05/03/2023 1

Jimmy Santana, MBA, P.A. - C

Diabetes Case Presentation

Diabetes Quiz

A 24-year-old, white female has recently being diagnosed with insulin-dependent diabetes. The disease is being managed on a split dose of 60/40 insulin suspension, which she injects herself at 8:00 a.m. and 5:00 p.m. She was told to call in if she experiences any strange symptoms, which she does this afternoon. At 2:45 p.m. she is not feeling well and notices that her skin is cool and damp. Her hands are shaking and she is very anxious. What do you tell her to do right away, before having somebody take her to your office?

A. Inject 4 IU of her insulin

B. Drink a can of diet soda

C. Drink six ounces of fruit juice

D. Eat a large candy bar

E. Eat a cube of sugar

Question 1

The above described symptoms are classical for hypoglycemia. An inexperienced patient needs to be monitored by medical personnel until the blood glucose level is stabilized again. The first priority though is to prevent the blood sugar to drop any further and send the patient into a coma.

A six-ounce drink of fruit juice should be sufficient. Since the symptoms suggest hypoglycemia, injecting insulin would worsen the situation. If in doubt if the patient is hypo- or hyperglycemic and there is no possibility for a test, always give sugar first and see if the patient improves. An increase of a blood glucose level of, for example, 350 is not going to hurt the patient, but lowering a level of 45 is going to send the diabetic into a coma.

Since diet soda contains only sugar substitutes it is not going to influence the blood glucose level. A large candy bar could be eaten too, but it may raise the glucose level higher than required, therefore the fruit juice is a better choice. One cube of sugar is an insufficient amount to raise blood sugar; it will take several cubes.

A 61-year-old white male presents to your office for the first time. In reviewing his medical records, you note a history of diabetes type 2 onset 4 years ago. He is currently well controlled to normal blood sugars and hemoglobin A1Cs. You do note that his previous blood pressure readings were above normal on multiple visits. In addition to his usual diabetic care, you recommend initiation of drug therapy for his hypertension. Your drug of choice is

A. Calcium channel blocker

B. ACE inhibitor

C. Alpha blocker

D. Thiazide diuretic

E. Beta blocker

Question 2

ACE inhibitors have been shown to slow the progress of proteinuria in patients with diabetes. Control of their blood pressure is just as important. Your drug of choice should be an ACE inhibitor for any diabetic with hypertension as long as there are no contraindications to giving them this medicine.

3. A 55-year-old male is brought into the urgent care center of your hospital by paramedics. He is obtunded, and today his wife could not get him out of bed. He has no significant past medical history. His wife states that he has not been well for the last week, with decreased energy and fatigue. In addition, he has had a productive cough, which has worsened during the last 3 days. Also, according to his wife, he appears to be drinking more water. Physical exam reveals a lethargic male who moves to deep pain but has no intelligible speech. Paramedics have given the patient Narcan with no change in his status but have withheld glucose bolus due to a high dextro stick reading. Vital signs are pulse 115; BP 90/50; respiration 18; Temp 38.2° C (100.7° F)

HEENT shows dry mucous membranes. Lungs are clear. Cardiac exam is significant for tachycardia. Abdominal exam is nonspecific. Neurologic exam shows the patient to be responsive only to pain, with withdrawal. No abnormal reflexes noted.

Initial laboratory studies show: Na 118; K 4.2; Cl 97; HCO3 21; Glucose 1050. ABG reveals pH 7.34, pCO2 20; pO2 79; O2 saturation 90%. CBC shows a normal H/H with WBC count of 14K; the serum is reported as very lipemic. Chest X-ray shows an LLL consolidation. The most likely cause for the change in the patient's mental status is

A. Acute diabetic ketoacidosis

B. Pseudohyponatremia

C. Pneumococcal pneumonia with hypoxia

D. Hyperglycemic hyperosmolar nonketotic coma

E. Central pontine myelinolysis

Question 3

Hyperglycemic hyperosmolar nonketotic coma (HHNC) represents a syndrome characterized by marked hyperglycemia, hyperosmolarity, and dehydration. It is manifested by decreased mental functioning that may progress to frank coma. Ketosis and acidosis are generally minimal.

