A
A 52 year old woman comes to the office due to type 2 diabetes mellitus. She has had diabetes for the last 12 years, and her glycemic control has been deteriorating over the last few years despite good adherence to oral medications and dietary recommendations. The patient walks 2 miles a day and eats three balanced meals a day. Insulin glargine was started a year ago, when her hemoglobin a1c spiked to 10.5%; other medications include metformin and atorvastatin. She reports symptomatic hypoglycemia when she skips a meal.
Blood pressure is 114/74 and pulse is 78/min. BMI is 26. Physical exam is unremarkable.
Lab results are as follows:
Creatinine 1.0
Blood urea nitrogen 12
Glucose 100
Hemoglobin 14
Hemoglobin a1c 8.1%
The 30 day average, fasting, finger-stick blood glucose at home is 112 mg/dL.
What is the most appropriate next step in management of this patient?
What is check post-prandial glucoses?
A 50 year old woman comes to the office to follow up on type 2 diabetes mellitus. She was diagnosed 5 years ago and is treated with metformin at the maximal tolerated dose. She has been unable to lose weight despite following a healthy diet and exercising at least 5 times a week. She has no chronic complications of diabetes but has had recurrent episodes of vaginal candidiasis in the last 2 years. She works as a commercial bus driver for a tourist company and does not use tobacco, alcohol, or recreational drugs.
Vital signs are normal. BMI is 27. Physical exam is otherwise unremarkable. Serum creatinine is 1 mg/dL, fasting glucose is 156 mg/dL, and hemoglobin a1c is 7.9%. Six months ago, hemoglobin A1c was 7.2%.
When added to metformin, what medication is most appropriate for this patient?
What is a GLP-1 agonist?
A 72 year old man with a seven year history of type 2 diabetes mellitus comes to the physician because of pain in his feet. He has had numbness and tingling in his feet up to his ankles for 2 years. He recently began experiencing burning pain in both feet that extends to the mid-calf. This discomfort keeps him awake at night. He has no associated weakness. He has tried capsaicin ointment without relief.
On examination, there is decreased sensation to light touch and pinprick involving both feet. Ankle jerk reflex is absent bilaterally. Muscle strength in both lower extremities is normal with normal pulses. The remainder of the examination is within normal limits.
Laboratory data reveals a normal complete blood count, TSH, protein electrophoresis, and vitamin B12 levels. His HbA1c is 7.5%.
What would be the best initial therapeutic option for this patient?
What is gabapentin?
A 40 year old woman comes to the office due to diabetes mellitus. The patient has a history of type 2 diabetes mellitus treated with metformin for the past 3 years; home blood glucose levels are 90-130 mg/dL. She is adherent with her medication and recommended lifestyle measures and has lost significant weight since being diagnosed. Since she stopped her birth control medication 5 months ago, her menstrual periods have been unpredictable, prolonged, and heavy.
Temperature is 37.2 C, blood pressure is 118/68, and pulse is 94/min. Physical exam is unremarkable, except for mucosal pallor.
Lab results are as follows:
Hemoglobin 9
MCV 65
Platelets 320,000
Leukocytes 7500
Ferritin 12 (normal 12-150)
Hemoglobin A1c 7.6 (6 months ago: 6.8%)
Vitamin B12 480 (normal 180-914)
Iron supplementation is prescribed, and a referral to gynecology is made. In addition to continuing lifestyle changes, what is the next step for her diabetes management?
No changes, repeat a1c in 3 months?
A 78 year old woman is brought to the physician by her daughter due to intermittent dizziness, weakness, and confusion. The patient was seen for fever and dysuria 3 days ago and started on trimethoprim/sulfamethoxazole. Her other medical problems include type 2 diabetes mellitus, hypertension, and chronic kidney disease with a baseline serum creatinine of 1.3. Her chronic medications include hydrochlorothiazide, amlodipine, glyburide, atorvastatin, calcium, vitamin D, and alendronate.
Her temperature is 36.8 C, BP is 140/85 supine and 144/89 standing, pulse is 84/min, and respirations are 20/min. BMI is 19. There are no focal neurologic findings. Her Mini-Mental State Examination score is 24/30.
Lab results are as follows:
Leukocytes 7300
Sodium 136
Potassium 3.6
Creatinine 1.4
Glucose 70
Urinalysis
Protein - trace
Leukocyte esterase - trace
Nitrites - negative
Bacteria - few
White blood cells - 10-15/hpf
Red blood cells - 3-5/hpf
Casts - none
Hemoglobin A1c - 6.1%
What is the best next step in management of this patient?
What is discontinue glyburide?
A 45 year old woman comes to the office due to frequent urination and increasing fatigue over the last 2 weeks. She urinates large volumes and gets up twice each night to urinate. She also thinks that she may have lost weight during this time. The patient’s general health has been good with the exception of discoid lupus erythematosus, which causes her to experience occasional skin rashes and photosensitivity.
Blood pressure is 130/78 and pulse is 75/min. BMI is 21. Physical exam shows moist mucous membranes and scattered areas of skin depigmentation.
