Question

P.A. is a 52-year old man who presented with a 2-week history of polyuria, polydipsia, polyphagia, weight loss, fatigue, and blurred vision. A random glucose test performed 1 day before presentation was 352 mg/dl. The patient denied any symptoms of numbness, tingling in hands or feet, dysuria, chest pain, cough or fevers. He had no prior history of diabetes and no family history of diabetes. Admission non-fasting serum glucose 248 mg/dl (N=<180 mg/dl), HbA1c 9.6% (N=4-6.1%). Electrolytes, BUN and creatinine were normal. Physical examination revealed weight of 180 pounds, height 5'5.5" (IBW 140-145). The rest of the examination was unremarkable, i.e., no signs of retinopathy or neuropathy. The patient was taught self-monitoring of blood glucose and begun on 5 mg glyburide once a day. He was instructed in diet (1800 cal ADA). Blood glucose levels ranged from 80 to 120 mg/dl within 2 weeks of starting glyburide, his symptoms disappeared and weight remained constant. During the next two months, blood glucose levels decreased to 80 mg/dl, and glyburide was stopped. Patient did not return until one year later; fasting serum glucose was 190 mg/dl, and HbA1c 8%. He again had polyuria and nocturia. Weight was unchanged from time of presentation. The physician put him on 5 mg/day of glyburide. His blood sugar one month later remained at 180 mg/day. At this point, his physician decided to put him on insulin alone, 20 units/day at bedtime. Two weeks later, his fasting plasma glucose was 120 mg/dl. 1. What are the mechanisms of blurred vision which was part of his initial symptoms? 2. Are there correlations between his abnormal blood chemistries and his other symptoms? 3. Calculate his approximate daily caloric needs. The patient is an accountant, and his daily exercise is limited to walking two blocks walking to and from the parking lot and his office. 4. Why did an 1,800 calorie a day diet fail to lower his body weight? 5. Was insulin treatment at this time the only possible option?

Answer 1

1. Blurred Vision in Initial Part of the diet could just be a temporary problem that develops rapidly and is caused by high blood sugar levels.

High blood Sugar causes the lens of the eye to swell, which changes your ability to see. To correct this kind of blurred vision, one need to get your blood sugar back into the target range.

2. Yes the blood chemistry shows rise in blood glucose level which cause the Rise of Serum osmolality hence requires more water for its filtration Causing Polyuria .

As a Result of Polyuria there occurs Polydipsia ( More thirst) .

Also In these patients we Find Polyphagia, As in these Patients we find due to Insulin resistance cell cannot take up the Glucose . Hence patients feel hunger and Eats more Food.

3. Daily Calorie Requirement for this patient is 1500 to 1800Kcal as This allow him to lose some Weight.

4. A calorie of 1800Kcal failed to lose his weight Because he lives very sedentary lifestyle walks only two blocks from parking lot to his office.

5. Yes, Insulin was the Only Treatment possible option at this time because even after giving glyburide his Blood glucose levels were about 180mg/dl. So to decrease the blood glucose level it was Important to start off with the Insulin.