type 1 diabetes case presentation

Type 1 Diabetes Mellitus Clinical Presentation

• Author: Romesh Khardori, MD, PhD, FACP; Chief Editor: George T Griffing, MD  more...
• Sections Type 1 Diabetes Mellitus
• Practice Essentials
• Pathophysiology
• Epidemiology
• Patient Education
• Physical Examination
• Complications
• Laboratory Studies
• Tests to Differentiate Type 1 from Type 2 Diabetes
• Approach Considerations
• Self-Monitoring of Glucose Levels
• Continuous Glucose Monitoring
• Insulin Therapy
• Management of Hypoglycemia
• Management of Hyperglycemia
• Management of Complications
• Glycemic Control During Serious Medical Illness and Surgery
• Glycemic Control During Pregnancy
• Consultations
• Medication Summary
• Antidiabetics, Insulins
• Antidiabetics, Amylinomimetics
• Hypoglycemia Antidotes
• Monoclonal Antibodies
• Allogeneic Islet Cells
• Questions & Answers

The most common symptoms of type 1 diabetes mellitus (DM) are polyuria, polydipsia, and polyphagia, along with lassitude, nausea, and blurred vision, all of which result from the hyperglycemia itself.

Polyuria is caused by osmotic diuresis secondary to hyperglycemia. Severe nocturnal enuresis secondary to polyuria can be an indication of onset of diabetes in young children. Thirst is a response to the hyperosmolar state and dehydration.

Fatigue and weakness may be caused by muscle wasting from the catabolic state of insulin deficiency, hypovolemia, and hypokalemia. Muscle cramps are caused by electrolyte imbalance. Blurred vision results from the effect of the hyperosmolar state on the lens and vitreous humor. Glucose and its metabolites cause osmotic swelling of the lens, altering its normal focal length.

Symptoms at the time of the first clinical presentation can usually be traced back several days to several weeks. However, beta-cell destruction may have started months, or even years, before the onset of clinical symptoms.

The onset of symptomatic disease may be sudden. It is not unusual for patients with type 1 DM to present with diabetic ketoacidosis (DKA), which may occur de novo or secondary to the stress of illness or surgery. An explosive onset of symptoms in a young lean patient with ketoacidosis always has been considered diagnostic of type 1 DM.

Over time, patients with new-onset type 1 DM will lose weight, despite normal or increased appetite, because of depletion of water and a catabolic state with reduced glycogen, proteins, and triglycerides. Weight loss may not occur if treatment is initiated promptly after the onset of the disease.

Gastrointestinal (GI) symptoms of type 1 DM are as follows:

Nausea, abdominal discomfort or pain, and change in bowel movements may accompany acute DKA

Acute fatty liver may lead to distention of the hepatic capsule, causing right upper quadrant pain

Persistent abdominal pain may indicate another serious abdominal cause of DKA (eg, pancreatitis

Chronic GI symptoms in the later stage of DM are caused by visceral autonomic neuropathy

Neuropathy affects up to 50% of patients with type 1 DM, but symptomatic neuropathy is typically a late development, developing after many years of chronic prolonged hyperglycemia. Peripheral neuropathy presents as numbness and tingling in both hands and feet, in a glove-and-stocking pattern; it is bilateral, symmetric, and ascending.

History in patients with established diabetes

It is important to inquire about the type and duration of the patient’s diabetes and about the care the patient is receiving for diabetes. Determination of the type of diabetes is based on history, therapy, and clinical judgment. The chronic complications of diabetes are related to the length of time the patient has had the disease.

Ask about the type of insulin being used, delivery system (pump vs injections), dose, and frequency. Also ask about oral antidiabetic agents, if any. Of course, a full review of all medications and over-the-counter supplements being taken is crucial in the assessment of patients with type 1 DM.

Patients using a pump or a multiple-injection regimen have a basal insulin (taken through the pump or with the injection of a long-acting insulin analogue) and a premeal rapid-acting insulin, the dose of which may be determined as a function of the carbohydrate count plus the correction (to adjust for how high the premeal glucose level is). In these patients, ask about the following:

Basal rates (eg, units per hour by pump, generally 0.4-1.5 U/h, potentially varying on the basis of time of day); the total daily dose as basal insulin is a helpful value to know

Carbohydrate ratio (ie, units of insulin per grams of carbohydrate, generally 1 unit of rapid-acting insulin per 10-15 g carbohydrate)

Correction dose (ie, how far the blood glucose level is expected to decrease per unit of rapid-acting insulin, often 1 U of insulin per 50-mg/dL decrease, though individuals with insulin resistance may need 1 U per 25-mg/dL decrease)

Some patients may be taking premeal pramlintide (an amylin analogue)

A focused diabetes history should also include the following questions:

Is the patient’s diabetes generally well controlled, with near-normal blood glucose levels? (Patients with poorly controlled blood glucose levels heal more slowly and are at increased risk for infection and other complications)

Does the patient have severe hypoglycemic reactions? (If the patient has episodes of severe hypoglycemia and therefore is at risk for losing consciousness, this possibility must be addressed, especially if the patient drives)

Does the patient have diabetic nephropathy that might alter the use of medications or intravenous (IV) radiographic contrast material?

Does the patient have macrovascular disease, such as coronary artery disease (CAD), which should be considered in the emergency department (ED)?

Does the patient self-monitor his or her blood glucose levels? (Note the frequency and range of values at each time of day; an increasing number of patients monitor with continuous sensors)

When was the patient’s hemoglobin A 1c (HbA 1c ) value (an indicator of long-term glucose control) last measured? What was it?

