Diabetes Mellitus Cases

1. R.P. is a 43-year-old woman visiting the drop-in clinic to obtain a routine physical examination for her new job. Her past medical history is significant for GDM. She was told during her two pregnancies (last child born 3 years ago) that she had “borderline diabetes,” which resolved each time after giving birth. Her family history is significant for type 2 diabetes (mother, maternal grandmother, older first cousin), hypertension, and CVD. She appears black and when asked identifies herself as African American. She denies tobacco or alcohol use. She states she tries to walk 15 minutes twice a week. Physical examination is significant for moderate central obesity (5 feet 4 inches; 160 lbs; BMI, 30.2 kg/m2) and BP 145/85 mmHg. R.P. denies any symptoms of polyphagia, polyuria, or lethargy. Upon checking her electronic medical record, she has documented hypertension and an FPG value of 119 mg/dL, measured 2 months prior. What features of R.P.’s history and examination are consistent with an increased risk of developing type 2 diabetes?

1- age 2- ethnicity 3- weight 4- family history of diabetes 5- history of GDM 6- documented IFG. 7- hypertension.

2. The physician orders another FPG for R. P 2. The physician orders another FPG for R.P., which comes back at 122 mg/dL. How should R.P. be managed at this time? 1- R.P. should be educated about her risk for developing type 2 diabetes. 2- lifestyle modifications (MNT, physical activity) that will help her to lose weight, improve her cardiovascular health, and decrease her risk for developing type 2 diabetes. Treatment There are three major components to the treatment of diabetes: 1- diet, 2- drugs (insulin and oral hypoglycemic agents, and other antihyperglycemic agents) 3- exercise.

Which findings are consistent with this diagnosis in A.H.? 3. A.H., a slender, 18-year-old woman who was recently discharged from the hospital for severe dehydration and mild ketoacidosis is referred to the Diabetes Clinic from the University Student Health Service (no records available). A fasting and a random plasma glucose ordered subsequently were 190 mg/dL (normal, 70–100) and 250mg/dL (normal, 140 to<200).Approximately 4weeks before she was hospitalized, A.H. had moved across the country to attend college—her first time away from home. In retrospect, she remembers that she had symptoms of polydipsia, nocturia (six times a night), fatigue, and a 12-lb weight loss over this period,which she attributed to the anxiety associated with her move away from home and adjustment to her new environment. Her medical history is remarkable for recurrent upper respiratory infections and three cases of vaginal moniliasis over the past 6 months. Her family history is negative for diabetes, and she takes no medications. Physical examination iswithin normal limits. Sheweighs 50 kg and is 5 feet 4 inches tall. Laboratory results are as follows: FPG, 280 mg/dL (normal, <100); HbA1c, 14%(normal, 4%–6%); and trace urine ketones as measured by Keto-Diastix (normal, negative). On the basis of her history and laboratory findings, the presumptive diagnosis is type 1 diabetes. Which findings are consistent with this diagnosis in A.H.?

1-She has classic symptoms of the disease (polyuria, polydipsia, weight loss, glucosuria, fatigue, recurrent infections) 2-a random plasma glucose above 200 mg/dL 3- FPG of 126 mg/dL or higher on at least two occasions4 4- elevated HbA1c 5- Features of A.H.’s history that are consistent with type 1 diabetes, in particular, include the relatively acute onset of symptoms in association with a major life event (moving away from home), 6- ketones in the urine, 7- negative family history 8- a relatively young age at onset

4. A. H. will be started on insulin therapy on this visit 4. A.H. will be started on insulin therapy on this visit. What are the goals of therapy? Will normoglycemia prevent the development or progression of long-term complications? The goal of diabetes management is the prevention of acute and chronic complications The ADA recommends an HbA1c goal of less than 7% for patients in general In summary, A.H. is a patient newly diagnosed with type 1 diabetes who has not yet developed any signs or symptoms of long-term complications. Therefore, she is an ideal candidate for basal-bolus insulin therapy and, if she is willing and motivated, normoglycemia with rare hypoglycemic reactions is a reasonable long-term goal. This goal should be achieved gradually over several months with insulin therapy, diet, education, and strong clinical support. A desirable goal is an HbA1c value as close to the normal range as possible with rare hypoglycemic reactions

5. What methods of insulin administration are available to achieve optimal glucose control? Two methods have been used to achieve a similar pattern of insulin release: (a) insulin pump therapy (previously referred to as “continuous subcutaneous infusion of insulin”) (b) basal-bolus insulin regimens consisting of once to twice daily doses of basal insulin coupled with pre-meal doses of rapid or short-acting insulin.

6. How can insulin injections be administered to A. H 6. How can insulin injections be administered to A.H. in a way that mimics the physiological release of insulin from the pancreas? Endocrinologists have developed a variety of insulin regimens that are intended to mimic the release of insulin from the pancreas. Examples of these are displayed in and illustrated in Figure 50-4. A total daily dose of insulin is estimated empirically (e.g., 0.5 unit/kg/day) or according to guidelines listed in Table 50-11. The total daily dose of insulin then is split into several doses. In general, the basal dose comprises approximately 50% of the total daily dose.

7. Should A.H. use an insulin pump or multiple insulin injections? Patients with type 1 diabetes should be placed on a basal-bolus insulin regimen. The ADA recommends that the use of insulin pumps be limited to highly motivated individuals under the guidance of a health care team trained and knowledgeable in their use. she should be initiated on a basal-bolus SC insulin therapy. Once she has acquired these skills, she may be considered for pump therapy

8. How should multiple-dose insulin therapy be initiated in A.H.? During the initial visit, 1- A.H. needs to learn how to inject her insulin 2- how to test her blood glucose 3- how and when to test her urine for ketones 4- how to recognize and treat hypoglycemia A reasonable first approach for A.H. is to provide a total daily dose of insulin of 24 units (∼0.5 unit/kg). Because 50% of the daily dose should be given as basal insulin with the remainder given as rapid-acting insulin divided into three doses, A.H. would take the following: 12 units of insulin glargine (Lantus) once daily (morning or bedtime) with 4 units of insulin aspart (Novolog) given with each meal. An alternative regimen using NPH would be 8 units of NPH in the morning with 8 units of Novolog, 4 units of Novolog with dinner, and 4 units of NPH at bedtime. Caveat: As A.H.’s glucose concentration returns to normal, glucose toxicity will recede and she may require less insulin