A PRESENTATION BY MEIGHAN O’CONNOR, POPPF

DIDACTICSONLINE.COM

Diabetes Mellitus

Case Presentation

CC: fatigue and abdominal painHPI: 7 y/o male reports above sx for past 3

months. Mother says he has been less active, taking more naps and wetting his bed, which he stopped doing 2 years prior.

Pmhx, Pshx, Famhx: unremarkableROS: Pertinent positives include weight drop

from the 75th percentile to the 50th percentile despite report from mother that his food and drink intake has increased.

Objective

Labs to be ordered: WBC count, Urinalysis, Glucose level

Labs return: WBC: 11,400/mm^3 BUN: 14 mg/dL, Creatinine: 1.2 mg/dL, Sodium: 132

mEq/L, Potassium: 5.0 mEq/L, Chloride: 100mEq/L Glucose: 350 mg/dL

General: child appears lethargic but AOx3 Skin: Appears dehydrated, no erythema or lesionsHEENT, Heart, Lungs, Abdomen: negative

findingsOsteopathic Structural Exam: T7-9ERrSr with

hypertonic paraspinals, CRI slow, decreased

Assessment and Plan

Diabetes Mellitus Type I Family and patient is trained in how to administer

insulin, check blood glucose levels, check for ketonuria, recognize hypoglycemia and how to treat it.

Family and patient is counseled on nutrition and timing of carbohydrates and how to measure, rotate and adjust insulin doses depending on the time of day, physical activity and food/drink intake.

F/U in two weeks. Eventually F/U appointments need to be made every 6

mo. to check weight, BP, eyes, extremities. Future concerns include ETOH intake and depression/mental illness.

Type I

Type IA diabetes is suggested by reduced insulin and the presence of pancreatic (islet) autoantibodies. Type IA vs. type IB

Type I diabetes also is usually suggested by reduced insulin and c-peptide levels.

Uncertain etiologyPeak onset bimodal:

4-6 and 10-14 years of agePrevalence in US:

2/1000 non-Hispanic whites Slightly lower in other ethnic groups

Type I

Classic new onset—most common presentation

Diabetic ketoacidosis—very severe Deep, rapid breathing Dry skin and mouth Flushed face Fruity smelling breath Nausea and vomiting Stomach pain

Incidental finding—take thorough hx of all patients, no matter how young.

Case Presentation

CC: new pt, physical exam HPI: 30 y/o African American female presents

for PE. Claims to be in good health but mentions she is urinating more frequently and has had several UTIs in the past year.

Meds: MetoprololPmhx: HTN; Pshx: unremarkableFamhx: Father and Gmother + heart attacks,

Mother, Aunt, Sister + diabetes.

Objective

Vitals: BP: 125/90 right arm; RR: 14 breaths/min; HR: 85

beats/minPE:

General: Morbid obesity at BMI of ~48 kg/m2 Heart, Lungs, Abdomen: negative findings

Urine dipstick: 2+ glucosuriaRandom plasma glucose: 240 mg/dLOsteopathic Structural Exam:

Hypertonic pelvic and abdominal diaphragm, hypertonic paraspinals T7-9, and diminished CRI

Assessment and Plan

Diabetes Mellitus type II Diet, exercise weight reduction Oral hypoglycemic agent Avoidance of macro/microvascular complications F/U in 2 weeks and eventually every 6 months to check weight, BP, eyes extremities and renal function.

Type II

Prevalence in the US: 0.18 per 1000 non-Hispanic white youth 10-19 years old 1.06 and 1.45 per 1000 African-American and Navajo

youth, respectively. All ages: 25.8 million people, or 8.3% of the U.S

Risk factors: Positive family history Obesity Female gender Pregnancy

Type II

Sx: Commonly asymptomatic Increased thirst, increased frequency of urination,

blurred visionGlucose testing

Random blood glucose test Fasting blood glucose test Hemoglobin A1C level Oral glucose tolerance test

Type II

Diagnostic Criteria: Sx of diabetes and a random blood sugar of 200 mg/dL

(11.1 mmol/L) or higher A fasting blood sugar level of 126 mg/dL (7.0 mmol/L)

or higher A blood sugar of 200 mg/dL (11.1 mmol/L) or higher

two hours after an oral glucose tolerance test. An A1C of 6.5 percent or higher The blood tests must be repeated on another day to

confirm the diagnosis of diabetes.

Type II

Complications: Macrovascular

Heart disease Stroke Peripheral vascular disease

Microvascular Retinopathy Nephropathy Neuropathy

Infections Staph infection at injection site Fungal infections involving oral mucosa, genitals, skin

and nails

Treatment

Medical: Type I:

Short acting insulin= lispro or insulin Intermediate acting= NPH Long acting: Lente or Ultralente

Type II: Biguanides: Metformin, mc first line Sulfonylureas: Tolbutamide, Chlorpropamide, Glipizide Glitazones: Pioglitazone, Rosiglitazone Alpha-glucosidase Inhibitors: Acarbose, Miglitol

Treatment

Osteopathic: We can directly improve circulation which indirectly enhances

hormone release, cellular uptake and cellular response and helps the patient avoid infection.

Pancreas T7-9: Treat paraspinals, somatic dysfunctions

Abdominal and pelvic diaphragm release and rib raising To improve circulation and lymphatic flow

Treat legs and feet Remove restrictions and SD, improve and maintain ROM thereby

helping the pt stay active and proactive in their own health Cranial

Improve CRI=improve flow of blood, nutrients from the CSF and lymphatics

Compile exercise and nutrition/diet program or refer to specialists

References

First Aid, Case Reports for the USMLE Step 1 Pub Med, Ketoacidosis

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001363/ CDC, Prevalence of Diabetes Mellitus in US

http://www.cdc.gov/diabetes/projects/cda2.htm Up To Date, Diabetes Mellitus I and II http://www.uptodate.com.ezproxylocal.library.nova.edu American Diabetes Association Home Page www.diabetes.org Rediscovering the classic osteopathic literature to advance

contemporary patient-oriented research: A new look at diabetes mellitus. John C Licciardone. http://www.om-pc.com/content/2/1/9

An osteopathic approach to type 2 diabetes mellitus. Shubrook JH Jr, Johnson AW.

Common crossroads in diabetes management. Michael Valitutto