In assessing glycemic exposure of a patient with established type 1 DM, review of self-monitored blood glucose levels is necessary. Ideally, this done by uploading time- and date-stamped levels from the patient’s meter to assure full understanding of the frequency of testing and the actual levels.

Questions regarding hypoglycemia and hyperglycemia

Hypoglycemia and hyperglycemia should be considered. Ask the following questions as needed:

Has the patient experienced recent polyuria, polydipsia, nocturia, or weight loss?

Has the patient had episodes of unexplained hypoglycemia? If so, when, how often, and how does the patient treat these episodes?

Does the patient have hypoglycemia unawareness (ie, does the patient lack the adrenergic warning signs of hypoglycemia)? (Hypoglycemia unawareness indicates an increased risk of subsequent episodes of hypoglycemia)

Questions regarding microvascular complications

Microvascular complications, such as retinopathy and nephropathy, should be considered as well. Ask the following questions as appropriate:

When was the patient’s last dilated eye examination? What were the results?

Does the patient have known kidney disease?

What were the dates and results of the last measurements of urine protein and serum creatinine levels?

Questions regarding macrovascular complications

Macrovascular complications should be explored. Questions should include the following:

Does the patient have hypertension? What medications are taken?

Does the patient have symptoms of claudication or a history of vascular bypass?

Has the patient had a stroke or transient ischemic attack?

What are the patient’s most recent lipid levels?

Is the patient taking lipid-lowering medication?

Questions regarding neuropathy

Potential neuropathy should be taken into account. Ask whether the patient has a history of neuropathy or symptoms of peripheral neuropathy or whether autonomic neuropathy is present (including erectile dysfunction if the patient is a man).

Other questions

The possibility of foot disease should be addressed. Inquire as to whether the patient has a history of foot ulcers or amputations or whether any foot ulcers are present. (See Diabetic Foot and Diabetic Foot Infections .)

The possibility of infection also should be considered. Be sure to inquire about whether frequent infections are a problem and, if so, at what sites.

In new cases of diabetes, physical examination findings are usually normal. Patients with DKA, however, will have Kussmaul respiration, signs of dehydration, hypotension, and, in some cases, altered mental status.

In established cases, patients should be examined every 3 months for macrovascular and microvascular complications. They should undergo funduscopic examination for retinopathy and monofilament testing for peripheral neuropathy.

Diabetes-focused examination

A diabetes-focused physical examination includes assessment of vital signs, funduscopic examination, limited vascular and neurologic examinations, and foot examination. Other organ systems should be assessed as indicated by the patient’s clinical situation. A comprehensive examination is not necessary at every visit.

Assessment of vital signs

Patients with established diabetes and autonomic neuropathy may have orthostatic hypotension. Orthostatic vital signs may be useful in assessing volume status and in suggesting the presence of an autonomic neuropathy. Measurement of the pulse is important, in that relative tachycardia is a typical finding in autonomic neuropathy, often preceding the development of orthostatic hypotension. If the respiratory rate and pattern suggest Kussmaul respiration, DKA must be considered immediately, and appropriate tests must be ordered.

Funduscopic examination

The funduscopic examination should include a careful view of the retina. Both the optic disc and the macula should be visualized. If hemorrhages or exudates are seen, the patient should be referred to an ophthalmologist as soon as possible. Examiners who are not ophthalmologists tend to underestimate the severity of retinopathy, which cannot be evaluated accurately unless the patients’ pupils are dilated.

Foot examination

The dorsalis pedis and posterior tibialis pulses should be palpated and their presence or absence noted. This is particularly important in patients who have foot infections: poor lower-extremity blood flow can delay healing and increase the risk of amputation.

Documenting lower-extremity sensory neuropathy is useful in patients who present with foot ulcers because decreased sensation limits the patient’s ability to protect the feet and ankles. If peripheral neuropathy is found, the patient should be made aware that foot care (including daily foot examination) is very important for the prevention of foot ulcers and lower-extremity amputation. (See Diabetic Foot and Diabetic Foot Infections .)

Infections cause considerable morbidity and mortality in patients with diabetes. Infection may precipitate metabolic derangements, and conversely, the metabolic derangements of diabetes may facilitate infection. (See Infections in Patients with Diabetes Mellitus .)

Patients with long-standing diabetes tend to have microvascular and macrovascular disease with resultant poor tissue perfusion and increased risk of infection. The ability of the skin to act as a barrier to infection may be compromised when the diminished sensation of diabetic neuropathy results in unnoticed injury.

Diabetes increases susceptibility to various types of infections. The most common sites are the skin and urinary tract. Dermatologic infections that occur with increased frequency in patients with diabetes include staphylococcal follicular skin infections, superficial fungal infections, cellulitis, erysipelas, and oral or genital candidal infections. Both lower urinary tract infections and acute pyelonephritis are seen with greater frequency.

