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Case study 1: spot the problem(s)


This week we will start a few examples of what I call “case studies.” These are all going to be real life scenarios, and hopefully, by now you will be able to spot some of the issues at hand.

A woman in her 60s was admitted to the hospital this week and I was asked to see her because of prior poor diabetes control, and because her medications had to be changed in the hospital, due to some other issues.{{more}} During my talk with her, she said that while at home, her blood sugars, are often “good”, but she has some low numbers when she wakes up. She has shakes and sweats at the time. Later in the day, when she checks her blood sugars they are always good. I looked up her prior hemoglobin A1C levels over the past few years and they were 10.5 per cent, 10 per cent and 11 per cent. I ordered a lab drawn to check one then and it was 9.9 per cent.

So, here we have a patient who is telling me that her blood sugars run low to normal at home, but when I look at her hemoglobin A1C level, it is high. What could be the issue or issues behind this scenario?

Answer 1: Some of you are saying, “Well, the woman is lying.” That is a possibility. She could be telling me misinformation about the numbers she gets when she checks her sugars, or she may not be checking at all! On the other hand, she COULD could be telling me the truth, as well as everything else be correct in this scenario.

Answer 2: Some of you think the lab study for the hemoglobin A1C might be wrong. This is always possible; labs are not perfect and sometimes mistakes do happen. BUT, given that all her prior hemoglobin A1C levels were high, this current one is most likely correct, given her history of poor control.

Answer 3: Perhaps there are blood sugars that are quite high when she is NOT checking, so she never sees them. This is my most likely explanation for the discrepancy between what she told me and what the lab result showed. Of course, she could be giving me misinformation, but I chose to believe this woman is telling me the truth. In which case, her medication regimen needs to change, so that she does not have any lows in the morning AND that her evening sugars (which I suspect are high) get better.

I changed her medications to better spread them out over the day and increased one of them. She will check in with her doctor in two weeks. This case hopefully illustrates how important it is to BOTH check your own sugars, if you can (and at different times of day), as well as get your labs drawn when your doctor requests them.

Until next week, stay safe and healthy Vincies!

Anita Ramsetty, MD [email protected]
Medical Director Endocrine Care Group
Tel: 843-798-4227