A 20-year-old man with recently diagnosed type 1 diabetes and on insulin therapy for 8 weeks presents for a check-up. He is interested in participating in a metabolic intervention study that requires evaluation of his incretin response to a mixed meal test. Physical examination reveals no abnormalities. How does the incretin response in this individual compare to that of non-diabetic individuals?
A 25-year-old woman presents to the emergency department with dyspnoea. She has a history of type 1 diabetes and is non-compliant with insulin treatment. She denies smoking or drinking alcohol and lives with her family.
Upon examination, her heart rate is 90 beats per minute, respiratory rate is 24/minute, blood pressure is 120/77 mmHg, and temperature is 36.7ºC. Arterial blood gas reveals a pH of 7.11 (7.35-7.45), pO2 of 14.1 kPa (11-13), pCO2 of 3.4 kPa (4.5-6), HCO3 of 10 mmol/L (22-26), glucose of 24 mmol/L (< 7.8), lactate of 2.6 mmol/L (0-2), potassium of 4.8 mmol/L (3.5-5.5), and sodium of 136 mmol/L (135-145). Blood ketones are elevated at 3.4 mmol/L (<0.6). The patient is treated with intravenous normal saline and appropriate potassium replacement, as well as a fixed rate insulin infusion (FRII) to normalize her academia, ketonemia, and hyperglycemia. During the resolution of this condition, what electrolyte abnormality is she at risk of developing?
A 20-year-old man with type 1 diabetes and poor compliance presents to the hospital with shortness of breath, vomiting, and feeling unwell. He is diagnosed with diabetic ketoacidosis and is transferred to the high dependency unit. After a period of recovery, he starts to feel unwell on day 3 of his treatment. He experiences fatigue, lethargy, and muscle aches, and his legs collapse beneath him while walking to the bathroom.
Upon examination, he is alert with moist mucosa, and there are no fasciculations or myoclonus. He has 4/5 power in all muscle groups with retained sensation. His abdomen is soft, and his chest is clear. His observations show tachypnea at 24 breaths/min.
Admission blood tests reveal the following values compared to current values:
– Sodium: 128 mmol/l (current: 133 mmol/l)
– Potassium: 6.1 mmol/l (current: 4.5 mmol/l)
– Urea: 9.2 mmol/l (current: 5.6 mmol/l)
– Creatinine: 134 µmol/l (current: 87 µmol/l)
– Glucose: 27.1mmol/l (current: 12 mmol/l)
– Ketones: 3.1 mmol/l (current: 0.2 mmol/l)
– pH: 7.01 (current: 7.35)
What is the expected progression of his deterioration?
A 72-year-old patient with type II diabetes visits her GP for a check-up. Her blood glucose levels are not well-controlled despite taking the highest doses of metformin and gliclazide. The GP decides to switch her from gliclazide to insulin glargine. What are the specific amino acid modifications present in glargine insulin?
A 35-year-old nurse is admitted for prolonged fasting. She presented to clinic with a six-month history of episodic sweating and light-headedness, which were relieved by eating. During one of these episodes, her blood glucose level was measured at 2 mmol/L, and she quickly recovered after taking glucose tablets. On examination, no abnormalities were found, and her vital signs were within normal limits. She was admitted for a 72-hour fast, during which she developed typical symptoms 16 hours in. Her blood glucose level was measured at 2.2 mmol/L, and the fast was stopped. Blood tests revealed a plasma glucose level of 1.8 mmol/L, 3 beta-hydroxybutyrate level of 0.5 mmol/L, insulin level of 450 pmol/L, and C peptide level of 0.2 nmol/L. What is the most likely diagnosis?
A 25-year-old nursing student presents with frequent episodes of fainting. One of these occurred during a clinical placement in the Emergency Department while a patient was experiencing a heart attack. Blood glucose at the time was noted to be 1.6 mmol/l. All other blood tests were normal.
