Recent Weight Loss and Polyuria in a 52Year Old

Anders H. Berg and David B. Sacks

A 52-year-old man with a history of hypertriglyceridemia and a recent toenail infection came to his primary care physician's office complaining of recent onset of nocturia, polyuria, and a 10-lb weight loss. His family history revealed that his father had developed diabetes mellitus at age 60. A limited physical examination revealed normal vital signs, normal fundi (by ophthalmoscopy), and no detectable peripheral neuropathy. Laboratory data at initial visit were as follows:

Value,

Reference

Reference

Conventional

Interval,

Value,

Interval,

Analyte

Units

Conventional Units

SI Units

SI Units

Sodium (B)

139 mmol/L

136-142

Same

Potassium (B)

3.6 mmol/L

3.5-5.0

Same

Chloride (B)

98 mmol/L

98-108

Same

CO2, total (B)

28 mmol/L

23-32

Same

Urea nitrogen (B)

13 mg/dL

9-25

12.1 mmol/L

3.2-8.9

Creatinine (B)

0.9 mg/dL

0.7-1.3

310 mmol/L

62-115

Glucose (B)

420 mg/dL

54-99

23.3 mmol/L

3.0-5.5

Anion gap (B)

13 mmol/L

3-15

Same

Calcium (B)

10.5 mg/dL

8.8-10.5

2.4 mmol/L

2.15-2.5

Insulin (B)

3.2 mU/mL

2-18

22 pmol/L

14-125

HbAic (B)

10.3%

4.2-5.8

Same

TSH (B)

1.28 mU/mL

0.5-5.0

1.28 mU/L

0.5-5.0

T4 (B)

10.5 mg/dL

5-11

135 nmol/L

65-142

Glucose (U)

3+

0-0

N/A

Ketones (U)

1 +

Negative

N/A

Specific gravity (U)

1.040

1.003-1.035

Same

pH (U)

7.0

4.5-8.0

Same

Albumin (U)

Negative

Negative

Urine blood (U)

Negative

Negative

The markedly increased random serum glucose concentration suggested diabetes mel-litus, and after considering the history and presentation, the physician thought that it was most likely type 2 diabetes. The increased HbA1c concentration indicated that the hyperglycemia had been present for some time.1 Measurement of plasma glucose on a subsequent day gave a value of 300mg/dL (16.7 mmol/L), establishing the diagnosis of diabetes mellitus.2 The patient was counseled regarding changes in diet and exercise, and was started on 850 mg oral metformin twice daily (bid). On a follow-up visit one week later his casual (nonfasting) capillary blood glucose concentration obtained by finger stick was 230mg/dL (12.8 mmol/L). The physician prescribed self-monitoring of blood glucose (SMBG) twice a day. Within a few months the patient gained 6 lb and his HbA1c had dropped to 6.1%. He returned to the clinic after 6 months for a follow-up visit to monitor his glycemic control. He admitted to having increased his consumption of carbohydrates and was exercising less. He denied polyuria or nocturia, visual disturbance, or neuropathic symptoms, and felt well.

Physical examination revealed a blood pressure of 122/72 mm Hg, a regular pulse rate of 64 bpm, and a respiratory rate of 12/minute. Heart sounds were normal with no murmurs, and the lungs were clear to auscultation. Examination of the abdomen revealed no masses or hepatomegaly, and bowel sounds were normal. Ophthalmologic examination showed normal fundi. There was no pedal edema, dorsalis pedis pulses were normal bilaterally, and toes and feet were sensitive to light touch and position.

Laboratory data from a fasting blood sample and urine collected the previous day:

Analyte

Glucose (B) HbAic (B) Albumin (B) Microalbumin (U)

Value, Conventional Units

Reference Interval, Conventional Units

Value, SI Units

Reference Interval, SI Units

Despite only a relatively mild increase in fasting glucose concentration, the physician was concerned by the increased HbA1c. Although the patient showed no obvious signs of diabetic microvascular complications, the earlier infection raised the possibility of peripheral vascular insufficiency and the resulting susceptibility to infection associated with diabetes.3 The patient was again counseled firmly to resume his exercise and control his diet, and the physician increased the metformin to 1000 mg bid. Another appointment was made for the patient to see the nutritionist and ophthalmologist, and a follow-up appointment was scheduled in 3 months to consider adding a sulfonylurea to the patient's therapy if no improvement was seen.

Diabetes 2

Diabetes 2

Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...

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