DKA, acute diabetic ketoacidosis, will have similar electrolyte abnormalities; however, there will be an associated metabolic acidosis and ketosis.

The patient does show pseudohyponatremia, which is due to the presence of hyperglycemia and hyperlipidemia. In the absence of marked lipemia, the true value for sodium can be approximated by adding 1.3 to 1.6 mEq/L to the sodium value for every 100 mg/dl glucose over the norm. But this is not the cause of this patient's altered sensorium.

The patient most likely has pneumococcal pneumonia, which is a common precipitating factor in the development of HHNC. He is mildly hypoxic, though this does not explain the degree of obtundation seen.

Overly aggressive restoration of serum sodium levels in hyponatremic patients can be associated with central pontine myelinolysis and circulatory overload.

A 28-year-old type I diabetic on multiple daily insulin injections regimen presents to your office for a follow up visit. She complained to you about her early morning glucose level during her last visit and you recommended for her to chart the numbers and bring it for her next appointment. Her pre-breakfast glucose averaged 285mg/dL; dinnertime was 95mg/dL and 68mg/dL at 3 AM. How will you treat her diabetes?

A. Increase the evening dose of long acting insulin

B. Decrease the evening dose of long acting insulin

C. Decrease the evening dose of short acting insulin

D. Increase the evening dose of short acting insulin

E. Increased activity before bedtime

Question 4

Three mechanisms can account for early morning hyperglycemia in patients with diabetes on insulin:

1. Inadequate dose of long acting insulin at night 2. Somogyi effect or rebound hyperglycemia is a condition often seen in

type I diabetes, in which there is nocturnal hypoglycemia. The hypoglycemia subsequently stimulates the release of counter regulatory hormones leading to increase of glucose level in the blood. Diagnosis can be made by several plasma glucose analyses done at 2.00 A.M, 3.00 A.M, and 7.00A.M.

3. In the dawn phenomenon, the hyperglycemia is secondary to increased need for insulin in the early morning due to the normal early morning surge of growth hormone, which antagonizes insulin action.

Checking the blood glucose level at 3 AM can help differentiate between Somogyi effect and dawn phenomenon: the level will be low in Somogyi phenomenon. The patient's early morning hyperglycemia is due to Somogyi effect since her 3 AM level was low. Treatment of this will be to decrease the evening dose of long-acting insulin or give bedtime snacks. The treatment of dawn phenomenon involves increasing the evening dose of long-acting insulin.

There is no nocturnal hypoglycemia if the night dose of insulin is inadequate.

A 62-year-old male with a history of diabetes for twenty-five years and hypertension for ten years is referred to your office by a retired physician. He complains of worsening edema on the right lower extremity during the last two weeks. Vital signs show T 97.8 Pulse 78 RR 20 BP 165/93. Physical examination disclosed periorbital edema and left lower extremity edema 1+ below the knee and right lower extremity edema 3+ below the knee that is nontender to palpation. He denies any fever, chills, or malaise. He is currently on glipizide 20 mg twice a day and amlodipine 10-mg once daily. Laboratory result from two weeks ago shows Na 145, K 4.5, Cl 102, HCO3 25, BUN 14, Creat 1.2, CA 7.2, Glucose 287, HgA1C 8.6, and Albumin 2.5. The U/A test shows 3+ proteins with no WBC or RBC.

Question: What is the most appropriate next step in management of his diabetes?

A. Start the patient on glyburide

B. Start the patient on insulin therapy

C. There is no indication to change his diabetes therapy. His HgA1C shows that his diabetes is under control

D. Start the patient on metformin

E. Repeat the patient's HgbA1C; result is too old to reflect the current HgbA1C level

Question 5

This patient's diabetes mellitus is poorly managed. Glycosylated hemoglobin (HbA1c) is the best indicator of glycemic control over the previous 3 months. Maintaining an HgA1C of 7 or less lowers the rate of complications of diabetes mellitus. Adding a second class of oral hypoglycemic agent would be the next best choice. Metformin is the drug from the biguanides class; therefore, it is the drug of choice.

