DM CASES

1. Mrs FR is 77-year-old woman. She is usually very

independent and has never taken any regular
medication. She was recently prescribed two courses
of antibiotics for urinary tract infections. Her daughter
visited this morning and called the ambulance because
her mother was very confused and looked very unwell.
Review in the emergency department identified that
Mrs FR is extremely dehydrated; her blood glucose
level on the standard machine read ‘HI’ (>27.8
mmol/L), and the laboratory blood glucose was
confirmed at 65 mmol/L. Her sodium is 168 mmol/L
(normal range 135–145 mmol/L). Her eGFR is reduced
to 13 mL/min from her usual baseline of 26 mL/min.
 Questions

1. What is the likely cause of Mrs FR’s symptoms and

elevated blood glucose?
2. How should Mrs FR be managed?
3. What advice should be given about the long-term
management of her blood glucose?
2. Mr JS is a 69-year-old man with longstanding type
2 diabetes. He has recently noticed that his left shoe
has been rubbing his foot, which he finds confusing
because he has been wearing these shoes for 6
months with no problems. His whole left foot now
looks red and swollen. When Mr JS inspected it
closely, he noticed that there was a weeping sore.
However, his foot is not painful, so he does not feel
too concerned.
 Questions

1. What is the most likely reason that Mr JS did not

feel any pain associated with the sore?
2. Why might Mr JS’s shoe suddenly have started to
rub his foot?
3. Should Mr JS be more concerned?
3. A.H., a slender, 18-year-old woman who was recently
discharged from the hospital for severe
dehydration and mild ketoacidosis, is referred to the
Diabetes Clinic from the University Student Health
Service (no records available). A fasting and a random
plasma glucose ordered subsequently were 190 and 250
mg/dL. Approximately 4 weeks before she was
hospitalized, A.H. had moved across the country to
attend college—her first time away from home. In
retrospect, she remembers that she had symptoms of
polydipsia, nocturia (6 times a night), fatigue, and a 12-
lb weight loss during this period, which she attributed to
the anxiety associated with her move away from home
and adjustment to her new environment.
Her medical history is remarkable for recurrent upper
respiratory infections and three cases of vaginal
moniliasis in the past 6 months. Her family history is
negative for diabetes, and she takes no medications.
Physical examination is within normal limits. She
weighs 50 kg and is 5 feet 4 inches tall. Laboratory
results are as follows: FPG, 280 mg/dL; A1C, 14%; and
trace urine ketones. On the basis of her history and
laboratory findings, the presumptive diagnosis is Type 1
diabetes.
 Questions
1. Which findings are consistent with this
diagnosis in A.H.?
2. A.H. will be started on insulin therapy on this
visit. What are the goals of therapy? Will
normoglycemia prevent the development or
progression of long-term complications?
3. What methods of insulin administration are
available to achieve optimal glucose