Diabetes Mellitus

Chapter 41 Diabetes Mellitus




Clinical Case Problem 1: An 18-Year-Old Woman with Weight Loss and Feeling Poorly


Jackie is an 18-year-old woman with no previous chronic medical problems who comes to your office with a chief complaint of “feeling rotten.” She tells you that she has lost 15 pounds in the past 2   months and has had increasing thirst and urination. The patient has been feeling fatigued and nauseous, which has gotten especially worse in the past 2   days after she “caught a cold” that had been going around her family members.


On examination, the patient is well below the 5th percentile for weight. She looks thin and pale and seems a little sluggish, but she answers questions appropriately. Her nose is slightly congested, but otherwise her mucous membranes are dry. Her temperature is 99°F, blood pressure is 95/70   mm Hg, and pulse is 110 beats/minute. Respirations are deep at a rate of 30 breaths/minute, and her breath smells fruity. She has a few anterior cervical and axillary nodes, each measuring 1   cm. Lungs are clear to auscultation. Her abdomen is slightly tender. No other abnormalities are found.



Select the best answer to the following questions




1. What is the most likely diagnosis?


a. diabetes insipidus

b. early diabetic ketoacidosis

c. type 2 diabetes mellitus (DM) under poor glycemic control

d. alcohol abuse

e. mild type 1 DM

2. What is the most appropriate course of action?


a. advise Jackie to begin psychotherapy for an eating disorder with comorbid alcohol abuse and monitor her weight carefully during the next several months

b. treat Jackie’s cold symptomatically; have her increase fluids such as juice and soups; order some basic laboratory tests, such as basic metabolic panel, glycosylated hemoglobin (HbA1c), complete blood count (CBC), and urinalysis; see her in 1   week for follow-up and to discuss the results; and tell her to call if she is feeling worse

c. check an office finger-stick glucose level and a urine dipstick, and if your suspicions are confirmed, admit Jackie to the hospital for stabilization and management with possible consultation with an endocrinologist

d. treat her in the office with 1   L of intravenous (IV) normal saline to correct her dehydration and then send her home with a prescription for an antinausea agent. Tell her to continue to push fluids; order a CBC, chemistry screen, and urinalysis; and see her back in 3   days for follow-up and to discuss the results. She is to call if she is feeling worse.

e. start the patient on desmopressin (DDAVP), order some basic laboratory tests, have the patient push fluids, and refer her to an endocrinologist

She follows your advice and is subsequently seen in the emergency department. Laboratory data include serum glucose concentration of more than 600   mg/dL, ketones in the urine at 4+, and a serum sodium concentration of 128   mEq/L (mmol/L).



3. Initial treatment should include which of the following?


a. IV bicarbonate should be routinely used to correct the likely acidosis

b. high-volume IV isotonic or half-normal saline fluids and regular insulin by IV pump

c. subcutaneous insulin every 4 to 6 hours in a sliding scale, with laboratory tests every 12 hours until the situation is stabilized

d. give D5NS IV fluid until Jackie can reestablish adequate oral intake

e. avoid adding potassium to the IV (unless the patient is frankly hypokalemic) because these patients tend to have excess potassium levels

4. To minimize risk of cerebral edema, lowering of the blood glucose level should be done no faster than what rate per hour in a patient with severe hyperglycemia?


a. 10 mg/dL

b. 20 mg/dL

c. 30 mg/dL

d. 80 mg/dL

e. 200 mg/dL

5. Principles regarding evaluation of possible triggers that worsen the underlying condition include which of the following?


a. cocaine abuse can trigger this condition

b. infection rarely triggers acute worsening or control of this condition

c. it is clinically useful to repeat a chest radiograph in 24 to 48 hours, even if the initial one was normal, if one suspects pneumonia

d. a and c

e. because of changes induced by the underlying disease, it is not useful to perform urinalysis and culture in searching for a trigger for this condition

6. All except which of the following are true regarding type 1 DM?


a. it is associated with other autoimmune disorders

b. age at onset is usually before 30 years

c. islet cell antibodies are found in approximately 90% of cases

d. suboptimal vitamin D nutrition is associated with increased incidence

e. there is approximately a 90% concordance in monozygotic twins for this type of DM