Starting the patient on glyburide is incorrect because both glyburide and glipizide belong to the sulfonylurea class. Starting the patient on insulin therapy is incorrect because oral therapy should be maximized before starting on insulin. HgA1c of 8.6 indicates poorly controlled diabetes. There is a need to change his diabetes management. There is no need to repeat HgA1C. Glycosylated hemoglobin (HbA1C) is the best indicator of glycemic control over the previous 3 months. The result is not too old.

A 38-year-old obese female with type 2 diabetes mellitus presents to your office for follow up visit. Her blood sugar has been well controlled on metformin. She wants to have a baby and wants to know if there is any special thing to do so that her diabetes will not affect her pregnancy. Which of the following is appropriate for her?

A. Switch her to insulin

B. Switch to glyburide

C. Tell her it is not advisable for her to be pregnant because her child will be diabetic

D. Increase the dose of her metformin to prevent worsening of her blood sugar during pregnancy

E. Continue her present treatment and dose

Question 6

Diabetic patients that are pregnant or attempting to get pregnant, irrespective of whether they are insulin requiring or not, should be switched to insulin therapy for their glucose control. Oral glucose lowering agents are contraindicated in pregnancy. Although a poor glucose control predisposes to increased maternal and fetal risks, it is not a contraindication to pregnancy. A good glucose control is however necessary prior to and during pregnancy.

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A 24-year old white male present to the flight physician assistant’s office for a routine physical. He has been taking flying lessons and is applying for a pilot’s license. Regulations state that he must have a physical examination.

Examination discloses a thin male, 74 inches, 140 pounds. Generally, the exam is unremarkable. Routine screening includes a urinalysis, which demonstrates 4+ glycouria.

Case 1

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There is insufficient information to establish a diagnosis. There are other reasons to spill glucose in the urine. You must ask additional questions.

You find out that even though he denies any history of diabetes, he admits to:

1. Having incessant thirst2. Increase hunger3. Increase urination4. He has lost 15 pounds over the last three months

Does this man have Diabetes Mellitus?

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A glucometer reading revealed a glucose of 490 mg/dl

A blood glucose revealed a glucose level of 496 mg/dl. With normal electrolytes and anion gap

Does this patient have diabetes?

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Three ways to diagnose diabetes mellitus:Fasting glucose of > 126 mg/dlOral glucose tolerance test with a 2

hr value of > 200 and one other value in-between of > 200

Grossly elevated serum glucose with classic signs and

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New onset Type I diabetics should be admitted because:He needs to start on insulinHe requires a lot of patient

education

Your patient is in shock. He does not feel ill and has multiple activities planned.

What should you do for him?

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32-year old woman who has type I diabetes calls you over the weekend. She has been having some nausea and vomiting for the last 24 hours and can not keep solids down. She has been able to keep liquids down. Her last glucometer reading was 261 mg/dl.

She is on a split dose of NPH and regular insulin twice daily. She did not take her morning insulin because a physician had told her never to take her insulin when she is not eating. She ask you for instructions?

Case II

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Many patients do not take their insulin if they are not eating; this is wrong.It is important for IDDM patients and

their providers to learn how to manage “sick days”.

Note that one of the most common reasons for patient to go into DKA is poor management of their diabetes when they are sick.

Insulin should be taken regardless of whether or not they are eating

Adequate carbohyrates should be taken (15 – 20g q2h)

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The patient can consume regular coke, Sprite, juices @ 4 – 6 oz q2hrs.

They can also have gelatin, crackers, soup

Patients that are sick require more insulin NOT less

The intermediate or long acting insulin should be given

Regular insulin should be given q4h as per a ‘sliding scale’

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69-year old white female was in good health until 3 weeks ago, when she suddenly developed severe polyuria, polydipsia and polyphagia. She has lost 20 pounds ( going from 120 to 100) during that period and feels extremely weak. When her daughter brings her to you, in the ED, she is somewhat lethargic. Past medical history reveals HTN(Tx with a small dose of enalapril). There is no history of cardiac disease.

Case III

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Physical Exam reveals a pale, lethargic, confused woman, breathing rapidly.

