷回答然后被骂了叫我公开发出来。
发之。。。
“我觉得不象是metabolism出了问题，是不是脑袋里面？厌食症么？
我要是问我就会问她每天diet习惯。” | a********n
发帖数: 182 | | d**o
发帖数: 618 | 17 Thanks for all your comments. Here is my 如梗在喉 part:
The basic dilemma here: trust HbA1c or glucose tolerance test?
Unfortunately, at this encounter, PCP did not really ask about diet like
Rubyheart did. PCP's plan included:
1) started pt with metformin 500mg, and told pt to cut down carbohydrate
intake (without asking pt first what pt was eating),
2) ordered vit B12, folic acid, blood smear tests, which all came back as
normal.
3) RTC in some months.
Before next visit, pt had HbA1c, BMP and glucose tolerance test again. They
were all like last time, and the post-tolerance glucose was even higher (3xx
). Pt did some research and read that HbA1c may be artificially low for
anemia patients. She raised this point to PCP, and PCP bought it. Pt
insisted for and got short-term postprandial insulin in addition to
metformin. Referral to endocrine was also made, but it required 3-6 months
of wait. At follow-up 1mo later (i.e. before endo consult), pt reported to
PCP that she felt very well with the insulin shots, and was very satisfied
that her glucose reading at home finally came down. Anyway, insulin shots
were continued.
The endo consult, however, concluded that: "She had no evidence of diabetes,
and currently she is having very low glucose on insulin. There are no
available lab data that suggests that she has diabetes. A glucose torelance
test can be abnormal if she is depriving herself of carbohydrate the way she
is currently doing. We would recommend that all insulin be stopped since
she is at very high risk for complications of hypoglycemia including death.
Once insulin is stopped we would not use glucose tolerance for the diagnosis
of possible diabetes, but fasting glucose and HbA1c."
Pt refused to accept endo's diagnosis, despite of PCP's efforts to convince
her that endo expert is more correct than himself. Despite that PCP stopped
insulin and metformin, pt probably continued to finish the remaining doses
anyway. Pt also escalated her efforts to over-limit her diet, and continued
to lose weight. Finally, she lost consciousness while driving and caused a
motor vehicle accident. Fortunately she only injured one of her legs out of
that. She believes the MVA was because her diabetic medicine was cut short,
and she fired the PCP, shopped around and came to see my teacher (another
PCP).
In my encounter with her, it is clear that she is pathetically obssessed
with the diabetic diagnosis. She claims that she has "diabetic anemia" that
biases HbA1c, and that her MVA was caused by heart attack because she had
palpitations before and after the accident. She even said something like "I
hate that you and I all ate so much carbohydrate in China, and I realized
too late that it is toxic." I asked her more about it and she told me about
her parents whose diabetes were diagnosed too late in China. She clearly had
emotional trauma from her parents' death.
She demanded for insulin or at least metformin, and threatened that "if you
don't give it to me and my sugar runs into 200s, you know, you
may be in trouble."
My teacher's plan at this time is:
1) referral to hematologist re: anemia.
2) referral to psychiatrist for obssession.
3) firmly denied her request for metformin or insulin, and told her she does
not have DM. | d**o
发帖数: 618 | 18 Moral of this story:
1) Technical point: Glucose tolerance test may be artificially high if pt self-starves too much and becomes hyper-sensitive to a glucose stimulus. The first PCP missed this point, and my teacher said he might miss it too. HbA1c could be artificially low if pt has hemolytic anemia, but her anemia has not been classified to be that.
2) Be aware that family history is a double-edged sword. It could guide or misguide diagnosis. In this case, pt likely had a limited diet from very early on and undiagnosed emotional trauma from parents' death. Her family history probably also made her more prone to developing pathologic obsession with the diabetes diagnosis and treatment.