A few infections, such as malignant otitis externa, rhinocerebral mucormycosis, and emphysematous pyelonephritis, occur almost exclusively in patients with diabetes, though they are fairly rare even in this population. Infections such as staphylococcal sepsis occur more frequently and are more often fatal in patients with diabetes than in others. Infections such as pneumococcal pneumonia affect patients with diabetes and other patients with the same frequency and severity. [ 84 ]

A study reported that out of 178 adult patients hospitalized with coronavirus disease 2019 (COVID-19), at least one underlying condition was found in 89.3%, the most common being hypertension (49.7%), obesity (48.3%), chronic lung disease (34.6%), diabetes mellitus (28.3%), and cardiovascular disease (27.8%). [ 85 ]

According to a report by Stokes et al, out of 287,320 US cases of COVID-19 in which the patient’s underlying health status was known, diabetes was the second most common underlying condition (30%), after cardiovascular disease (32%), which in this study included hypertension. [ 86 , 87 ]

The aforementioned study by Barrera et al found the overall prevalence of diabetes in patients with COVID-19 to be 12%, with the prevalence being 18% in severe COVID-19. [ 63 , 64 ]

In patients with type 1 DM who were diagnosed with COVID-19, a study by Ebekozien et al found that high blood glucose (48.5%), elevated temperature (45.5%), dry cough (39.4%), excess fatigue (33.3%), vomiting (33.3%), shortness of breath (30.3), nausea (30.2%), and body aches/headaches (21.2%) were the most prevalent presenting symptoms reported. Moreover, diabetic ketoacidosis was the most prevalent adverse outcome (45.5%) among these patients. [ 88 , 89 ]

The Centers for Disease Control and Prevention (CDC) includes type 2 DM in the list of conditions that increase the likelihood of severe illness in persons with COVID-19, and type 1 DM in the list of conditions that may increase this likelihood. [ 90 ]

Ophthalmologic complications

Diabetes can affect the lens, vitreous, and retina, causing visual symptoms that may prompt the patient to seek emergency care. Visual blurring may develop acutely as the lens changes shape with marked changes in blood glucose concentrations.

This effect, which is caused by osmotic fluxes of water into and out of the lens, usually occurs as hyperglycemia increases, but it also may be seen when high glucose levels are lowered rapidly. In either case, recovery to baseline visual acuity can take up to a month, and some patients are almost completely unable to read small print or do close work during this period.

Patients with diabetes tend to develop senile cataracts at a younger age than persons without diabetes. Rarely, patients with type 1 DM that is very poorly controlled (eg, those with frequent episodes of DKA) can acutely develop a “snowflake” (or “metabolic”) cataract. Named for their snowflake or flocculent appearance, these cataracts can progress rapidly and create total opacification of the lens within a few days.

Whether diabetes increases the risk of glaucoma remains controversial; epidemiologic studies have yielded conflicting results. [ 91 ] Glaucoma in diabetes relates to the neovascularization of the iris (ie, rubeosis iridis diabetica).

Diabetic retinopathy is the principal ophthalmologic complication of DM. (See Diabetic Retinopathy .) Diabetic retinopathy is the leading cause of blindness in the United States in people younger than 60 years and affects the eyes in the following different ways:

Background retinopathy involves retinal small vessel abnormality leading to hard exudates, hemorrhages, and microaneurysms; it does not affect acuity

Proliferative retinopathy involves extensive proliferation of new retinal small blood vessels; a sudden loss of vision can occur because of vitreous hemorrhage from proliferating new vessels or retinal detachment

Maculopathy involves edema and hard exudate or retinal ischemia; it causes a marked reduction of acuity

Whether patients develop diabetic retinopathy depends on the duration of their diabetes and on the level of glycemic control. [ 92 , 93 , 94 ] The following are the 5 stages in the progression of diabetic retinopathy:

Dilation of the retinal venules and formation of retinal capillary microaneurysms

Increased vascular permeability

Vascular occlusion and retinal ischemia

Proliferation of new blood vessels on the surface of the retina

Hemorrhage and contraction of the fibrovascular proliferation and the vitreous

The first 2 stages of diabetic retinopathy are jointly referred to as background or nonproliferative retinopathy. Initially, the retinal venules dilate, then microaneurysms (tiny red dots on the retina that cause no visual impairment) appear. The microaneurysms or retinal capillaries become more permeable, and hard exudates appear, reflecting leakage of plasma.

Rupture of intraretinal capillaries results in hemorrhage. If a superficial capillary ruptures, a flame-shaped hemorrhage appears. Hard exudates are often found in partial or complete rings (circinate pattern), which usually include multiple microaneurysms. These rings usually mark an area of edematous retina.

The patient may not notice a change in visual acuity unless the center of the macula is involved. Macular edema can cause visual loss; therefore, all patients with suspected macular edema must be referred to an ophthalmologist for evaluation and possible laser therapy. Laser therapy is effective in decreasing macular edema and preserving vision but is less effective in restoring lost vision. (See Macular Edema in Diabetes .)

Preproliferative (stage 3) and proliferative diabetic retinopathy (stages 4 and 5) are the next phases in the progression of the disease. Cotton-wool spots can be seen in preproliferative retinopathy. These represent retinal microinfarcts from capillary occlusion and appear as off-white to gray patches with poorly defined margins.

Proliferative retinopathy is characterized by neovascularization, or the development of networks of fragile new vessels that often are seen on the optic disc or along the main vascular arcades. The vessels undergo cycles of proliferation and regression. During proliferation, fibrous adhesions develop between the vessels and the vitreous. Subsequent contraction of the adhesions can result in traction on the retina and retinal detachment. Contraction also tears the new vessels, which hemorrhage into the vitreous.

Diabetic nephropathy

About 20–30% of patients with type 1 DM develop evidence of nephropathy, [ 95 ] and all patients with diabetes should be considered to have the potential for renal impairment unless proven otherwise. Chronically elevated blood pressure contributes to the decline in renal function. The use of contrast media can precipitate acute renal failure in patients with underlying diabetic nephropathy. Although most recover from contrast medium–induced renal failure within 10 days, some have irreversible renal failure. (See Diabetic Nephropathy .)