B/P is 102/72 P 110 Resp 32Her skin is very dry, bowel sounds are

weakly positiveBlood test revealed

Na+ 130 (135 – 145)K+ 5.1 (3.5 – 5.1)Glucose 794 ( 70 – 110)Cl- 104 (95 – 105)HCO3 3mEq/L (21 – 30)pH 6.92 (7.35 – 7.45)pO2 92 mm (80 – 105)

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A 37 year old white female has a 20 year history of diabetes mellitus. She has been having difficulty with hypoglycemia in the early morning. She used to be on beef-pork insulin and did not have any problems.

She takes:Human NPH 16U am; 8 U pmHuman Regular 8 U am; 3 U pm

CASE IV

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Blood glucose monitoring reveal:3am 7am 12pm

5pm41 66 109 7247 132 82 10035 182 134 142

Why is she developing early-morning hypoglycemia?

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Insulin have different peaks and duration of action.

In this case you must note that animal insulin has a slower peak than human insulin

In this case this lady was advised to move the NPH evening dose to qhs --- which allowed the NPH peak to occur later

To cover the evening problem one should also increase the bedtime regular insulin --- in this case it was increased by 2 U

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A 56-year male has a history of type II diabetes for 10 years. He is currently on glipizde 20 mg BID and monitors his glucose twice a day. Over the last 2 weeks his fasting glucose were 157 – 278 (average 199); supper values were 145 – 292 (average 212).

CASE V

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Yesterday his fasting glucose was 234 and HgA1c was 14.8%

P.E.: B/P 142/90 P 72 Resp. 12height:72 inches weight: 212

The rest of the physical was normal with no evidence of retinopathy or neuropathy

What is the best option for this patient?

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Though this patient may not want to go on insulin …. We have no choice. He has unacceptably high

glucose valuesHgA1C confirms the fact that

insulin is needed

What do we start him on?

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Many clinicians start their type II that now require insulin on NPH or ultralente and add regular insulin later as needed to tune – up treatment.

After knowing what it would take to treat this patient --- you may then decide to use pre-mixed insulin.

Should this patient be hospitalized?No

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A 30-year female has no prior medical problems. As part of a routine obstetric care, she has a glucose screen at 24 weeks. She is given 50-g glucose to drink and a glucose level is obtained 1 hour later. Her results revealed a level of 156 mg (<140)

She is 64 inches tall and weighs 220What do you do know?

CASE VI

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You should now order a 3 hr GTT, which they give 100 g of glucose

Her results wereFasting: 112mg1hour: 183mg2hour: 172mg3hour: 147mg

What is your opinion?

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This patient has Gestational Diabetes. According to the National Diabetes Data Group – Dx is made if two or more values exceed the norm.

You should start this patient on a ADA 2000 calorie diet, give her a glucometer(she to take readings four times daily) and see her in a week.

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You see her back in a week and her glucose log reveal:

Fasting Lunch Supper Bedtime97 93 115 104112 101 107 99101 101 89 12293 105 102 111115 112 121 118

99 107 113 10596 101 117

109

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What should you do now?

This patient should be started on insulin. Though these level appear good; in pregnancy glucose levels are significantly lower.

Target glucose goals are:Fasting: 60 – 90Non-fasting (before breakfast) 60 – 105After meals: < 1202am – 6am: >60

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Since most of these patients seem to be insulin resistant it is recommended to start with 0.6U/kg/day. In this patient we would give 30 – 32 U NPH (or Longer acting) BID. She returns in four days with the following readings:

Fasting Lunch SupperBedtime

93 99 97 12286 100 98 11374 78 99 10768 90 79 112

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How is our patient doing?These reading show that we still have a

problem at bedtime. Therefore, we should add 2U of regular insulin in the evenings

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A 58 year-old man with a 12 year history of type 2 diabetes comes to your office because of an ulcer in his right foot. Physical exam reveals a 1-cm irregular ulceration over the right metatarsal head, surrounded by an area of black gangrenous skin. The patient is admitted and undergoes amputation of the right forefoot. Which of the following would have been most effective in preventing this complication?