7. The Diabetes Control and Complications trial and other landmark trials clearly demonstrated which of the following?


a. myocardial infarction and stroke were markedly improved in patients with tight glycemic control

b. once-daily combined insulin or oral medications were adequate for tight glycemic control in most patients

c. primary care physicians can easily accomplish tight glycemic control in their type 1 diabetic patients

d. tight glycemic control tends to lead to better weight control

e. intensive glycemic control of type 1 DM decreases microvascular complications

8. True statements regarding macrovascular complications in type 1 or type 2 DM include all except which of the following?


a. low-density lipoprotein (LDL) level should be kept at least < 2.6   mmol/L (100   mg/dL), and probably < 70   mg/dL, if the patient has confirmed vascular disease

b. blood pressure goal is < 130/80   mm Hg

c. treatment with insulin or sulfonylureas has clearly been shown to worsen macrovascular disease by worsening of hyperinsulinemia

d. strict blood pressure control is more beneficial than tight glycemic control in reducing macrovascular complications

e. virtually all type 2 diabetics older than 40   years who do not have a contraindication to statins should be receiving them

9. Which of the following statements regarding diabetic ketoacidosis (DKA) management is (are) true?


a. serum sodium level (serum chloride    +    bicarbonate) is usually elevated

b. DKA occurs only in type 1 DM

c. in a patient with a serum potassium level of 4.5   mEq/L (mmol/L), there is likely to be total body potassium depletion that needs replacement

d. a and c

e. DKA usually develops during a period of 1 or 2 weeks

10. Regarding fluid and electrolyte management in DKA, all except which of the following are true?


a. fluid deficits are often on the order of 6 to 8 L

b. the initial fluid replacement should generally be normal (0.9%) saline unless there is severe hypernatremia

c. in the otherwise healthy adult with DKA, a reasonable rate of infusion generally needed for the first 3 hours of treating full DKA is 150   mL/hour

d. potassium level should be monitored frequently (every hour at first and then every 2 to 4 hours) during the initial treatment phase of DKA

e. in a patient with acute DKA but otherwise normal organ function, 20 to 40   mEq/L of potassium chloride can be added to the IV fluid if the serum potassium concentration is 4 to 5   mEq/L


Clinical Case Problem 2: A 35-Year-Old Man Who Comes in for a Routine Periodic Health Examination


Mr. Couchpo is a 35-year-old man who comes to your office for a routine health examination. He works as a computer programmer, is recently married, and came in because, as he said, “I want to make sure i am healthy.” The following are other key elements of the history and physical:



Feels fine, except occasionally a little “sluggish” after a long day at the office.


No past medical history.


Family history: His mother and an older brother have type 2 DM, both with onset in their 40s, and his father has had hypertension since his 30s. His father developed coronary artery disease in his 50s.


Patient states that his diet is “regular.”


Exercise: He used to play varsity soccer in college. Now he plays golf occasionally on weekends in the warmer months when he can get away from his job. He likes to walk when he can, but he feels that he doesn’t have the time.


Stress level: “High”—many deadlines and long hours at work; commutes into the city by train.


Physical examination: height, 5 feet, 10 inches; weight, 195 pounds; body mass index, 28; waist circumference, 43 inches; blood pressure, 135/88   mm Hg; pulse, 76 beats/minute. Physical examination is otherwise unremarkable.


Screening laboratory tests: fasting blood glucose, 115   mg/dL; C-reactive protein, 4.3   mg/L; total cholesterol, 230   mg/dL; high-density lipoprotein (HDL), 35   mg/dL; LDL, 125   mg/dL; and triglycerides, 180   mg/dL.


A 3-day dietary diary for this patient is summarized as follows:



Breakfast: usually a mug of coffee and a Danish or bagel


Midmorning: often snacks on treats or pastries brought in by colleagues


Lunch: has a 1-hour lunch break during the workday and usually goes out to a local diner for a sandwich, such as ham and cheese on rye or a burger, with a soft drink or coffee


Dinner: starch such as mashed potatoes with butter or French fries, a serving of green beans or other vegetable, and an 8- to 10-ounce piece of chicken or steak


Use this diet diary to answer questions 12 through 17.



