Differentiating Diabetes mellitus type 1 from other diseases: Difference between revisions

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__NOTOC__
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{{Diabetes mellitus type 1}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Diabetes_mellitus_type_1]]
{{Diabetes mellitus}}
{{Diabetes mellitus}}
{{CMG}}
{{CMG}}


==Overview==
==Overview==
[[Type 1 DM]] must be differentiated from [[type 2 DM]], MODY-DM, [[psychogenic polydipsia]], [[diabetes insipidus]], transient hyperglycemia, steroid therapy, [[Renal tubular acidosis|renal tubular acidosis type-1]], [[glucagonoma]], [[cushing's syndrome]], and [[hypothyroidism]].
[[Type 1 diabetes mellitus]] must be differentiated from [[type 2 diabetes mellitus]], [[maturity onset diabetes of the young]] ([[Maturity onset diabetes of the young|MODY-DM]]), [[psychogenic polydipsia]], [[diabetes insipidus]], transient [[hyperglycemia]], [[steroid]] [[therapy]], [[Renal tubular acidosis|renal tubular acidosis type-1]], [[glucagonoma]], [[cushing's syndrome]], and [[hypothyroidism]].


== Differentiating Diabetes mellitus type 1 from other Diseases==
== Differentiating Diabetes mellitus type 1 from other Diseases==
Differential diagnosis of type 1 DM, include: <ref name="pmid17727381">{{cite journal| author=Barrett TG| title=Differential diagnosis of type 1 diabetes: which genetic syndromes need to be considered? | journal=Pediatr Diabetes | year= 2007 | volume= 8 Suppl 6 | issue=  | pages= 15-23 | pmid=17727381 | doi=10.1111/j.1399-5448.2007.00278.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17727381  }}</ref><ref>Type 1 Diabetes mellitus "Dennis Kasper, Anthony Fauci, Stephen Hauser, Dan Longo, J. Larry Jameson, Joseph Loscalzo"Harrison's Principles of Internal Medicine, 19e Accessed on December 27th,2016</ref>
* [[Differential diagnosis]] of [[type 1 diabetes mellitus]], include: <ref name="pmid17727381">{{cite journal| author=Barrett TG| title=Differential diagnosis of type 1 diabetes: which genetic syndromes need to be considered? | journal=Pediatr Diabetes | year= 2007 | volume= 8 Suppl 6 | issue=  | pages= 15-23 | pmid=17727381 | doi=10.1111/j.1399-5448.2007.00278.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17727381  }}</ref><ref>Type 1 Diabetes mellitus "Dennis Kasper, Anthony Fauci, Stephen Hauser, Dan Longo, J. Larry Jameson, Joseph Loscalzo"Harrison's Principles of Internal Medicine, 19e Accessed on December 27th,2016</ref><ref>{{Cite web|url=http://www.namrata.co/diabetes-mellitus-differential-diagnosis-and-management/|title=namrata|last=|first=|date=|website=|publisher=|access-date=}}</ref>
* [[Type 2 diabetes mellitus|Type 2 DM]]
** [[Type 2 diabetes mellitus|Type 2 DM]]
* [[Maturity onset diabetes of the young|MODY-DM]]
** [[Maturity onset diabetes of the young|MODY-DM]]
* [[Psychogenic polydipsia]]
** [[Psychogenic polydipsia]]
* [[Diabetes insipidus]]
** [[Diabetes insipidus]]
* Transient hyperglycemia
** Transient [[hyperglycemia]]
* Steroid therapy
** [[Steroid]] [[therapy]]
* [[Renal tubular acidosis|Renal tubular acidosis type-1]]
** [[Renal tubular acidosis|Renal tubular acidosis type-1]]
* [[Glucagonoma]]
** [[Glucagonoma]]
* [[Cushing's syndrome]]
** [[Cushing's syndrome]]
* [[Hypothyroidism]]
** [[Hypothyroidism]]
* [[Wolfram syndrome]]  
** [[Wolfram syndrome]]  
* [[Alstrom syndrome]]
** [[Alstrom syndrome]]
<SMALL><SMALL>
 