A. Appropriate instructions on self-care of the feetB. Doppler exam of the lower extremitiesC. Nuerophysiologic and electromyographic studiesD. Local application of platelet-derived growth factorE. Prophylactic treatment with cholesterol-lowering

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Outpatient Diabetes1. Screening2. Current guidelines3. Use of oral agents4. Insulin regimens5. Gestational diabetes

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Who Should be Screened for Diabetes?45 years old; repeat q 3 yearsOverweight (BMI 25 kg/m2*) Physically inactiveHave a first-degree relative with diabetesHigh-risk ethnic population h/o GDM or baby >9 lbsHTNHyperlipidemiaPCOSOther sx of insulin resistance (acanthosis)h/o vascular disease

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Criteria for the diagnosis of diabetes

1. Symptoms of diabetes and a casual plasma glucose 200 mg/dl or..

2. FPG 126 mg/dl ( no caloric intake for at least 8 hr) or…3. BS 200 mg/dl after OGTT (2 hr after 75 gm glucose).

In the absence of unequivocal hyperglycemia, thesecriteria should be confirmed by repeat testing on a different day.

OGTT is not recommended for routine clinical use, but may be required in the evaluation of patients with IFG or when diabetes is still suspected despite a normal FPG as with the postpartum evaluation of women with GDM.

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Recommendations for Adults w/ DMA1C<7.0% (q 3 mo if uncontrolled; twice yr if at goal)Preprandial BS 80-110 mg/dl (60-90 if pregnant)Postprandial BS<140 mg/dl (<120 if pregnant)Blood pressure<130/80 mmHgLDL<100 mg/dl Triglycerides <150 mg/dl HDL>40 mg/dl Annual influenza vaccine Pneumococcal vaccine for adults with diabetesRevaccination is for individuals >64 if vaccine was

administered >5 years ago. Other indications for repeat vaccination include nephrotic syndrome, chronic renal disease, and other immunocompromised states, such as after transplantation.

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Health Maintainance

SMBG TID w/ DM1 and GDMBP each visitAnnual urinary microalbumin (<30ug/mg)Annual lipidsAnnual optho exam starting 3-5 yrs after

onset w/ DM1, and upon diagnosis in DM 2Visual foot exam each visit. Comprehensive

exam yearly (sensation, biomechanics, foot structure, vascular status and skin integrity)

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Mnemonic for Diabetes Office Visits

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Screening for Gestational DiabetesRisk assessment at first prenatal visitLow-risk status requires no glucose

testingAge <25 yearsWeight normal before pregnancyMember of an ethnic group with low

prevalence No known diabetes in first-degree

relativesNo history of abnormal glucose toleranceNo history of poor obstetric outcome

High risk features (obesity, h/o GDM, glycosuria, or FH) should undergo glucose testing as soon as possible

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Diagnosis of GDM FPG 126 mg/dl or a casual plasma glucose 200 mg/dl meets the

threshold for the diagnosis of diabetes (confirm on subsequent day)

High-risk women not found to have GDM at initial screening and average-risk women should be tested between 24 and 28 weeks of gestation. Testing should follow one of two approaches:

One-step approach: 100-g OGTT 95 mg/dl fasting 180 mg/dl at 1 h 155 mg/dl at 2 h and 140 mg/dl at 3 h. *Two or more of the plasma glucose values must be met or

exceeded for a positive diagnosis

Two-step approach: perform an initial screening by measuring the plasma or serum glucose concentration 1 h after a 50-g oral glucose load and perform a diagnostic 100-g OGTT on that subset of women exceeding 140 mg/dl 49

Oral Hypoglycemic Agents

Drug Class Mechanism of Action Side Effects

Sulfonylureas/ secretagogues ↑insulin secretion weight gain, hypoglycemia

Metformin ↓hepatic glucose output GI upset, lactic acidosis,

TZD’s ↑ peripheral glucose disposal

fluid retention, weight gain

Alpha-glucosidase inhibitors ↓ intestinal carbohydrate absorption

flatulence, diarrhea

*Each will lower A1c by 1-2% compared to placebo. When combined, efficacy typically is additive

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FDA-Approved Combination Therapies

Sulfonylurea + MetforminSulfonylurea + α-glucosidase

inhibitorsSulfonylurea + TZDMetformin + SecretagoguesMetformin + TZDInsulin + SulfonylureaInsulin + MetforminInsulin + TZD

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InsulinKnow the types of insulin and onsetKnow how to adjust insulinAll regimens include basal and bolus

