Here comes a real challenge for you. A 8-year old girl comes to the doctor to the monitoring of her type 1 diabetes (T1D), diagnosed 2 years prior this consultation. We have these results: Fasting Plasma Glucose (FPG): 84mg/dl (4.6mmol/L) A1C: 6,4% Even with satisfactory results, her mother tells you that she have some unusual hypoglycemias and got stressed easily. Also, when she gets stressed, her blood glucose levels (BGL) goes up quickly, reaching 300-400mg/dl (16.6-22.2mmol/L). While you are thinking what to do about her insulin dosis, you ask the mother the common question: "Do you have any other complaint?" The mother answers you that she is complaining about a pain in the left flank (insidious onset, dull, scored 8/10, without irradiation, constant, without relief using ibuprofen, paracetamol or scopolamine, without improvement or worsening factors and without accompanying symptoms). She also tells you that the girl is "coming into age" (menarche), and she felt it strange because her own "age signals" came when she was 13. At the physical examination, we have: Vital signs: Temperature 36,8°C | Breathing 19ipm | Heart Rate 72bpm | Arterial Pressure 106x64mmHg General: Looking good, colored, hydrated, anicteric, afebrile, acyanotic, located and oriented in time and space. No lymphonodomegalies. Heart and Lungs: No abnormalities. Abdomen: No palpable masses, no tenderness. Giordano signal negative. No visceromegalies. Extremities: Pulses present and palpables, edema (1+/4+). Neurological: No abnormalities. ~ Then, you don't know - at that time - what to do, and decides to admit the girl. ~ What would you do, doctors? Send me some questions and I'll answer you all with the results of any other test you wish to make. Open your Guytons, Cecils, UpToDates... You are now part of House MD team! (Based on an actual case, collected by me. I'll thell you the story after the case is solved...) ~RW
Okay! All that is possible to notice is a slight hairiness of the genitals. No sign of breast buds or other signs. Menarche was just mentioned. ~RW
Well, in my experience I've seen many patients with diabetes who complain about abdominal pain. This pain sometimes is diffuse another times is focused on any flank, but this pain is seen in patients who are decompensated ( ketoacidosis in a high percentage) . The leading causes of pain in diabetic patient are: diabetic gastroparesy, diabetic thoracic polyradiculopathy, acute suprarrenal insufficiency ,chronic pancreatitis . The thing that calls my attention is the puberty of the girl. As a rule the menarche comes after development of the mammas and pubic hair. Do you know when the pubic hair started to show up?
Hmmm, perhaps you are going in the right way about the pain... When asked about the pubic hair, the mother said that hasn't noticed it until the menarche date (something like 30-35 days prior the consultation), and the girl itself tells that she can't remember when it started. Please be aware that they are people with a low income and low culture. ~RW
Well, too. This was one of the exams we asked. By the way, no abnormalities in the ovarian ultrasound. ~RW
No? Any ovarian follicles? I guess if she already had the menarche at the eco we could had seen some changes due to the ovarian cycle
Hmm, well pointed, but, in the radiology report there were no abnormalities. I'm not sure about an ovarian cycle (35 days without another bleeding?), but, what else could cause these symptoms? And, what if this bleeding were "only" another bleeding? ~RW
Bingo! We noticed a mass in the abdominal ultrasound, with aproximated dimensions of 8x6cm, near (actually, up the kidney) the left kidney. The kidneys itself, ureters, and every other organs had no abnormalities.
The girl was a little distressed when she realized that we would collect more blood (fear of needles?). BGL (fasting): 204 mg/dl Na: 152 mEq/L K: 5,2 mEq/L Ca: 10,6 mg/dl Cortisol (fasting, in the morning): 93,2 ug/dl ~RW