{| class="wikitable"
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
!
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;"|Disease
! colspan="6" |History and symptoms
! colspan="5" align="center" style="background:#4479BA; color: #FFFFFF;"|History and symptoms
!Physical examination
! colspan="8" align="center" style="background:#4479BA; color: #FFFFFF;"|Laboratory findings
!
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;"|Additional findings
!Investigations
!
!
!
!
!
!
!
!
|-
|-
!
!align="center" style="background:#4479BA; color: #FFFFFF;"|Polyuria
!Polyuria
!align="center" style="background:#4479BA; color: #FFFFFF;"|Polydipsia
!Polydipsia
!align="center" style="background:#4479BA; color: #FFFFFF;"|Polyphagia
!Polyphagia
!align="center" style="background:#4479BA; color: #FFFFFF;"|Weight loss
!Weight loss
!align="center" style="background:#4479BA; color: #FFFFFF;"|Weight gain
!Weight gain
!align="center" style="background:#4479BA; color: #FFFFFF;"|Serum glucose
!Positive medical history
!align="center" style="background:#4479BA; color: #FFFFFF;"|Urinary Glucose
!General appearance
!align="center" style="background:#4479BA; color: #FFFFFF;"|Urine PH
!Skin manifestations
!align="center" style="background:#4479BA; color: #FFFFFF;"|Serum Sodium
!Serum glucose
!align="center" style="background:#4479BA; color: #FFFFFF;"|Urinary Glucose
!Urinary Glucose
!align="center" style="background:#4479BA; color: #FFFFFF;"|24 hrs cortisol level
!Urine Ph
!align="center" style="background:#4479BA; color: #FFFFFF;"|C-peptide level
!Serum Sodium
!align="center" style="background:#4479BA; color: #FFFFFF;"|Serum glucagon
!Urinary Glucose
!24 hrs cortisol level
!C-peptide level
!Auto antibodies
!Serum glucagon
|-
|-
!'''Type 1 Diabetes mellitus'''
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Diabetes mellitus type 1|Type 1 Diabetes mellitus]]
!
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |
!
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |
!
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |
!
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |
!
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
!✖
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |'''↑'''
!Usually patients are young and lean
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |'''''↑'''''
!―
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
!'''↑'''
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
!'''↑'''
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |N/'''↑'''
!N
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
!N
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |'''↓'''
!'''↑'''
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
!N
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[autoantibody|Autoantibodies]] present ([[GAD65|Anti GAD-65]] and anti [[insulin]] [[autoantibody|autoantibodies]])
!'''↓'''
!
* Measurements of IA2 autoantibodies within 6 months of diagnosis can help differentiate between type 1 and type 2 DM
* Anti-GAD65 usually present
* Anti-insulin autoantibodies usually present
!
|-
|-
|Type 2 Diabetes mellitus
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Diabetes mellitus type 2|Type 2 Diabetes mellitus]]
|✔
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |✔
|✔
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |✔
|✔
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |✔
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |✔
|✔
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |'''↑'''
|Usually patients are middle age or elderly and obese
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |'''↑'''
|Acanthosis nigricans
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|'''↑'''
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|'''↑'''
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |'''↑'''
|N
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|N
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|'''↑'''
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |'''↑'''
|N
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Acanthosis nigricans]]
|N
|
|N
|-
|-
|MODY
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[MODY]]
|✔
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |✔
|✔
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |✔
|✔
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |✔
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |'''↑'''
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |'''↑'''
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|'''↑'''
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|'''↑'''
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |'''↑'''
|N
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|N
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|'''↑'''
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |N
|N
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|N
|
|N
|-
|-
|Psychogenic polydipsia
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Psychogenic polydipsia]]
|✔
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |✔
|✔
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |✔
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|N
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |'''↓'''
|N
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|N
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|'''↓'''
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|N
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|N
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|N
|
|N
|-
|-
|Diabetes insipidus
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Diabetes insipidus]]
|✔
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |✔
|✔
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |✔
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|N
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |'''↑'''
|N
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|'''↑'''
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|N
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|N
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|N
|
|N
|-
|-
|Transient hyperglycemia
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |Transient [[hyperglycemia]]
|N
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |'''↑'''
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |'''↑'''
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|'''↑'''
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|'''↑'''
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |'''↑'''
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|N
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|'''↑'''
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |N/'''↑'''
|N
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |In hospitalized patients especially in [[ICU]] and [[CCU]]
|N
|
|N
|-
|-
|Steroid therapy
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Steroid]] [[therapy]]
|✔
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |✔
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |✔
|✔
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |'''↑'''
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |'''↑'''
|Acanthosis nigricans
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|'''↑'''
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|'''↑'''
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |'''↑'''
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |'''↑'''
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |N/'''↑'''
|'''↑'''
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |N/'''↑'''
|'''↑'''
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Acanthosis nigricans|Acanthosis nigricans,]]
|N
|
|N
|-
|-
|RTA 1
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[RTA|RTA 1]]
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|✔
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |✔
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |''''''
|N
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |'''↑'''
|''''''
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|'''↑'''
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|N
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Hypokalemia]], [[nephrolithiasis]]
|N
|
|N
|-
|-
|Glucagonoma
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Glucagonoma]]
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |'''↑'''
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|Necrolytic migratory erythema (NME) 
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|'''↑'''
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |'''↑'''
|N
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Necrolytic migratory erythema]]
|N
|
|'''↑'''
|-
|-
|Cushing disease
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Cushing's syndrome|Cushing syndrome]]
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |'''↑'''
|Patients can present with moon face,
|style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
obesity and buffalo hump
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|Acanthosis nigricans
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |''''''
|'''↑'''
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |N/'''↑'''
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |'''↑'''
|
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|'''N'''
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal
|N/'''↑'''
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Moon face]], [[obesity]], [[buffalo hump]], easy [[Bruising|bruisibility]]
|'''↑'''
|N
|
|N
|-
|Hypothyroidism
|✖
|✖
|✖
|✖
|✔
|✖
|Patients may present with weight gain and swelling of face  
|―
|N
|―
|
|'''N'''
|N
|N
|N
|Antibodies assocaited with hypothyroidism are:
* Thyroid Peroxidase Antibody
* Thyroglobulin Antibody
* Thyroid Stimulating Hormone Receptor Antibody
|N
|}
|}
</SMALL></SMALL>


