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A 46-Year Old woman was brought to the emergeny room
Dr.Syrian - الجمعة, 2007-03-16 13:54 |
الوصف الكامل Background: A 46-Year Old woman was brought to the emergeny room at 9 AM ,beacuse of servere confusion.She has a three year history of psychiatric illnes, manifested as abnormal behavior. there is no history od diabetic mellitus
الشكوى الرئيسية CC: القصة المرضية HPI: الأجهزة الأخرى ROS: السوابق المرضية الشخصية PMH: السوابق المرضية العائلية FMH: الوضع الصحي والاجتماعي SH: الفحص السريري Clinical Exam: her physical examninattion , except for mild obesity, is unremarkable. Her blood pressure is 110/65 mmhg and her pulse rate is 92 beats/min. Her confusion improves following intravenous glucose.
التشخيص التفريقي DD: الاستقصاءات Investigations: The Following morning inthe fasting laboratory studies revealed :
plasma glucose = 39 mg/dl (2.2 mmol/L) (normal,overnight fast =65 to 115 mg/dL (3.6 to 6.4 mmol/L) serum insulin = 25 mircro U/mL (nromal,overnight fast =5 to 25 micro U/mL) serum C-Peptide = 2,8 ng/mL (normal overnight fast =0.5 to 3.0 ng/mL) serum proinsulin = 0.4 ng/mL (normal ,overnight fast =0.0 to 0.2 ng/mL التدبير Managment: كتابة حرة وطرح موضوع النقاش!: which of the following is the most likely casue of her hypoglycemia?
A.Insulinoma |
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c-peptide is high (high borderline) which excludes exogenous insulin..now we have three options ... insulinoma, sulfonylureas and insulin autoantibodies..all of them have high C-peptide.
proinsulin is high which is an indicator for insulinoma ...
so i think the cause is insulinoma (choice A)
First we check the levels of C-peptide which is produced in a 1:1 ratio with insulin when they are both cleave from proinsulin.
The C-peptide is at the high stage of its normal rane just
like insuline. that tells us that it is endogenous insulin.
now we have three posipilities of this endogenous insulin:
1. sulfonylureas : but here we want to do an extra test which rule in or out oral hypoglycemic use. it is ( Urinary / Plasma Sulfonylyrea )
2. insulinoma : Insulin levels in insulinomas tend to be less than 200 MU/ml and usually less than 100 MU/ml.
they also tend to cause a higher proportion of proinsulin in the serum.
and our story show an elevated proinsulin level.
3. autoimmune : in which the proinsulin is almost 10% of insulin level. and insulin is more than 100 MU/dl.
We may still want to do the test of sulfonylureas since our patient has some abnormal behavior and may do somthing stupid like having drugs.
also additional work up to rule in or uot insulinoma should be done.
right my friends
thank you