Diabetic neuropathy

In the peripheral nerves, diabetes causes peripheral neuropathy. (See Diabetic Lumbosacral Plexopathy and Diabetic Neuropathy .) The 4 types of diabetic neuropathy are as follows:

Peripheral distal symmetrical polyneuropathy, predominantly sensory

Autonomic neuropathy

Proximal painful motor neuropathy

Cranial mononeuropathy (ie, cranial nerve III, IV, or VI)

Of these 4 types, distal symmetric sensorimotor polyneuropathy (in a glove-and-stocking distribution) is the most common. [ 96 ] Besides causing pain in its early stages, this type of neuropathy eventually results in the loss of peripheral sensation. The combination of decreased sensation and peripheral arterial insufficiency often leads to foot ulceration and eventual amputation.

Acute-onset mononeuropathies in diabetes include acute cranial mononeuropathies, mononeuropathy multiplex, focal lesions of the brachial or lumbosacral plexus, and radiculopathies. Of the cranial neuropathies, the third cranial nerve (oculomotor) is most commonly affected, followed by the sixth nerve (abducens) and the fourth nerve (trochlear).

Patients can present with diplopia and eye pain. In diabetic third-nerve palsy, the pupil is usually spared, whereas in third-nerve palsy due to intracranial aneurysm or tumor, the pupil is affected in 80-90% of cases.

It is important to consider nondiabetic causes of cranial nerve palsies, including intracranial tumors, aneurysms, and brainstem stroke. [ 97 ] Therefore, evaluation should include nonenhanced and contrast-enhanced compute4d tomography (CT) or, preferably, magnetic resonance imaging (MRI). Neurologic consultation is recommended. Acute cranial-nerve mononeuropathies usually resolve in 2-9 months. Acute thrombosis or ischemia of the blood vessels supplying the structure involved is thought to cause these neuropathies.

Macrovascular complications

People with diabetes experience accelerated atherosclerosis, affecting the small arteries of the heart, brain, lower extremity, and kidney. Coronary atherosclerosis often occurs at a younger age and is more severe and extensive than in those without diabetes, increasing the risk of ischemic heart disease. Atherosclerosis of the internal carotid and vertebrobasilar arteries and their branches predisposes to cerebral ischemia.

Severe atherosclerosis of the iliofemoral and smaller arteries of the lower legs predisposes to gangrene. Ischemia of a single toe or ischemic areas on the heel are characteristic of diabetic peripheral vascular disease; these result from the involvement of much smaller and more peripheral arteries.

Atherosclerosis of the main renal arteries and their intrarenal branches causes chronic nephron ischemia, which is a significant component of multiple renal lesions in diabetes. However, not all people with type 1 DM are at risk for nephropathy, because there are some polymorphisms in the various factors involved in its pathogenesis, which can modulate the course of this disease from one person to the other.

Risk factors for macrovascular disease

Macrovascular disease is the leading cause of death in patients with diabetes, causing 65-75% of deaths in this group, compared with approximately 35% of deaths in people without diabetes. Diabetes by itself increases the risk of myocardial infarction (MI) 2-fold in men and 4-fold in women, and many patients have other risk factors for MI as well.

The HbA1c value per se, rather than self-reported diabetes status or other established risk factors, robustly predicts MI odds. Each 1% increment in HbA1c independently predicts 19% higher odds for MI. [ 98 ] The risk of stroke in people with diabetes is double that of nondiabetic people, and the risk of peripheral vascular disease is 4 times that of people without diabetes.

Patients with diabetes may have an increased incidence of silent ischemia. [ 99 ] Diastolic dysfunction is common in patients with diabetes and should be considered in patients who have symptoms of congestive heart failure and a normal ejection fraction.

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Contributor Information and Disclosures

Romesh Khardori, MD, PhD, FACP (Retired) Professor, Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Eastern Virginia Medical School Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinology , American College of Physicians , American Diabetes Association , Endocrine Society Disclosure: Nothing to disclose.

George T Griffing, MD Professor Emeritus of Medicine, St Louis University School of Medicine George T Griffing, MD is a member of the following medical societies: American Association for Physician Leadership , American Association for the Advancement of Science , American College of Medical Practice Executives , American College of Physicians , American Diabetes Association , American Federation for Medical Research , American Heart Association , Central Society for Clinical and Translational Research , Endocrine Society , International Society for Clinical Densitometry , Southern Society for Clinical Investigation Disclosure: Nothing to disclose.

Howard A Bessen, MD Professor of Medicine, Department of Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Program Director, Harbor-UCLA Medical Center

Howard A Bessen, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha , American Academy of Emergency Medicine , American College of Chest Physicians , American College of Emergency Physicians , American College of Physicians , American Heart Association , American Thoracic Society , Arkansas Medical Society , New York Academy of Medicine , New York Academy ofSciences ,and Society for Academic Emergency Medicine

Aneela Naureen Hussain, MD, FAAFM Assistant Professor, Department of Family Medicine, State University of New York Downstate Medical Center; Consulting Staff, Department of Family Medicine, University Hospital of Brooklyn

Aneela Naureen Hussain, MD, FAAFM is a member of the following medical societies: American Academy of Family Physicians , American Medical Association , American Medical Women's Association , Medical Society of the State of New York , and Society of Teachers of Family Medicine

Anne L Peters, MD, CDE Director of Clinical Diabetes Programs, Professor, Department of Medicine, University of Southern California, Keck School of Medicine, Los Angeles, California, Los Angeles County/University of Southern California Medical Center

Anne L Peters, MD, CDE is a member of the following medical societies: American College of Physicians and American Diabetes Association

