Applying my learning - Case study 3

Jason is 19 years old and lives in student accommodation in the city. He comes into the surgery without having booked an appointment and asks to see the doctor or practice nurse because he is feeling unwell. The doctor is on visits and will be back soon, and the practice nurse is doing the baby vaccine clinic so is really busy. The receptionist asks if you can see him while he is waiting.

You can see that Jason looks unwell. He is a little flushed, looks very skinny and says he is a little breathless. He tells you that over the past couple of weeks he has been really thirsty and has lost over a stone in weight. He was underweight before he became unwell and is now worried because his clothes don’t fit anymore. Jason gets up at night to pass urine almost every hour but attributes this to the fact he is drinking copious amounts of water as he is so thirsty and his vision is blurred.

You wonder what could be the matter and in order to reassure Jason about his weight you decide to weigh him. You check his records and find that when he registered at the surgery when he started college his weight was 11 stone 10 llbs he now weighs 10st 9 Ilbs. What do you suspect could be the cause?

  • Option 1: Urine Infection
  • Option 2: He is not eating healthily
  • Option 3: He is probably drinking too much

The correct answer is Option 1.

Feedback: His symptoms and his frequency of micturition could be due to a urine infection

What tests can you do to confirm this?

  • Option 1: Urine test
  • Option 2: Blood pressure test
  • Option 3: Blood test

The correct answer is Option 1.

Feedback: A dip stick urine test will show if there is blood present and quantify it and it will show if there are leukocytes present, these are white blood cells and are high when infection present, as we make white blood cells specifically to fight infections.

You decide to do a urine test in case his frequency of micturition is due to a urine infection. You ask him to provide a urine sample which you dip test using a multistix. This shows that he has a very high level of glucose and ketones in the urine and he is not known to have diabetes.

What do you do next?

  • Option 1: You have been trained to use this and regularly help out in the diabetic clinic so you think he probably has undiagnosed diabetes.
  • Option 2: You explain to Jason that as the nurse is still busy it might be useful to check his blood glucose reading as the urine has shown positive to glucose. He agrees so you do a quality control test on the meter first as you know it should be checked on a daily basis. He washes his hands to ensure there is no glucose on the fingers and then you do the test. The reading shows a blood glucose of 28.3 mmol/l.

The correct answer is Option 2.

Feedback: Yes, if you have been trained to do a blood glucose test, then you can test Jason to confirm your suspicions. A trained nurse may confirm their suspicions - an unregistered nurse should not discuss the implications of the test with Jason

What is the diagnostic level for the confirmation of diabetes?

  • Option 1: fasting plasma glucose of more than 7.0 mmol/l or a random plasma glucose of more than 11.1 non fasting
  • Option 2: fasting plasma glucose of less than 7.0 mmol/l or a random plasma glucose of less than 11.1 non fasting
  • Option 3: fasting plasma glucose of more than 5.0 mmol/l or a random plasma glucose of more than 9.0 non fasting

The correct answer is Option 1.

Feedback: The diagnostic level for confirmation of diabetes is a fasting plasma glucose of more than 7.0 mmol/l or a random plasma glucose of more than 11.1 non fasting. Usually 2 laboratory tests need to be done but as Jasons blood glucose is very high and he has some of the common symptoms of type 1 diabetes there cannot be any doubt about the diagnosis ( see Diabetes UK for information on the diagnosis of diabetes).

What is the relevance of ketonuria in diabetes?

  • Option 1: Ketones are toxic and if insulin is not received in the next couple of hours his condition will deteriorate
  • Option 2: Ketones show that the patient is not following the correct diet and he should be given advice about how to correct this
  • Option 3: Ketones can show which form of diabetes the patient has

The correct answer is Option 1.

Feedback: Ketonuria is a sign of either an absolute or relative lack of insulin and confirms the diagnosis of type 1 diabetes when seen with heavy glycosuria. His breath may smell of ketones (pear drop aroma) but not all people can detect this. Ketones are toxic and if the young man does not receive insulin in the next couple of hours his condition will deteriorate quickly and he could become very nauseated or vomit. High levels of ketones can cause the individual to become acidotic so his breathing could become laboured and he could go into coma.

What is the relevance of his thirst and polyuria?

  • Option 1: His body is trying to quickly remove the excess glucose by filtering it through the kidneys, so he passes copious amounts of urine. He also becomes really thirsty but will be unable to maintain his fluid balance so he has become extremely dehydrated
  • Option 2: It is the concentration of certain osmolites, such as salt. If the water volume of the body falls below a certain threshold or the osmolite concentration becomes too high, then the brain registers a need 'thirst'. His body has excess salt which has triggered his thirst and he needs to increase his intake of fluids to balance the levels

The correct answer is Option 1.

Feedback: His body is trying to quickly remove the excess glucose by filtering it through the kidneys, so he passes copious amounts of urine. He will be unable to maintain his fluid balance so will become extremely dehydrated

What should do you do next?

  • Option 1: He needs to be given glucose immediately and told to rest.
  • Option 2: He needs to be given insulin immediately

The correct answer is Option 2.

Feedback: The young man will need to be given insulin as soon as possible and may need to be admitted to hospital as an emergency for intravenous insulin and intravenous fluids to correct the acidosis and dehydration. Report your findings to the registered nurse immediately – she should call the GP straight away and explain the situation.

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