Salwa, is a 7-year-old, 30-kg , 50 inches tall girl, was brought to the emergency department (ED) by her parents because of nausea, vomiting, and persistent '' stomach ache'' secondary to the flu.
For the past week, Salwa had flulike symptom, resulting in 6-Ib weight loss. Initial laboratory values revealed a blood glucose of 600 mg/dL, serum pH of 6.8 with bicarbonate level of 13 mEq/l, plasma ketone level of 5.2 mmol/L, and positive ketonuria.
Salwa was diagnosed with diabetic ketoacidosis secondary to new-onset type 1 diabetes. In retrospect and on further questioning, Salwa's parents realized that she probably had symptoms as early as 4 weeks before her hospitalization.
While on a driving vacation, she drank large quantities of juice and had to stop hourly to urinate.
She began experiencing enuresis, which her parents attributed to her increased fluid intake.
1- What signs and symptoms are consistent with the diagnosis of type 1 diabetes in a child?
2- What are the goals of therapy for Salwa?
3- Should we start treating the patient with insulin and if we should , what type of insulin should we use?
4- Are the recommended sites of injection different for children? Does the age of the child play a factor?
5- How often should Salwa monitor her blood glucose?
Diana, is a 45-year-old moderately centrally obese(height, 5'5'';weight, 160 Ib; BMI 26.6 kg/m) Mexican- American woman, who was referred to the diabetes clinic when her gynecologist, who had been treating her for recurrent monilial infections, noted glucosuria on routine analysis. Subsequently, on two separate occasions she was found to have an FPG of 150 mg/dL and 167 mg/dl.
Diana denies any symptoms of polyphagia or polyuria, although lately she has been more thirsty than usual. She does complain of lethargy and often takes afternoon naps.
Diana's other medical problems include mild hypertension, which is well controlled on lisinopril 20 mg/day, and recurrent monilial infections, which are treated with fluconazole. She has given birth to four children( birth weighs, 7,8.5.,10, and 11 Ib, respectively) and was told during her last pregnancy that she had ''borderline diabetes''. She currently works as a loan officer in a local bank and spends her weekends '' catching up on her sleep'' and reading. Diana has been smoking one pack of cigarettes/day for 20 years and drinks an occasional glass of wine.
Her family history is significant for a sister, aunt, and grandmother with type two diabetes; all have weight problems.'' Diana's mother is alive and well at age 77; her father died of heart attack at age 47.
Laboratory assessment reveals an FPG of 147 mg/dL (normal, 70 to 100); fasting plasma triglycerides of 400 mg/dL; and A1C of 9.2 %( normal, 4% to 6%). All other values(including the complete blood count [CBC], electrolytes, liver function tests, and renal function tests) are within normal limits. Diana is given the diagnosis of type 2 diabetes.
1- What features in Diana's history and physical examination are consistent with this diagnosis?
2- What should the goals of therapy be for Diana and other patients with type 2 diabetes? Which biochemical indices should be monitored?
3- How should Diana be managed initially and chronically?