Upon examination immediately after an episode, her blood pressure was 120/80 mmHg, pulse was 90/min and regular, and she was clammy and cold. Blood taken at the time confirmed a venous blood glucose of 1.3 mmol/l, C-peptide level was low-normal, and insulin levels were significantly elevated.
What is the most probable diagnosis in this scenario?
You are asked to see a 28-year-old woman who is 10 weeks into her first pregnancy. She has been experiencing frequent nausea and has lost weight as a result.
During the examination, she appears nervous. Her blood pressure is 110/75, with a pulse of 80 and regular. Her BMI is 21.
The following investigations were conducted:
s
Haemoglobin (Hb) 122 g/l 135 – 175 g/l
White cell count (WCC) 6.0 × 109/l 4.0 – 11.0 × 109/l
Platelets (PLT) 195 × 109/l 150 – 400 × 109/l
Sodium (Na+) 142 mmol/l 135 – 145 mmol/l
Potassium (K+) 3.6 mmol/l 3.5 – 5.0 mmol/l
Creatinine (Cr) 95 μmol/l 50 – 120 μmol/l
Glucose 5.0 mmol/l 3.9 – 7.1 mmol/l
Total Thyroxine (T4) 190 nmol/l 58 – 174 nmol/l
Thyroid-stimulating hormone (TSH) 0.8 mu/l 0.4 – 5.0 mu/l
What is the most appropriate course of action in this scenario?
A 50-year-old male presents with impotence and diabetes. He was diagnosed with diabetes four years ago after experiencing erectile dysfunction. He reports complete impotence, a poor libido, and infrequent shaving. Despite trying sildenafil (Viagra), he has not had any success. His current medications include glibenclamide 10 mg daily, aspirin 75 mg daily, and amlodipine 5 mg daily for hypertension. On examination, he has normal secondary sexual characteristics, an irregular pulse of 80 bpm, a blood pressure of 126/86 mmHg, and a BMI of 24.4 kg/m2. Investigations reveal normal haemoglobin, white cell count, and platelets, but elevated liver enzymes and low testosterone levels. Which of the following is the most appropriate investigation for this patient?
A 35-year-old man presents to the hypertension clinic with daily headaches for the past 3 months. He reports feeling otherwise well. On examination, his blood pressure is 165/90 mmHg, heart rate is 80 beats per minute, temperature is 37.2 ºC, and SpO2 is 96% on air. Notably, he has pronounced lower jaw protrusion with increased interdental spaces. Laboratory results show a hemoglobin level of 145 g/L, platelets of 225 * 109/L, WBC of 8.2 * 109/L, Na+ of 138 mmol/L, K+ of 3.8 mmol/L, urea of 5.4 mmol/L, and creatinine of 66 µmol/L. His random glucose level is 14.5 mmol/L. What is the initial investigation that should be performed?
You are urgently called to review a 44-year-old woman in the emergency department. She presented earlier in the day with fever, a productive cough and confusion. The emergency department doctors diagnosed her with community acquired pneumonia after seeing consolidation on her chest X-ray and sepsis secondary to this with associated delirium. According to her partner, she had been feeling unwell for two days with a cough and become increasingly unwell, confused and agitated. The partner also explained that she had recently been diagnosed with an overactive thyroid and been told to start urgently on anti-thyroid tablets, but had not done so when she had read the label of these tablets and found that they should not be taken during pregnancy and she is trying to become pregnant. She had been taking paracetamol only for fever.
Despite treating with IV co-amoxiclav and oral clarithromycin and fluid resuscitation with three liters of fluid as well as IV paracetamol the patient has not improved.
On examination, she is very agitated and aggressive and is difficult to examine. She feels very hot and clammy to touch, but peripheries are well perfused. Auscultation shows left sided crepitations. Her heart rate is 170 bpm, blood pressure 81/40 mmHg, temperature 39.2ºC, oxygen saturations 100% on 2L via nasal cannulae.
Blood tests from this admission are still pending. Outpatient blood tests show an undetectable low TSH two weeks ago, as well as a free T4 of 53 mmol/ml.
What is the most appropriate immediate treatment?