Case Report

(Laboratory interpretation report)

Name of clinician (student): _________________________________ Date: 2007 01 22.

Patient’s name: Charles de Angelis.

40-year-old accountant complains that he has become impotent and has dizziness when
getting out of bed. This started about three months ago. He has been married for 15 years
without previous sexual problems.
Recently he has had episodes of diarrhoea, which began usually at night and lasted for a
few days. For the last year he has had epigastric discomfort, distension and nausea after
food. He has self-medicated with an alkali product.
He has had episodes of angina, which start whenever he is in a hurry.

Additional information on request:

Temperature 37.2oC,
Pulse 90 beats/minute
Blood pressure 90/40 standing. 110/60 lying down.
Respiration 22 breaths/minute
Absent posterior tibial pulse
Absent ankle reflexes
Absent vibrations sense and impaired position sense.

His medical history was that 14 years ago he developed insulin dependant diabetes
mellitus and 16 years ago he had mumps parotitis.

Sexual history: happy marriage, intercourse twice a week.

Healthy twin sons aged 12 years.
Weight loss of 4 kg without change in diet.
Diabetes: 16 units soluble insulin, 32 units protamine zinc each morning. No family
history of diabetes. These days more difficult to control. Hypoglycaemia in early morning
and occasional heavy glycosuria after meals.
Parotitis: unpleasant. Right side orchtits, severe epigastric pain. Atrophy of the affected
testis.

Work history: job secure, enjoys work. Financially secure.

No domestic worries.

Diabetic retinopathy – bilateral blot hemorrhages. Hard exudates at the periphery.

Stools unformed, clay coloured and greasy looking.

Laboratory results and differential diagnosis:

Differential dx. Test Healthy Result Meaning

range
Malabsorption Fecal fat < 5 g/day 10.5 Malabsorption
Chronic Serum 30-130 150 Malabsorption usually
Pancreatitis amylase U/L precedes diabetes
Diabetes mellitus Urinalysis Glucose, 2% Diabetes perhaps not in
albumin 200mg/L good control
Vascular disease, Troponin T <3 ug/L 4 ug/L Some vascular disease
angina prior to mi CRP < 10 mg/L 12 ug/L
Coeliac disease Antibody Negative Negative No coeliac
Vitamin B12 Vitamin B12 150-600 100 pmol/L
deficiency Folate 10-50 10 nmol/L
Bacterial Urinary < 100 200 mg/d Ileal disease or
overgrowth indican mg/d Hartnup’s disease
Underline the working diagnosis
Comments, qualifications:
Mumps causes sterility not impotence. Causes pancreatitis but not chronic illness.
Absence of foot pulses indicates vascular disease. Vascular diseases giving mesenteric
ischaemia. Could lead to small bowel infarction – possibly lethal.
Neuropathy of diabetes could explain impotence and dizziness.
Indican test needs sample to the laboratory within one hour.

Further diagnostic test(s) required and why.

Barium meal to check for stasis and dilation of loops of small intestine and perhaps the
stomach.
Valsalva maneuver – lack of repose means autonomic neuropathy. Increase of
intrapulmonary pressure by forced exhalation against the closed glottis.
Aspiration and culture of small intestine contents is difficult.
Vitamin B12 absorption test – malabsorption.
Improvement of symptoms and steatorrhoea after 5-day course of broad-spectrum
antibiotics.

Treatment by antibiotics when needed.

Attempts to improve diabetic control needed. Monitor by urine protein etc.