Disclosure: Amylin Honoraria Speaking and teaching; AstraZeneca Consulting fee Consulting; Lilly Consulting fee Consulting; Takeda Consulting fee Consulting; Bristol Myers Squibb Honoraria Speaking and teaching; NovoNordisk Consulting fee Consulting; Medtronic Minimed Consulting fee Consulting; Dexcom Honoraria Speaking and teaching; Roche Honoraria Speaking and teaching

Don S Schalch, MD Professor Emeritus, Department of Internal Medicine, Division of Endocrinology, University of Wisconsin Hospitals and Clinics

Don S Schalch, MD is a member of the following medical societies: American Diabetes Association , American Federation for Medical Research , Central Society for Clinical Research , and Endocrine Society

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Miriam T Vincent, MD, PhD Professor and Chair, Department of Family Practice, State University of New York Downstate Medical Center

Miriam T Vincent, MD, PhD is a member of the following medical societies: Alpha Omega Alpha , American Academy of Family Physicians , American Association for the Advancement of Science , Medical Society of the State of New York , North American Primary Care Research Group , Sigma Xi , and Society of Teachers of Family Medicine

Disclosure: Joslin Diabetes Group, Harvard Honoraria Speaking and teaching

Scott R Votey, MD Director of Emergency Medicine Residency, Ronald Reagan UCLA Medical Center; Professor of Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine

Scott R Votey, MD is a member of the following medical societies: Society for Academic Emergency Medicine

Frederick H Ziel, MD Associate Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine; Physician-In-Charge, Endocrinology/Diabetes Center, Director of Medical Education, Kaiser Permanente Woodland Hills; Chair of Endocrinology, Co-Chair of Diabetes Complete Care Program, Southern California Permanente Medical Group

Frederick H Ziel, MD is a member of the following medical societies: American Association of Clinical Endocrinologists , American College of Endocrinology , American College of Physicians , American College of Physicians-American Society of Internal Medicine , American Diabetes Association , American Federation for Medical Research , American Medical Association , American Society for Bone and Mineral Research , California Medical Association , Endocrine Society , andInternational Society for Clinical Densitometry

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Faculty and Disclosures

Zachary t bloomgarden, md.

Associate Clinical Professor of Medicine, Mount Sinai Medical School, New York, NY

Disclosure: Zachary T. Bloomgarden, MD, has disclosed that he receives research grant support from Hoechst Marion Roussel, Novartis, and TCPI Inc. He has consulting agreements with Hoechst Marion Roussel, Novartis, Parke-Davis, Bristol-Myers Squibb Company, Novo Nordisk, Pfizer Inc., Eli Lilly and Company, Takeda, and GlaxoSmithKline.

Case Study 1: Patient with Newly Diagnosed Type 1 Diabetes

• Authors: Author: Zachary T. Bloomgarden, MD
• THIS ACTIVITY HAS EXPIRED FOR CREDIT

Target Audience and Goal Statement

This activity is intended for physicians and pharmacists.

This article reviews the physiologic consequences of diabetes mellitus and presents evidence that supports the benefits of aggressive intervention to achieve glycemic control. Real-life clinical scenarios will be presented to illustrate the practical clinical applications of insulin preparations in patients with diabetes.

• Describe the physiologic consequences of diabetes mellitus.
• Outline the importance of maintaining glycemic control in reducing the risk of diabetic complications.
• Detail specific clinical applications of insulin therapy to achieve both basal and meal-related glycemic control.
• Manage a patient's glycemic status by continuously refining the therapeutic approach.

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For physicians.

Medical Education Collaborative, a nonprofit education organization, is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Medical Education Collaborative designates this educational activity for a maximum of 1 hour in Category 1 credit towards the AMA Physician's Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the educational activity.

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For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]

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Case 1 History

Results of hospital laboratory studies (Table 1-1) revealed that the patient's initial blood glucose level was 1192 mg/dL and clinical presentation and laboratory findings were consistent with a diagnosis of diabetic ketoacidosis (DKA). The patient reported no family history of diabetes. His father died at age 35 of renal failure.

The patient was treated successfully for DKA and discharged from the hospital 3 days later on an insulin regimen consisting of 30 units of NPH/regular human insulin 70/30 mixture (70/30 mix) before breakfast, 15 units of regular human insulin before dinner, and 20 units of NPH insulin at bedtime.

On discharge, he was instructed to perform blood glucose measurements 4 times a day. The patient was seen as an outpatient 4 days after he is discharged from hospital.

Table 1-1. Hospital Laboratory Studies

2 AM 4 AM 5 AM 9 AM 11 AM 1 PM Plasma Glucose mg/dL 1192 958 718 358 288 222 Sodium mEq/L 154 -- 158 167 -- 161 Potassium mEq/L -- -- 3.3 4.0 -- 3.5 Creatinine (mg/dL) 1.7 1.6 -- -- 0.9 -- pH 7.34 -- -- -- -- -- Urine Acetone -- -- -- 2+ -- --

This patient presented to the emergency department with acute-onset diabetes with classic symptoms of insulin deficiency compatible with a diagnosis of type 1 diabetes. Approximately 25% of patients that present with DKA have new onset of type 1 diabetes. Antibody testing was not performed, presumably because of the typical type 1 presentation. During his hospital stay, the patient received instructions regarding diet, medication schedule, and home glucose monitoring. The patient was discharged on an insulin regimen designed for ease of administration, consisting of a premixed 70/30 mix before breakfast. The evening insulin regimen included regular insulin before dinner and NPH at bedtime. Because the peak action of NPH is expected approximately 8-10 hours following administration, giving the evening dose of NPH at bedtime rather than before dinner avoids the nocturnal (2-3 AM) hypoglycemia that is often associated with dinnertime NPH administration.