3) Refer to specialists. It's only luck that the pt's MVA happened after the endo consult, otherwise the first PCP could be in real legal trouble. | a********n
发帖数: 182 | 19 Very good case. Pt deserve a psych consult. She has anorexia nervosa on top
of all her conditions, prognosis is not good down the road. | A*******s
发帖数: 9638 | 20 This case is not that simple as you initially claimed.:)
I agree with the endo that this patient can not be diagnosed DM. I posted
the answer at my very first reply but had it revised because our endo specialist,
like againstwind or newprozac, would hammer me badly, lol
A patient with typical clinical symptoms and abnormal OGTT, or abnormal
fasting glucose, is easy to be diagnosed. For one time abnormal OGTT and
normal HgA1c and normal fasting, I would not diagnose DM, and legally would
not start any treatment correspondently.
Her clinical symptoms have nothing to do with diabetes. Instead, anemia and
leukocytopenia could better explain her symptoms as well as her syncope spell/auto accident.
I still do not understand why anorexia could artifically increase OGTT?
Hypersensitivity to glucose only triggers more insulin secretion and leads
to hypoglycemia and a lower OGTT value.
Did you check C-peptide on this patient? | | | a********n
发帖数: 182 | 21 Hypoglycemia trigger hyperglycemia. Remember Fight or flight? When
hypoglycemia, the negative feedback give body rebound under the influence of
all the hormones including glucocorticoid.
All her anemia,leukopenia,fatigue... caused by Anorexia. She need to see an
anorexia specialist. :) | d**o
发帖数: 618 | 22
This point also surprised both PCPs. I copied the endo's report verbatim as
above. Maybe we shall offer baozi to againstwind or newprozac to explain
this to us?
I forgot to mention above, but my teacher did order this and a lot other
tests. Pt sat there and read the lab order carefully, and asked me what C-
peptide is. I chagrined and pretended I didn't know. Personally, I won't be
surprised if she is using insulin shipped from China //sigh
【在 A*******s 的大作中提到】
: This case is not that simple as you initially claimed.:)
: I agree with the endo that this patient can not be diagnosed DM. I posted
: the answer at my very first reply but had it revised because our endo specialist,
: like againstwind or newprozac, would hammer me badly, lol
: A patient with typical clinical symptoms and abnormal OGTT, or abnormal
: fasting glucose, is easy to be diagnosed. For one time abnormal OGTT and
: normal HgA1c and normal fasting, I would not diagnose DM, and legally would
: not start any treatment correspondently.
: Her clinical symptoms have nothing to do with diabetes. Instead, anemia and
: leukocytopenia could better explain her symptoms as well as her syncope spell/auto accident.
| d**o
发帖数: 618 | 23 What saddens me most is that her anorexia is likely triggered by her parents
' diabetes and early death. 走不出上一辈人的阴影而死去，实在可怜. I doubt
her compliance with the psychiatrist. Sad.
an
【在 a********n 的大作中提到】
: Hypoglycemia trigger hyperglycemia. Remember Fight or flight? When
: hypoglycemia, the negative feedback give body rebound under the influence of
: all the hormones including glucocorticoid.
: All her anemia,leukopenia,fatigue... caused by Anorexia. She need to see an
: anorexia specialist. :)
| n*******c
发帖数: 501 | 24 Thanks for the very educational case.
1. Glucose tolerance test should be done properly before we can rely on its
result. It is very important to make sure for days or even weeks before the
test, the patient has not been restricting carbohydrate. Secondly the
patient should be fasted properly (8hrs rule). You would be surprised how
people understand fasting.lol I have had a patient (back in china) who
thought fasting means no meals but fruits doesn't count so she had some
grape before bed...
2.In terms of diagnosis, it is not simple just to check the numbers to see
if they fit with criteria. One should always think about why? OK, she has
diabetes, but why? Type 1? Obviously her sugar is not too high and should
have enough insulin reserve. Type 2? BMI is 18, how likely she is insulin
resistant. Maybe other causes? That is probably why she should have those
hormone test to exclude secondary diabetes. But in that case finding the
cause is the most important because medication would not help except insulin
if glucose is way too high.