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
{{WH}}
{{WS}}


[[Category:Needs content]]
[[Category:Needs content]]
[[Category:Endocrinology]]
[[Category:Endocrinology]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Primary care]]
{{WH}}
{{WS}}

Latest revision as of 16:51, 1 September 2020

Diabetes mellitus Main page

Patient Information

Type 1
Type 2

Overview

Classification

Diabetes mellitus type 1
Diabetes mellitus type 2
Gestational diabetes

Differential Diagnosis

Complications

Screening

Diagnosis

Prevention

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Type 1 diabetes mellitus must be differentiated from type 2 diabetes mellitus, maturity onset diabetes of the young (MODY-DM), psychogenic polydipsia, diabetes insipidus, transient hyperglycemia, steroid therapy, renal tubular acidosis type-1, glucagonoma, cushing's syndrome, and hypothyroidism.

Differentiating Diabetes mellitus type 1 from other Diseases

Disease History and symptoms Laboratory findings Additional findings
Polyuria Polydipsia Polyphagia Weight loss Weight gain Serum glucose Urinary Glucose Urine PH Serum Sodium Urinary Glucose 24 hrs cortisol level C-peptide level Serum glucagon
Type 1 Diabetes mellitus - Normal Normal N/ Normal Normal Autoantibodies present (Anti GAD-65 and anti insulin autoantibodies)
Type 2 Diabetes mellitus - Normal Normal Normal Normal Acanthosis nigricans
MODY - Normal Normal Normal Normal N -
Psychogenic polydipsia - - - Normal Normal Normal Normal Normal Normal Normal -
Diabetes insipidus - - - Normal Normal Normal Normal Normal Normal Normal -
Transient hyperglycemia - - - - - Normal Normal Normal Normal N/ In hospitalized patients especially in ICU and CCU
Steroid therapy - - - Normal Normal N/ N/ Acanthosis nigricans,
RTA 1 - - - - Normal Normal Normal Normal Normal Normal Hypokalemia, nephrolithiasis
Glucagonoma - - - - - Normal Normal Normal - Normal Normal Necrolytic migratory erythema
Cushing syndrome - - - - - Normal N/ Normal Normal Moon face, obesity, buffalo hump, easy bruisibility

References

  1. Barrett TG (2007). "Differential diagnosis of type 1 diabetes: which genetic syndromes need to be considered?". Pediatr Diabetes. 8 Suppl 6: 15–23. doi:10.1111/j.1399-5448.2007.00278.x. PMID 17727381.
  2. Type 1 Diabetes mellitus "Dennis Kasper, Anthony Fauci, Stephen Hauser, Dan Longo, J. Larry Jameson, Joseph Loscalzo"Harrison's Principles of Internal Medicine, 19e Accessed on December 27th,2016
  3. "namrata".

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