Nursing Case Study for Type 1 Diabetes

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Michael is a 14-year-old male brought into a small ER by his mother. They were driving a long distance after he competed in a wrestling tournament. He had not felt well on the bus ride with the team so his mother decided he should ride with her. His mother denies a history of chronic illness but did say he had “like a cold but with a stomachache” about 3 months ago.

She also says that he has been very thirsty, and they had to stop several times for him to urinate. She is also worried because he almost missed his wrestling “weight class” parameters because he was significantly lighter this past weekend than he has been in the past. And that is even with him eating more than usual.

What symptoms are most worrisome to the triage nurse?

• He has 2 of the 3 “p’s” – polydipsia (thirst), polyuria (frequent urination), polyphagia (hunger) which are trademarks of diabetes mellitus (DM) and/or diabetic ketoacidosis (DKA). They happen in response to the body lacking insulin and its response is to try to achieve homeostasis with these mechanisms. His weight loss could be indicative of DM as well. 
• They describe a recent viral-like illness which may precipitate a diagnosis of DM (it is thought the body has an inappropriate immune response to the illness leading to DM)

In triage, the nurse obtains a point-of-care blood glucose (BG) level and the machine gives no value. Instead, an error message indicating “hi” displays on the machine.

Why did the nurse do this test? What should they do next?

• Clues point to possible DM or DKA. Getting a BG immediately can help guide care. Always follow the facility protocol/procedure on “hi” or “lo” (often spelled this way on glucometers) readings. The protocol might dictate (standing order) stat venous draw and send it to the lab. It may be advised to try again on a different machine with a new sample. Whatever the guidance, a BG level is imperative for this patient.

Michael is AAO x 4. He complains of a “stomachache” and reports he has nausea and experienced vomiting shortly before arrival. His skin is warm and dry, but his face is flushed. When asked about pain, he says he has a headache, and his vision is blurry. The nurse notices a fruity odor on his breath when obtaining vital signs. 

BP 90/54 mmHg SpO 2 98% on Room Air

HR 122 bpm and regular

RR 26 bpm at rest

The patient and his mother are placed into an exam room immediately and the triage nurse verbally reports this to the accepting nurse.

How does the nurse interpret these symptoms?

• Michael’s symptoms are consistent with hyperglycemia (link here to cheatsheet?) DKA

What orders does the accepting nurse anticipate?

• Labs, ABGs, urinalysis, IV access (bilateral upper extremities, largest possible in case patient deteriorates). One lab, in particular, can give the provider an idea of the last 2-3 month BG average, the hemoglobin A1C.

The provider orders stat labs, urinalysis and ABGs then examines the patient. 

Why stat orders?

• This patient’s condition could deteriorate rapidly, and treatment should begin ASAP. Labs are needed to guide the plan of care. The nurse should watch for changes in the level of consciousness, respiratory changes, his response to potential fluid & electrolyte imbalances. Place on continuous cardiac monitoring as well.

Lab results are as follows:

WBC 15000 cells/mcL

Glucose 420 mg/dl

BUN 21 mg/dl

Creatinine 0.77 mg/dl

Anion gap 12

Glucose positive

Ketones positive

What do these results mean?

• CBC WBC 15000 cells/mcL – an immune response, possibly to viral illness or another issue HgbA1C 9% – indicates the average BG over the past 2-3 months has been about 212mg/dLBMP Glucose 420 mg/dl – hyperglycemia K 5.8 – electrolyte imbalance, can cause cardiac changes and need to monitor closely if IV insulin is started (will need frequent checks of this and BG) BUN 21 mg/dL – fluid imbalance Creatinine 0.77 mg/dL – normal but necessary to check for kidney function Anion gap 12 – indicative of DKAABG – metabolic acidosis Ph 7.25 HCO3 15 PaCo2 35 PaO2 88Urine – indicative of DKA Glucose positive Ketones positive

What medication orders should the nurse anticipate?

• IV fluids, insulin (either IV or SQ). NOTE: only REGULAR INSULIN can be given IV, and if it is, then IV dextrose and potassium chloride should be included in the insulin IV titration protocol/order). SQ insulin may be ordered using a sliding scale. O2 via NC possibly due to potential respiratory concerns (Kussmaul respirations)

The provider tells Michael and his mother that he suspects diabetic ketoacidosis which is not uncommon for new type I diabetics. He plans to transfer Michael to a nearby city via helicopter for a higher level of care.  The patient’s mother asks why he has to be transferred.

How does the nurse explain the transfer to the mother and patient?

• DKA requires monitoring in a critical care unit. Because of his age and new-onset DM, a higher level of care is recommended in order to have access to the best resources

The flight team arrives and assesses the patient. The ER completes a report using SBAR format at the bedside. The patient and his mother are given the chance to ask questions.

What are the transport team’s priorities as they move this patient?

• Airway, breathing, and circulation (ABC) status; Mental status; Volume status.

Upon arrival to the higher level of care, Michael is admitted to the ICU overnight. By the morning he is transferred to a pediatric floor for further observation. His mother remains at his bedside. They plan to return to their home after discharge. 

How should the pediatric medical unit prepare this family for discharge? What specific teaching should be provided?

• Condition-specific education is vital including DM management with medications, exercise, nutrition, psychosocial concerns, preventative care (i.e. vaccinations), parental/family involvement. A specialized diabetic educator and/or dietician would be ideal. Assessing their education preferences and literacy level is important as well. How to give insulin injections and check BG (glucometer use) are key takeaways (have patient and parent return-demonstrate). Case management may need to get involved for prescription/supplies. An endocrinologist may be consulted so education about his specialist is also important.