3.For any new diabetes, a dietitian review is a must-have. Because diet
control is the most important and basic part of management of diabetes. Some
patients can even achieve blood glucose control by diet control only.You
would not know how to control diet before you take a detail history of diet.
As a PCP, you cannot just tell the patient to cut...how? If he takes a
proper history of diet before giving advise on diet, then diagnosis would
not be mistaken.
I am not an Endocrinologist. Honestly I may not find out the cause for the
abnormal OGTT test in the first visit. But I think I would not start
medication right away before trial of diet control only, which should be
guided by a proper history of diet.
A young girl with low BMI...should do diet history like a reflex lol
self-starves too much and becomes hyper-sensitive to a glucose stimulus. The
first PCP missed this point, and my teacher said he might miss it too.
HbA1c could be artificially low if pt has hemolytic anemia, but her anemia
has not been classified to be that.
misguide diagnosis. In this case, pt likely had a limited diet from very
early on and undiagnosed emotional trauma from parents' death. Her family
history probably also made her more prone to developing pathologic obsession
with the diabetes diagnosis and treatment.
the endo consult, otherwise the first PCP could be in real legal trouble.
【在 d**o 的大作中提到】
: Moral of this story:
: 1) Technical point: Glucose tolerance test may be artificially high if pt self-starves too much and becomes hyper-sensitive to a glucose stimulus. The first PCP missed this point, and my teacher said he might miss it too. HbA1c could be artificially low if pt has hemolytic anemia, but her anemia has not been classified to be that.
: 2) Be aware that family history is a double-edged sword. It could guide or misguide diagnosis. In this case, pt likely had a limited diet from very early on and undiagnosed emotional trauma from parents' death. Her family history probably also made her more prone to developing pathologic obsession with the diabetes diagnosis and treatment.
: 3) Refer to specialists. It's only luck that the pt's MVA happened after the endo consult, otherwise the first PCP could be in real legal trouble.
| b******a
发帖数: 704 | 25 我怎么就不问"is the body weight loss intentional?" BMI稍偏低，我如此担心她的
体重，这个年纪，我就活生生没往厌食想。应该要考虑精神因素的影响。 血糖波动那么大
，我还在考虑可能胰岛素分泌延迟，或其他不正常啥的。 我潜意识的字典里只有“贪
吃”，没有”厌食“，要扩容啊。看了大家的讨论，最收益的是我这个危险的PCP。谢
谢如此简单，又不简单的病例。
不过，在没有明确的诊断前，病人病情并不紧急，连我都会药物治疗不要先上，耐心等
Endocrinologist的咨询. | c***x
发帖数: 57 | 26 I saw a similar but different cars recently. A 68 yo f referred for leg
weakness, loss of memory.
Upon more questioning, she eats only Veg and occasional fruits. Her fasting
glucose in the last two ys was in 60's, the day I saw her, glucose 56, hg b
a1c 4.5. PCP never dresses her glucose issues, sent to us for possible
normal pressure hydrocephalus wo a head ct.
I sent pt back, still not sure how her PCP would dress her issues. | A*******s
发帖数: 9638 | 27 So does she has NPH?
Glucose 60s is not bad. Her PCP ia more concerned about leg weakness/memory
loss.
fasting
b
【在 c***x 的大作中提到】
: I saw a similar but different cars recently. A 68 yo f referred for leg
: weakness, loss of memory.
: Upon more questioning, she eats only Veg and occasional fruits. Her fasting
: glucose in the last two ys was in 60's, the day I saw her, glucose 56, hg b
: a1c 4.5. PCP never dresses her glucose issues, sent to us for possible
: normal pressure hydrocephalus wo a head ct.
: I sent pt back, still not sure how her PCP would dress her issues.
| c***x
发帖数: 57 | 28 No ct scan. But chronic hypoglycemia will cause memory loss, or even
psychosis, and generalized weakness. Brain and muscle needs glucose as fuel.
Ct is still pending, |
|