Fasting laboratory results are as follows:
Hematocrit 38%
Leukocytes 7,400
Sodium 134
Potassium 3.8
Chloride 98
Bicarbonate 24
Creatinine 1.2
Glucose 250
What additional test would most likely to establish the cause of this patient’s current condition?
What is glutamic acid decarboxylase (GAD65) antibodies?
A 35 year old man comes to the physician with complaints of dizziness and fatigue. These episodes occur immediately after he exercises on the treadmill for 30 minutes, and are accompanied by shaking and sweating. He has a history of type 1 diabetes mellitus and takes insulin glargine once daily at breakfast and pre-meal injections of insulin aspart. The patient checks his blood glucose every day prior to breakfast and pre-meal injections of insulin aspart. The patient checks his blood glucose every day prior to breakfast; the usual range is 110-140 mg/dL. His last hemoglobin a1c was 7.2%. He has no other medical problems.
What is the best next step in management of this patient?
What is extra food consumption before exercise?
A 25 year old man is brought to the emergency department due to acute onset dizziness, weakness, sweating, and confusion. The patient has a blood glucose level of 36 mg/dL, and his symptoms resolve with IV dextrose. He has no medical conditions and takes no medications. The patient has smoked intermittently for the last 5 years but does not use alcohol or illicit drugs. He is unemployed and lives with his parents. His father has type 2 diabetes mellitus and takes metformin and glyburide. His mother has hypertension treated with lisinopril.
Physical exam is unremarkable. The patient is hospitalized for observation. On the second day, he develops similar symptoms with a blood glucose level of 34; intravenous dextrose is again administered and his symptoms improve.
Lab results drawn during the second episode of hypoglycemia are as follows:
Serum chemistry:
Sodium 142
Potassium 4.2
Chloride 104
Bicarbonate 24
Blood urea nitrogen 10
Creatinine 0.8
Calcium 9.6
Glucose 36
Insulin 20 (normal 5-20)
C-peptide 0.67 (normal 0.17-0.66)
What is the best next step in evaluation of this patient?
What is oral hypoglycemic drug screen?
A 60 year old woman is transferred from an outpatient surgery facility to the ED due to diffuse abdominal pain, nausea, and vomiting. She developed these symptoms immediately following knee replacement surgery. The patient has type 2 diabetes mellitus, which is managed by sitagliptin, canagliflozin, and insulin glargine; the insulin was held the night before the procedure. Other medical conditions include hypertension and hyperlipidemia. Temperature is 36.7, BP is 130/70, pulse is 90/min, and respirations are 24/min. Oxygen saturation is 99% on room air. BMI is 34. Oral mucous membranes are dry but the remainder of the exam is unremarkable. Lab results are as follows:
Serum Chemistry:
Sodium - 136
Potassium - 3.6
Chloride - 102
Bicarbonate - 14
BUN - 24
Cr - 1.2
Ca - 8.8
Glucose - 160
Urinalysis:
Specific gravity 1.028
pH 5.4
Protein none
Blood negative
Glucose - present
Ketones - present
ABG:
pH - 7.28
PaO2 - 99
PaCO2 - 28
What is the most likely cause of this patient’s laboratory findings?
What is DKA?
A 23 year old woman with a 12 year history of Type 1 diabetes mellitus is hospitalized with diabetic ketoacidosis. On admission, her blood pressure is 80/60, pulse is 120/min, and respirations are 28/min. She weighs 60 kg (132 lb). Her oropharynx is very dry. Abdominal examination reveals diffuse tenderness without guarding or hepatosplenomegaly. The remainder of her examination is within normal limits.
Her clinical status improves significantly with IV fluids and insulin. In the first 2 hours, she receives 2 liters or isotonic saline, and this is later changes to ½ NS with potassium chloride (KCL) at 250 ml/hr. The patient is also receiving IV regular insulin infusion. Her blood glucose declines steadily to 188 mg/dL after 6 hours of treatment. She states that she is feeling better but still feels very nauseous.
Labs are as follows:
At presentation After 6 hours of treatment
Glucose 437 188
Sodium 132 142
Potassium 3.8 4.8
Chloride 99 108
Bicarbonate 13 17
BUN 25 12
Creatinine 1.4 0.7
Calcium 9.7 9.0
Ketones Moderate Trace
What is the most appropriate fluid management for this patient?
What is switch IV fluids to D5% 1/2 NS + KCL?
A 56 year old woman comes to the office for follow up for uncontrolled type 2 diabetes mellitus. Despite optimal lifestyle modifications and adherence with medications, her fasting blood glucose levels on home monitoring are 140-160. Her last hemoglobin a1c performed 4 weeks ago was 8.2%. Other medical conditions include hypertension and hyperlipidemia. Current medications include metformin, sitagliptin, amlodipine, hydrochlorothiazide, and simvastatin.
Blood pressure is 102/70 and pulse is 89/min. BMI is 34. Physical exam is unremarkable.
The patient does not want to start insulin or any other injectable medications. Adding canagliflozin to her current antidiabetic medication is considered.
What medication will most likely need dose adjustment or discontinuation if canagliflozin is added?
What is HCTZ?