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Nursing case studies.

This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

Nursing Case Studies Introduction

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Mental health nursing case studies.

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A case report: First presentation of diabetes mellitus type 1 with severe hyperosmolar hyperglycemic state in a 35-month-old girl

Affiliations.

• 1 Division of Pediatric Intensive Care Department of Pediatrics Shiraz University of Medical Sciences Shiraz Iran.
• 2 Division of Pediatric Metabolism and Endocrinology Department of Pediatrics Shiraz University of Medical Sciences Shiraz Iran.
• PMID: 34765201
• PMCID: PMC8572339
• DOI: 10.1002/ccr3.4984

Hyperglycemic hyperosmolar syndrome (HHS) is a rare complication of diabetes mellitus among pediatric patients. Since its treatment differs from diabetic ketoacidosis (DKA), hence, pediatricians should be aware of its diagnosis and management.

Keywords: case report; diabetes mellitus; hyperglycemic hyperosmolar syndrome (HHS); pediatric patients; rhabdomyolysis; thrombosis.

© 2021 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.

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Conflict of interest statement

The authors declare that they have no competing interests.

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• A Rare Presentation of New-Onset Type 1 Diabetes Mellitus in a Developmentally Delayed Child With an Overlap of Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Parra Villasmil MG, Patel S, Tansey M, Badheka A, Chegondi M. Parra Villasmil MG, et al. Cureus. 2022 Sep 9;14(9):e28983. doi: 10.7759/cureus.28983. eCollection 2022 Sep. Cureus. 2022. PMID: 36237743 Free PMC article.
• Combined diabetic ketoacidosis and hyperosmolar hyperglycemic state in type 1 diabetes mellitus induced by immune checkpoint inhibitors: Underrecognized and underreported emergency in ICIs-DM. Zhang W, Chen J, Bi J, Ding N, Chen X, Wang Z, Jiao Y. Zhang W, et al. Front Endocrinol (Lausanne). 2023 Jan 4;13:1084441. doi: 10.3389/fendo.2022.1084441. eCollection 2022. Front Endocrinol (Lausanne). 2023. PMID: 36686495 Free PMC article. Review.
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• Arch Clin Cases
• v.8(3); 2021

An atypical presentation of type 1 diabetes

Brandon w. knopp.

1 Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA

Parvathi Perumareddi

2 Department of Integrated Medical Science, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA

Type 1 and type 2 diabetes have been described historically as occurring in distinct patient populations; however, atypical demographics are becoming more frequent as the prevalence of diabetes increases, crossing boundaries of ages. Some of these cases can be challenging to diagnose clinically as the patient symptomatology and progression can differ from the standard features of type 1 and 2 diabetes. Our case is an example of a patient whose type 1 diabetes presented atypically with characteristics often associated with type 2 diabetes. Patient presentations such as this are uncommon, with our patient having presented with the “textbook” characteristics of type 2 diabetes. When first diagnosed with diabetes mellitus type 2, the patient was 60 years old, had a BMI around 30 and experienced a gradual onset of symptoms over the course of several months. At the age of 64, the patient tested positive for GAD65 autoantibodies following a year of declining glycemic control and was re-evaluated and classified as a type 1 diabetes patient. Subsequent insulin injections resolved his diabetes-related complications which included polyuria, weakness and weight loss and improved his glycemic control. This case provides an example of an unusual clinical presentation of type 1 diabetes and serves to raise awareness for atypical presentations of diabetes to improve accurate classifications at earlier stages.

Introduction

Diabetes mellitus is a metabolic disease characterized by insulin deficiency and/or insulin resistance. Type 1 diabetes results from the autoimmune destruction of pancreatic β cells and is typically found in younger patients while type 2 diabetes occurs due to insulin resistance and is most often found in middle aged to older adults. Each type has been associated with a distinct patient population, however, there are reports of cases with atypical demographics characterized by a crossover in age, weight and other factors [ 1 , 2 ].

These rare cases are difficult to identify clinically and may require antibody testing to confirm the diagnosis. The incidence of atypical presentations of diabetes mellitus is unknown, however, with the rise in diabetes cases over the past several decades and an expected increase of 54% between 2015 and 2030 [ 3 ], a concomitant increase in atypical cases can be reasonably expected.

Case report

This case describes a 64-year-old Caucasian male who was referred for evaluation and treatment of diabetes mellitus which was first diagnosed at the age of 60. At the age of 60 he presented with minimal clinical signs of diabetes mellitus, including mild fatigue, and was diagnosed with type 2 diabetes due to hyperglycemia and elevated HbA1c. He was treated as a type 2 diabetes patient for four years before being placed on insulin at the age of 64 following a significant deterioration in glycemic control. He had no known risk factors for diabetes mellitus and was screened with self-monitoring of blood glucose (SMBG). His past medical history was significant for elevated thyroid stimulating hormone (TSH), but otherwise no significant abnormalities.

