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35-year-old woman with polyuria

History of present illness: A 35-year old woman presents today for follow-up after recent diagnosis with type 2 diabetes. She was given metformin and insulin, and bloodwork reveals an improvement of her blood glucose levels and A1C. The patient reports being unable to sleep through the night because she suffers from frequent urination and has dizzy spells.

Social history: Patient denies illicit drugs, alcohol, and tobacco. Patient lives with her husband and plans on having children in the next couple of years. She is interested in pursuing fertility treatments.

Medications: Metformin. Insulin.

Allergies: None.

What further testing would you perform on this patient to characterize her illness?

What medication options or lifestyle changes would you explore with this patient in order to control her symptoms?

Do you have any concerns about potential fertility treatment?

  • 3 weeks 5 days
    Check UA. Limit caffeine and water intake in evenings. Check glucose during her dizziness, look for hypoglycemia.
  • from Endocrinologist Nation 1 month
    Agree with testing for UTI and downloading glucometer to exclude uncontrolled diabetes is not the cost. Also, exclude hypoglycemia is not occurring when dizzy, instruct her to test during those times and to check her blood pressure. Then, I would consider pituitary issues and exclude DI, could go a modified overnight water deprivation test and check serum and urine Osm. Check chem panel to exclude hypercalcemia that could cause nephrogenic DI. PE and check other meds as well. Check other pituitary hormones based on results.
  • from Endocrinologist Nation 1 month
    Rule out UTI first, check BG at night, her diabetes is probably not controlled and she will benefit from mealtime insulin. Once avg BG is less than 259 her symptoms will most likely resolve.
  • 1 month
    Better control diabetes. Rule out uti.
  • 1 month
    Agree with Muhammad Nawaz—we need to determine if she is Type-1 or 2. First thought is often to increase insulin in an uncontrolled diabetic patient. Instead we should think, why insulin? Not enough information is provided in the case. What is her A1c now and what was it before insulin & metformin? Is she obese? What about more strict lifestyle modification, clean eating, or even fasting to improve her blood sugars and insulin resistance?
  • 1 month
    Most likely, but not certainly, her symptoms relate to glycosuria uncontrolled by the insulin and metformin. A UA with culture is the proper first step. Monitoring for elevated sugar before bedtime and caution regarding fluid and food intake right before bed is warranted. Adjustment of her insulin to further improve her sugar may be the most important thing; this could include a basal insulin at nighttime. If these interventions fail, consideration of other urologic/nephrologic entities may need to be considered.
    Fertility would be a significant issue with diabetes at her age. She should not be on metformin if anticipated. Tight control of sugar going into and during pregnancy with several injections or pump is paramount. Referral to an expert in these matter would be appropriate.
  • 1 month
    would get full labs U?A and culture to check status of patient first
  • from Generation NP 1 month
    I agree with John Testa and include education on life style changes on diet and exercises as first line of treatment especially if fertility is an issue. Preserving fertility is a priority with a 35 y/o female if this is a first pregnancy
  • from PA Unite 1 month
    Need other lab results, UA, Micro as well as typical thyroid, CMP/CBC as well as fasting insulin or C peptide. need to determine type 1 or 2. Also would try something like a GLP-1 and or SGLT 2 instead of insulin. Would need to stop Met and ACE for pregnancy. also DM education to help with weight loss and diet changes.
  • from Endocrinologist Nation 1 month
    Would start with UA. Then decide on urine osm, serum, osm. Fertility maybe an issue if she has DI.
  • from Pharmacist Society 1 month 1 week
    Has anemia been checked in this patient? Metformin can lower b12 levels and worsen anemia. Fertility can improve if diabetes is more controlled so would stress getting diabetes under control before starting IVF.
  • from PA Unite 1 month 1 week
    I would definitely need to look at a U/A with a culture. Also run a CMP as well as LH, FSH, and estrogen levels. Consider also fingerstick ACHS to see if the insulin is too high and contributing to her dizziness.
  • 1 month 1 week
    1. A1c is better, what does that mean?
    2. Why insulin after Metformin?
    3 what are the glucose logs from home testing showing any low glucose numbers
    4 type 1 considers? GAD -65?
    5. Look for other issues TSH , B12
    6 Metformin is a No go for pregnancy
    7. What the urine for micro show?
    8 ACE OR ARB would need to be stop for preganancy