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Adjusting Insulin• Make changes slowly, taking into account diet,

activity, stress

• Asses the effectiveness of insulin at its peak time of action

• Increase short/rapid insulin based on post-prandial readings

• Increase long-acting when BG high fasting or throughout day

• Inject into subcutaneous abdomen and rotate sites

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To ↓ pre-dinner BG…….↑AM intermediate-acting (e.g., NPH)

To ↓ fasting BG……….. ↑PM long/intermediate-acting insulin (e.g., glargine, NPH)

To ↓ pre-lunch BG……..↑AM short/rapid-acting insulin (e.g., regular, lispro, aspart)

To ↓ bedtime BG…...….↑PM short/rapid-acting insulin (regular, lispro, aspart)

Complications - acuteOnset within 24 hoursDiabetic ketoacidosis DKA

usually seen with Type 1Liver cannot metabolize and kidneys cannot

excreteHyperglycemia (>250)Ketosis (positive urine dipstick)Metabolic acidosis (HCO3 < 15; pH <7.3)May mimic “flu” Polyuria, polydipsia,

nausea, vomiting, abdominal pain, breath smells like booze.

DKADecreased insulin, high counterregulatory hormones (catecholamines, glucagon, GH, cortisol), leading to hyperglycemia, proteolysis, lipolysis & ketone production

Diagnostic Criteria hyperglycemia: glucose>250 mg/dl acidosis: pH <7.35; HCO3 < 18 ketosis (blood &/or urine)

Therapeutic Goals Improve circulating volume & tissue perfusion Identify precipitating factors FLUIDS restores intravascular volume, decreases

counterregulatory hormones and lowers glucose levels Reduce Gluc. & serum osmolarity: lytes q2, glucose q1 Clear ketones, fix electrolytes

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Complications - acuteHHNK - Hyperglycemic, hyperosmolar,

non-ketotic coma. Onset 2 days to 2 weeks.Osmolarity > 310Glucose > 600Usually seen with Type 2

exhibiting increasing insulin resistance, esp. after gorging on CHO.

Presents with marked dehydration and CNS SSx often mimicking a stroke.

Must correct S-L-O-W-L-Y to prevent cerebral edema. Watch K+ levels.

Complications - acuteHypoglycemia

Glucose < 50Causes:

Not enough to eat (or forgot)Too much insulin (or pills)Did not allow for exercise

CNS- confusion, delirium, comaAutonomic - hunger, anxiety, SWEATING,

tachycardia.If patient is conscious - give OJ. Otherwise

injection of glucagon, glucose gel in mouth, or 50% glucose by IV push.

Complications - long termNeuropathies - peripheral

Obstruction of vessels that supply nervesDemyelinationSensory

ParesthesiasDecreased sensitivity to pain, temperature and

light touch.Decreased proprioception and vibration sense.

MotorWeaknessAtrophy

Complications - long termNeuropathies - central and autonomic

orthostatic hypotensiongastrointestinal atonyatonic urinary bladderimpotenceimpairment of special senses

Complications - long termNephropathy

Glomerulosclerosis (arteriolonephrosclerosis)Thickened basement membrane in glomerulusCauses microalbuminuria (300 mg / day)Nodular scarring and destruction of

glomerulus. Kimmelstiel - Wilson lesion. Pathognomonic for diabetes mellitus.

Complications - long termRetinopathyLeading cause of blindness. DM has

increased risk for cataracts and glaucomaPathogenesis:

new vessels, fragile vessels, microaneurysms, hemorrhage. Followed by scarring and retinal detachment. Takes 20 years to develop. 100% of Type 1; 60% Type 2. Need to evaluate yearly. Retinal photos excellent.

Complications - long termFoot ulcers

Most common reason for hospitalizationDue to impaired circulation (PVD)

Abnormal glycoprotein thickens vessel wallChronic hypoxia (glycohgb has > affinity for O2)

Due to neuropathyCannot feel pain to prevent injury

Prevention: Wear good closed-toe shoes, white cotton socks, keep feet clean and dry, clip toenails straight across, inspect feet daily.

Complications - long term

InfectionsSkin: boils and abscessesUrinary tract infections - quickly spread to

kidneysOsteomyelitisInfected cuts of extremitiesPeridontal diseaseFinger and toenail fungus