Chapter 41 Diabetes Mellitus
Clinical Case Problem 1: An 18-Year-Old Woman with Weight Loss and Feeling Poorly
Select the best answer to the following questions
1. What is the most likely diagnosis?
2. What is the most appropriate course of action?
3. Initial treatment should include which of the following?
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?
5. Principles regarding evaluation of possible triggers that worsen the underlying condition include which of the following?
6. All except which of the following are true regarding type 1 DM?
7. The Diabetes Control and Complications trial and other landmark trials clearly demonstrated which of the following?
8. True statements regarding macrovascular complications in type 1 or type 2 DM include all except which of the following?
9. Which of the following statements regarding diabetic ketoacidosis (DKA) management is (are) true?
10. Regarding fluid and electrolyte management in DKA, all except which of the following are true?
Clinical Case Problem 2: A 35-Year-Old Man Who Comes in for a Routine Periodic Health Examination
Feels fine, except occasionally a little “sluggish” after a long day at the office.
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?
12. Choose the best answer regarding this patient’s carbohydrate sources.
13. Choose the best answer regarding this patient’s calorie intake.
14. Choose the best answer regarding the fat sources.
15. Choose the best answer regarding the protein sources in his diet.
16. Choose the best answer regarding this patient’s vegetable and fruit intake.
17. Choose the best answer regarding how this patient might handle sweets and sugar intake.
18. Regarding this patient’s exercise habits, assuming he has been medically cleared and can safely exercise, what would be the best advice?
19. Which of the following statements regarding type 2 DM is false?
20. Choose the best answer regarding the endocannabinoid system.
Clinical Case Problem 3: A 45-Year-Old African American Woman with Type 2 DM Diagnosed 6 Months Ago
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.
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.
22. Initial management at your first visit should include all except which of the following?
23. When Mrs. Jones returns for her next visit, her HbA1c level is 8.8%. What lifestyle changes would you suggest next?
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?
25. Which of the following statements regarding type 2 DM is true?
26. Choose the best answer regarding the patient’s use of chromium for DM.
27. Choose the best answer regarding the patient’s use of α-lipoic acid.
28. What is the best way to manage Mrs. Jones’s hyperlipidemia?
29. Initial steps in helping Mrs. Jones manage her mild knee osteoarthritis include all except which of the following?