    So many questions
  • 1 month 1 week
    35 year old is rather young for a Type-2 diabetic to go on Insulin so first have to make sure not dealing with Type-1 by doing Insulin Autoantibodies and C peptide levels to make sure that does not need the oral medication for Diabetes Control if is Type-1 , Frequent Urination ?etiology ? Uncontrolled diabetes and Glycosuric effect , ? UTI ? Overactive Bladder? Diabetic Autonomic Neuropathy , Urine Analysis and Urine Culture to rule out UTI ,Uroflow studies can be done to eval for the Over Active bladder , Continous Glucose monitor for 72 hours can detect Nocturnal Hypoglycemia causing dizziness and the over all glycemic control , Dizziness could be due to hypovolumia associcated with the Glycosuria , Management of these issues will depend on the diagnosis , Infertility is whole different Pandora box and needs a very extensive work up but if she has Type 2 diabetes and PCOS or some degree of it then Metformin is a great Insuling sensitizer and so is losing weight and the aerobic activity !
  • 1 month 1 week
    Cmp, ua, a1c, microalbumin needed. Better diabetes control. Therapeutic lifestyle changes. R/O hypoglycemia and UTI. BP check. FBS check bid
    Diabetes education
    Education about hypoglycemia tx
  • 1 month 1 week
    Needs to know how is her glycemic control, only know it is better than before. Certainly a simple UA to be done to rule out UTI ( common in uncontrol diabetic patient ). In quires about fluid intake at night, alcohol intake, whether she is on a diuretic, excess caffeine. Does she has autonomic neuropathy, MS. What is her BMI, prior attempt in pregnancies, diabetic with poor control will suffer anovulatory irregular period. Basic lab work such as thyroid, chemistry panel, CBC, UA/C&S, FBS, PPG, may be pelvic US lo looking for PCOS will get started.
  • 1 month 1 week
    Need to do UA to r/o bladder infection.limit water and caffeine intake in evenings.Need FS readings to rule out hypoglycemia as cause for her dizzy spells and keep other causes in mind too.Metformin should help fertility,then endocrine consult if unable to conceive.
  • 1 month 1 week
    Renal studies
    Urine for microalbumin
  • 1 month 1 week
    Need to know renal function, u/a results, full metabolic panel and alc result as well as post prandial, bedtime and blood sugar value at the time she gets up to urinate, in order to know whether she has nocturia due to diabetes or uti, or some other cause. Also need to know her BMI and complete physical exam results. The dizzy spells could be due to dehydration from elevated blood sugar or hypoglycemic spells, or some other cause; needs to check blood sugar at the time. Regarding fertility, she would need optimization of diabetes control, weight loss if significantly overweight and menstrual history as well as any past history regarding attempts to conceive. Would also check thyroid function and possibly refer to a fertility specialist at a later date, depending on findings.
  • 1 month 1 week
    Were the urinary frequency and dizzy spells symptoms that enabled a diagnosis of DM or did it begin after her meds were started? Is she having vertigo or lightheadedness that could be related to insulin-related hypoglycemia? It would be useful to know her A1C to know whether insulin is appropriate. Is she on a long-acting once-Daily insulin like Lantus or on a preprandial insulin? If she is obese (as I would anticipate) could she have polycystic ovaries? She might benefit more from pioglitazone than Metformin. If her A1C has normalized and frequency continues (assuming negative u/a and culture) she might need referral for cystoscopy to rule out interstitial cystitis.
  • 1 month 1 week
    I agree with Michael Evans. Check for bladder infection. Monitor her A1C for improvement and adjust dosage as needed. Adjust water intake before sleep. Better control of her blood glucose levels reduces her fertility risks.
  • 1 month 1 week
    Start with a ua for uti initially. Lifestyle would be limit caffeine and free water intake before bedtime. No concerns with fertility treatment other than letting her specialists know her history