11. Correct statements about this symptom complex include all except which of the following?


a. this syndrome affects approximately one fifth of U.S. adults and is increasing in prevalence

b. the elevated C-reactive protein is an added risk factor that the patient will progress to frank type 2 DM and coronary artery disease

c. body mass index is a better predictor of risk for progression to related chronic diseases than is waist circumference

d. lifestyle issues superimposed on a genetic distribution are the main cause

e. other associated disorders of this syndrome include chronic kidney disease and fatty liver

12. Choose the best answer regarding this patient’s carbohydrate sources.


a. the patient tends to eat high glycemic index (GI) and glycemic load foods with a low nutrient/calorie ratio that are likely to worsen his overweight, C-reactive protein, dyslipidemia, and vascular disease risk

b. most whole-wheat commercial breads have a low GI

c. avoiding commercial flour products, such as by switching to sprouted grain flourless breads, and substituting nonwhite starchy vegetables, such a squash or yams, would much improve the quality of his carbohydrate intake

d. a and c

e. carrots have a high glycemic load and should be avoided by those with metabolic syndrome or diabetes

13. Choose the best answer regarding this patient’s calorie intake.


a. total calorie balance is more important than whether the calories come from fat, carbohydrate, or protein in determining body weight

b. the calorie (energy) density of foods has not been demonstrated to be important for weight control

c. a redistribution of calories, with more at breakfast and less at dinner, would likely benefit the patient, such as by decreasing midmorning snacking

d. a and c

e. adequate fiber in the diet to improve calorie balance is 10 to 15   g/day

14. Choose the best answer regarding the fat sources.


a. different types of fats are basically equal in their effect on health—it is the total fat that counts

b. the patient needs to increase polyunsaturated seed oils, such as corn, sunflower, or safflower oil

c. substituting stick margarine containing partially hydrogenated corn or soybean oil for the butter he currently uses would be a good first step in improving the quality of fats in his diet

d. the balance between omega-3 and omega-6 fatty acids is likely to be distorted, with excess saturated and trans–fatty acid intake

e. flax and walnut oils would be excellent cooking and sautéing oils

15. Choose the best answer regarding the protein sources in his diet.


a. total protein is likely to be excessive and may, over time, lead to impaired renal function

b. substituting a protein powder diet drink for a meal would be an effective way to help him lose weight and to build muscle

c. emphasizing plant sources of protein, such as those made from legumes, would improve multiple aspects of his diet

d. a and c

e. a high-protein, low-carbohydrate diet (with protein > 2   g/kg body weight/day and total carbohydrates < 130   g/day), when combined with regular vigorous aerobic and muscle strengthening exercises, is an excellent strategy for the patient with glucose intolerance or DM

16. Choose the best answer regarding this patient’s vegetable and fruit intake.


a. adding iceberg lettuce and a slice of tomato to his sandwich, switching from soft drinks to fruit juice, and snacking on dried fruit rather than pastries would be a major step in improving his vegetable and fruit intake

b. recommending a standard daily multivitamin/multimineral supplement would be the best strategy—it has all the necessary nutrients found in fruit and vegetables and would be easier for the patient to implement

c. although fruit and vegetable intake is slightly low, there is no credible evidence that increasing it leads to better health outcomes

d. the patient needs to gradually increase his intake to three to five servings of vegetables, ideally with at least one a dark leafy green, and two or three servings of whole fruit per day

e. recommending a nutraceutical food bar with extra antioxidants and vitamins is a more practical way to help this patient attain the equivalent nutrition found in fruit and vegetables

17. Choose the best answer regarding how this patient might handle sweets and sugar intake.


a. it is critical to ban sugar from the diet of patients with DM and metabolic syndrome because it is a main cause of these disorders and contains empty calories that deplete the body of necessary nutrients

b. because studies do not show worsening of glycemic control from sugar, there is no reason to limit it in patients with metabolic syndrome or DM

c. establishing a reasonable quota and teaching the patient to mindfully and slowly savor sweets and treats can naturally limit them so that they do not derail the patient’s treatment in the context of a balanced whole foods diet

d. switching from table sugar (sucrose) to high-fructose corn syrup sweeteners has been shown to decrease sweet craving and associated overeating and to lower triglyceride levels

e. whole fruit in general should be avoided in patients with metabolic syndrome and DM because the high fructose content has been shown to bypass normal satiety mechanisms and to worsen glycemic control