Clinical Progression

On 10/28/2020, the patient presented with a multi-day history of polyuria and weakness with deterioration since his previous visit on 7/3/20. Following a weight loss of 5.4 kg during the previous several days, the patient weighed 84.4 kg with a BMI of 29.1. He rarely checked his blood glucose but measured a value of almost 500 mg/dL at home during this time and a value of close to 400 mg/dL in office. On a physical exam, the patient did not appear weak or ill and reported no changes in vision or neurologic symptoms. He reported consistency in taking metformin and glimepiride, with sertraline being added a few months prior. Because of the significant hyperglycemia and concerns of potential diabetic ketoacidosis, he was injected with 20 units of insulin degludec, given 5 units of insulin lispro with instructions for later use and asked to drink 5 cups of water while in office. ( Note : treatments vary among providers)

At his follow up on 11/5/2020, he improved with no significant incidences of hyperglycemia, though he experienced blood sugar spikes after breakfast. Along with dietary interventions to mitigate post-breakfast spikes, Insulin degludec increased to 23 units daily and 5 units of insulin lispro with meals. Metformin and Glimepiride were discontinued.

During his visit on 3/29/2021, the patient stated his diabetes was not well-controlled and had variable glucose ranges with hypoglycemia typically occurring before dinnertime. He had a temperature of 36.4 o C, weight of 90.7 kg, height of 171.5 cm and BMI of 30.86. The physical exam findings were normal with no foot ulcers or other visible abnormalities. He also had an intact sensory exam. The patient had a recent c-peptide of 0.5 ng/mL on 12/24/2020 and an HbA1c of 7.4% (normal 4.2–5.7%).

During his visit on 5/17/2021, the patient stated his diabetes was well-controlled. He used an insulin pump and continuous glucose monitoring (CGM) sensor between 5/4/2021 and 5/17/2021. Between those dates, his blood glucose was 88% in range with no significant hypoglycemia since beginning insulin pump use. He gained 3.6 kg since 3/29/2021 with no new development of diabetes-related symptoms. Table 1 presents the most important laboratory parameters.

Select laboratory results

Insulin Growth Factor 1	255 ng/mL (high)	Normal: 46-219 ng/mL
Fibrinogen	530 mg/dL (high)	Normal: 276-471 mg/dL
Urea nitrogen	25 mg/dL (high)	Normal: 6-23 mg/dL
Creatinine	1.1 mg/dl	Normal: 0.7–1.3 mg/dl

Diagnosis and outcome

The patient tested positive for a concentration of 16 IU/mL of GAD 65 autoantibodies on 3/29/2021, indicating a diagnosis of type 1 diabetes. Likewise, he tested positive for Thyroid Peroxidase antibodies (TPO) at 499 IU/mL, confirming his diagnosis of autoimmune thyroid disease, Hashimoto thyroiditis in this case.

As indicated on Table 2 , the patient’s HbA1c levels rose from 9.1% to 13.5% in about 9 months before being treated with insulin in November 2020. While taking insulin in the form of insulin lispro and insulin degludec, his HbA1c levels dropped from 13.5% to 7.4% in under 4 months. Based on the continuous glucose monitoring (CGM) values between 5/4/21 and 5/17/21, the Glucose Management Indicator (GMI) predicted an HbA1c of 6.4% just 7 months after the first insulin injection. Likewise, his glycemic control improved with a blood glucose 88% in range with no significant lows as of 5/17/21.

HbA1c level evolution

Date	HbA1c
1/13/20	9.1%
7/3/20	10.4%
10/29/20	13.5%
12/24/20	8.8%
2/18/21	7.4%
5/4/21-5/17/21	Expected HbA1c (GMI) = 6.4%

Discussions

Type 1 and 2 diabetes have clinically distinct pathophysiologic etiologies. These discrete pathologies lead to unique presentations for each type and are useful in informing clinical diagnostic practices as well as treatment regimens. The clinical determination of type 1 vs. 2 diabetes is made with consideration of factors including the patient’s age, body composition, symptom progression and clinical presentation. Type 1 diabetes typically manifests in young patients, often before the age of 14, who frequently appear thin and have a sudden onset of symptoms, with diabetic ketoacidosis presenting as the first sign of disease in many cases. Type 2 diabetes, on the other hand, often develops around the age of 45 or later and is associated with obesity and metabolic syndrome and usually has a gradual onset.

As both types of diabetes generally have distinct etiologies, diagnosis can often be made based on patient demographics. However, atypical cases can exist in contravention of diagnostic norms. The case detailed above discusses one such patient whose clinical characteristics and progression matched closely with the criteria for type 2 diabetes, even though his pathophysiology pointed to type 1 diabetes. While his initial diagnosis of type 2 diabetes was made based on his clinical characteristics, antibody tests significant for glutamic acid decarboxylase 65 autoantibody (GAD 65 ) confirmed his diagnosis with type 1 diabetes [ 3 ]. While rare, similar atypical cases of diabetes have been reported [ 1 , 2 ]. With the increasing number of diabetes cases expected in the coming years [ 4 ], unusual cases such as the case presented above may become more common. To ensure timely and accurate diagnosis and management of patients with atypical cases of diabetes, we seek to raise awareness of cases which do not adhere to presentational or diagnostic norms.

Key Messages

• It is known that atypical cases of diabetes exist and can complicate the diagnosis of diabetes mellitus.
• This manuscript provides evidence that atypical cases can present with symptoms typically associated with another type of diabetes.
• The case described is an example of a type 1 diabetes patient presenting with several classic features of type 2 diabetes.

Conflicts of interest

There are no personal, financial, or other conflicts of interest to disclose.

Consent for publication

Written informed consent from the patient has been taken and is available for review by Editor in chief of the journal.

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Our rationale for choosing this condition:

Throughout our clinical experiences, previous careers, and personal lives, diabetes has been prevalent. As practitioners, we will continue to see this condition often and have to recognize/treat it in our patients. In light of this, we wanted to have a good understanding of Type 1 diabetes, its presentation, and its treatment.