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October 2011: Endocrine

A 47 year-old male radio operator presents to the clinic with a complaint of dizziness, blurring of vision, and numbness in his feet for the last week. He denies any trauma, chest pains or shortness of breath.

Upon further questioning his symptoms have been off and on for several months usually resolving on their own and no known exacerbating factors. He denies dysuria but notes that he has been peeing more than usual. He feels this has been caused by his increase in drinking water.

Vitals

  • Temp: 98.9
  • Pulse: 99
  • Respirations: 15
  • BP: 149/94
  • O2: 100% on room air
  • BMI 36

Physical Exam

  • Alert male with no acute distress
  • HEENT: atraumatic normocephalic, PERRL, EOMI, Funduscopic exam normal,
  • Oral Cavity: no lesions, tonsils appear normal, mucus membranes appear dry
  • Heart: Regular rate and rhythm, no murmurs
  • Lungs: Clear to auscultation
  • Abdomen: Protuberant, non-tender, non-distended, normal bowel sounds
  • Extremities: muscle strength 5/5 (upper and lower),
  • Neuro: Cranial nerve II-XII grossly intact, 1+ patellar and ankle reflex, decrease in sensation to pin prick on the plantar surface of both feet

Lab Work

  • AccuCheck: Error
  • Urinalysis:
    • Color=yellow
    • Clarity=clear
    • SG=1.030
    • pH=6.5
    • Glucose=2000mg/dL
    • Bilirubin=negative
    • Urobilinogen=0.2 EU
    • Protein=1+
    • Ketones=5+
    • Nitrite=negative
    • Leucocyte esterase=negative

How would you approach this patient?

Clinical Impression: New Onset Diabetes Mellitus


Treatment:

  • IV normal saline
  • Urine output closely monitored
  • Blood glucose to be monitored and urine dip to be completed every 4 hours
  • Patient to remain in sickbay until transport arrives for CASEVAC

Considerations:

The error sign on the AccuCheck could represent either a broken machine or a blood glucose level elevated over the maximum limit of the machine. This makes the urine analysis an even more important diagnostic test because it can demonstrate glucosuria, ketonuria or altered specific gravity all useful clues to assist in developing your clinical impression. Orthostatic vital signs could be valuable in the field in order to evaluate the patient’s volume status which could be altered due to ongoing polyuria. Patient will likely require insulin therapy when he gets to shore as this is a new onset diabetic. He will also need additional lab work including a full comprehensive metabolic profile, CBC, and hemoglobin A1C. Patient will need to work with personal family physician to develop a treatment and maintenance plan to include diabetes education, lifestyle change and potentially medication(s).

Return to Work:

  • 2 consecutive Hemoglobin A1C of ≤8.0 separated by 90 days*
  • Symptoms need to be resolved
  • Stable on medications

*As recommended in the current U.S. Coast Guard NVIC.

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