18. Regarding this patient’s exercise habits, assuming he has been medically cleared and can safely exercise, what would be the best advice?


a. encourage the patient to exercise vigorously each weekend by jogging or swimming

b. get a stationary bike and try to do 30 minutes of biking and 30 minutes of calisthenics each evening

c. do not emphasize the need for exercise; although it is often recommended, there is little evidence that regular exercise improves health outcomes

d. assuming that a suitable area to do so is available, encourage him to “brown bag” a lunch and then go for a 30- to 45-minute walk for the remainder of his lunchtime during the workweek; on weekends, after 2 or 3   months of reconditioning, take up a sport or activity that he finds fun and meaningful, such as amateur soccer

e. direct the patient to join a semiprofessional traveling soccer league because he already has skills in soccer from his college years, and people tend to continue activities they are good at

19. Which of the following statements regarding type 2 DM is false?


a. impaired glucose tolerance is defined by a fasting blood glucose in the range of 100 to 125   mg/dL

b. elevated fasting blood glucose concentration provides the first evidence of loss of glucose control

c. lifestyle changes of increased physical activity and improved nutrition can decrease the risk for development of DM by 50% or more

d. metformin may be effective in decreasing the risk for development of diabetes

e. lifestyle changes are more effective than treatment with metformin

20. Choose the best answer regarding the endocannabinoid system.


a. a collection of weight loss medicines that work at the level of the hypothalamic-pituitary-adrenal axis

b. a newly discovered and conceptualized endocrine system involved in stress recovery, homeostasis, and energy balance including food intake

c. a new weight loss system using plant-derived medicines

d. a new approach to treating metabolic syndrome and early DM using a complex herbal system that is unproven clinically but is popular

e. a weight loss system that uses modulation of endogenous cannabinoid receptors


Clinical Case Problem 3: A 45-Year-Old African American Woman with Type 2 DM Diagnosed 6 Months Ago


Mrs. Jones is a 45-year-old asymptomatic obese African American woman who comes to your office for the first time for follow-up of her DM. She has transferred to you from her primary care physician out of state and was diagnosed with type 2 DM 6   months ago. She states that her previous physician started her on glyburide 5   mg daily before breakfast, told her to “cut out sugar and heavy foods,” and advised her to try to walk for 20 minutes three times a week. She is taking no other prescription medications, but she does take over-the-counter ibuprofen, a few pills a day, for knee osteoarthritis. She also takes chromium picolinate 200 μg/day and α-lipoic acid 600   mg/day because she heard from a friend at church that it helps diabetes. He also gave her a 2000-calorie American Diabetes Association (ADA) diet leaflet to follow. She has run out of test strips, but the last time she checked her fasting blood glucose level 2   months ago, it was 160, which is approximately average for her. She brings the results of his office records and most recent laboratory test results from 6   months ago, which show the following:



Past medical history: positive for mild hypertension (range, 130/85 to 140/90   mm Hg at various office visits), hyperlipidemia (fasting total cholesterol, 230   mg/dL; LDL, 125   mg/dL; HDL, 38   mg/dL; triglycerides, 180   mg/dL), obesity (weight, 190 pounds; height, 5 feet, 8 inches), mild osteoarthritis of knees.


No known drug allergies.


Health insurance: Has a basic plan that covers visits but no prescription plan.


Family history: Positive for DM in her mother and older sister; hypertension and coronary artery disease in her mother, father, older sister, and younger brother.


Social history: Negative for smoking, alcohol, or illicit drug abuse. Married with three adult children. Works as a cashier at a local supermarket. Recreation: likes to socialize and dance.


Laboratory test results (from 6   months ago): basic metabolic profile: blood urea nitrogen/creatinine ratio, 15/1.1; estimated glomerular filtration rate, 67   mL/min per 1.73   m2; electrolyte values, normal; albumin, 3.5   g/dL; CBC, within normal limits; HbA1c, 8.2%.


Her examination is consistent with the history and laboratory findings.



21. Choose the best answer regarding Mrs. Jones’s overall health status.


a. her diabetes, hypertension, weight, and lipids are inadequately controlled, and she would benefit from a multidisciplinary approach to resolution of these issues

b. her diabetes, weight, and lipids need better control, but hypertension is adequately controlled for her age

c. Mrs. Jones, as an African American, statistically has a poorer prognosis for her diabetes

d. instructing her to continue to follow her 2000-calorie ADA diet brochure will probably resolve her medical problems

e. a and c

22. Initial management at your first visit should include all except which of the following?


a. refill her medications and glucometer supplies

b. order an HbA1c, chemistry screen, urine dipstick and microalbumin/creatinine ratio, and fasting lipid panel

c. start her on regular insulin three times daily before meals

d. give her diet and blood glucose diaries to return within 1 or 2 weeks

e. referral to an ophthalmologist

23. When Mrs. Jones returns for her next visit, her HbA1c level is 8.8%. What lifestyle changes would you suggest next?


a. encourage her to continue her walks, perhaps increasing these to four times a week if she is comfortable with this

b. have her start jogging for 45 minutes, 5   days a week to maximize weight loss and metabolic control

c. review her diet and blood glucose diary and arrange for her to receive ongoing dietary instruction, with a goal of losing 1 pound per week during the next 3 months

d. a and c

e. because she seemed to have failed to lose weight on the 2000-calorie ADA diet, give her an 1800-calorie ADA diet brochure to follow instead

24. Mrs. Jones does lose 10 pounds during several months of coaching, but her repeated HbA1c level is 7.5%. If you wanted to add a second medication to her glyburide, what would you choose?


a. add metformin to her regimen, starting at 1   g twice daily

b. add pioglitazone (Actos)

c. add metformin, but start at 500   mg or 850   mg daily

d. add regular insulin given three times daily before meals

e. add nateglinide (Starlix) three times daily before meals

25. Which of the following statements regarding type 2 DM is true?


a. most patients present to their physicians with symptoms directly related to their diabetes

b. most patients are essentially asymptomatic at diagnosis (apart from being obese)

c. most patients can control the DM by diet and exercise

d. most patients will not manifest complications

e. most patients are younger than 40 years

26. Choose the best answer regarding the patient’s use of chromium for DM.


a. it appears to facilitate uptake of glucose into cells

b. chromium natural sources include brewer’s yeast and whole grains, but supplementation is probably required to achieve a clinically significant effect

c. there is level B (moderate) scientific evidence of efficacy in at least some subpopulations of diabetics, although some high-quality studies show no benefit

d. a, b, and c

e. there is no credible scientific evidence that chromium supplements improve type 2 DM control

27. Choose the best answer regarding the patient’s use of α-lipoic acid.


a. adding a teaspoon of this low pH supplement to each meal of the day lowers the glycemic load of the meal, but it can lead to hypoglycemia if medications are not adjusted

b. this supplement is a “fat burner” that is popular for weight loss

c. this potent antioxidant enhances glucose uptake, helps prevent glycosylation, and appears to help diabetic neuropathy in some studies, although it can induce thiamine deficiency if this vitamin is not supplemented

d. this supplement has been shown in multicenter trials to reduce macular degeneration

e. α-lipoic acid is a fad supplement with no credible scientific basis to support its use in diabetics

28. What is the best way to manage Mrs. Jones’s hyperlipidemia?


a. prescribe a fibric acid derivative such as gemfibrozil

b. assuming she has no contraindications, prescribe her a “statin” while continuing diet and exercise efforts

c. prudent diet and exercise will likely be sufficient, provided she can lower her LDL level to less than 130   mg/dL and raise her HDL level to more than 35   mg/dL within 6 months

d. better glycemic control will likely improve her lipid profile sufficiently

e. adding a 500-mg fish oil capsule daily will likely normalize her triglycerides

29. Initial steps in helping Mrs. Jones manage her mild knee osteoarthritis include all except which of the following?


a. tell her to try to limit her ibuprofen use to when she has flare-ups of her arthritis

b. add glucosamine sulfate

c. even modest weight loss may improve her symptoms

d. a regular program of knee muscle strengthening will likely help her symptoms

Related posts:

  1. Alcohol
  2. Pancreatic Carcinoma
  3. Urticaria Angioneurotic Edema
  4. Illustrated Review

Stay updated, free articles. Join our Telegram channel
Tags:
Oct 1, 2016 | Posted by in GENERAL SURGERY | Comments Off on Diabetes Mellitus

Full access? Get Clinical Tree
Get Clinical Tree app for offline access