questions 17

Diabetes Mellitus

Topic updated on 10/20/17 12:06pm

Snap Shot
  • A 56-year-old woman comes to your clinic for her annual physical exam. She reports increased urinary frequency and thirst but is otherwise feeling generally well. She is obese, does not exercise, and regularly eats fried foods. A random blood glucose level is 223 ml/dL, and her hemoglobin A1c is 9.2.
  • Type 1 diabetes (formerly Insulin Dependent Diabetes Mellitus or Juvenile Diabetes)
    • immune mediated destruction of beta cells and loss of insulin production by pancreas
      • Hypoparathyroid may also have antibodies against insulin
    • 5-10% of diabetes cases
    • classically occurs in thin people younger than 30
      • most commonly presents before age 20
      • NOT related to obesity
    • sudden onset (after about 90% beta cells destroyed)
    • uncommon to have a family history
    • associated with HLA DR3 and DR4
      • also seen concurrently with other autoimmune diseases (e.g. Graves', Hashimoto's, ect.)
    • severe insulin deficiency; these patients require exogenous insulin 
  • Type 2 diabetes
    • insulin insensitivity (resistance) in peripheral organs requiring increased insulin production to where the pancreas cannot produce enough insulin to keep up 
      • insulin levels are usually normal to high but may diminish after the disease is present for many years
    • gradual onset
    • 90%+ of diabetes cases
    • typically in older individuals, though increasingly found in children with obesity
    • common to have a family history
    • associated with obesity (greatest risk factor)
    • amyloid deposition in β-cells
  • Complications are due to long-term poor glycemic control
    • if a diabetic maintains glucose in the normal range, there is nothing pathological about the disease
    • damage mediated by
      • non-enzymatic glycosylation which makes vessels more permeable
      • increased synthesis of type IV collagen in basement membrane
      • osmotic damage secondary to glucose conversion to sorbitol by aldose reductase
  • Symptoms 
    • Type I
      • polyuria
      • polydipsia
      • polyphagia
      • fatigue
      • weight loss
      • Diabetic ketoacidosis (DKA) - is commonly the initial presentation
        • the symptoms of type I diabetes mellitus often develop rapidly (days to weeks) and often manifest after a preceding illness
      • hypoglycemia
        • sympathetic and parasympathetic nervous activation
    • Type II
      • polyuria
      • polydipsia
      • polyphagia
      • fatigue
      • weight loss (however, these patients are typically overweight)
      • blurry vision
      • candidal infections (especially vaginitis)
      • neuropathy - numbness, tingling of hands and/or feet
      • hyperosmolar nonketotic coma (link)
      • hypoglycemia
    • Consider the time-course and natural history of disease
      • Type I diabetics often present in acute manner shortly after developing the disease - they have not had the disease long enough to develop many of the long-term macrovascular and microvascular disease complications
      • Type 2 diabetics may have had underlying disease for many years (5-10+ years) and may often present initially with profound neuropathy, retinopathy, nephropathy or other complications, as discussed below
  • Signs/Physical Exam Findings 
    • Physical examination in diabetic patients should focus on identifying potential complications of the disease:
    • Type II:
      • Foot examination - pulses (may be diminshed), signs of ulcerations/infections 
      • Vascular disease examination - Coronary artery disease and peripheral vascular disease - cold, hairless lower extremities with diminished pulses
        • hypertension is commonly coexistent
        • orthostatic hypotension may result from autonomic neuropathy in advanced disease
      • Neurologic examination - diminished sensation to touch or temperature; loss of proprioception; loss of ankle deep tendon reflexes
      • Fundoscopic (eye) examination - hemorrhages, exudates, neovascularization 
      • Infection - fungal infections - vaginitis or thrush common
      • Skin - acanthosis nigricans (neck or axilla) 
    • Type I:
      • In new cases of disease, the above complications are unlikely to be detectable on physical exam due to the short time-course of the disease to-date; however, they should monitored in the future
      • DKA presents with: Kussmaul respirations, dehydration, hypotension, altered mental status
  • Diagnosis of DM is made by one of the following:
    • random blood glucose level of > 200mg/dL AND diabetic symptoms
    • 2 separate fasting glucose levels of > 126 mg/dL
    • 2 hour postprandial glucose level (glucose tolerance test) of > 200 mg/dL
    • Hemoglobin A1c of > 6.5% 
  • Monitoring/evaluation of glycemic control
    • hemoglobin A1c
      • represents mean glucose level from previous 8-12 weeks (approx lifespan of an RBC)
      • useful to gauge the 'big-picture' overall efficacy of glucose control in patients (either Type 1 or Type 2) to assess the need for changes in medication/insulin levels
      • Treatment goal of A1c < 7.0%
    • "finger-stick" blood glucose monitoring
      • useful for insulin-dependent (either type 1 or 2) diabetics to monitor their glucose control and adjust insulin doses according to variations in diet or activity
      • Treatment goals: < 130 mg/dL fasting and < 180 mg/dL peak postprandial 
  • See Diabetes pharamacology (link)
    • Recall that diet and exercise should always be a part of any management plan for type II diabetics
    • Strict glycemic control is the best treatment for diabetes (type I or type II), as it minimizes the incidence and severity of complications that may develop
  • Complication treatment:
    • Macrovascular disease (CAD, PVD, stroke) - RISK FACTOR REDUCTION - lipid control (statins), blood pressure control, smoking cessation, daily aspirin, regular exercise, improved diet
      • Target blood pressure (130/80) and LDL (<100) is lower in diabetics than in the nondiabetic population
    • peripheral neuropathy
      • duloxetine (serotonin/norepinephrine reputake inhibitor), amitriptyline, pregabalin, NSAIDs
    • diabetic kidney disease
      • ACE-inhibitor or ARB - good BP control slows progression of proteinuria and decrease in GFR  
    • gastroparesis 
      • metoclopramide, erythromycin 
      • exercise, dietary modification
    • Retinopathy
      • ophthalmologist referal for regular eye-exams and photocoagulation or other procedure as needed 
    • Foot ulcers
      • regular foot exams and care by a podiatrist; amputation as final resort in an infected limb
Prognosis, Prevention, and Complications
  • Macrovascular complications - accelerated atheroscelrosis
    • Coronary artery disease (CAD) - leading to MI or CHF
      • 4 times more likely in DM patients
      • Coronary artery disease is the leading cause of death in diabetic patients
    • Peripheral vascular disease (PVD)
    • Stroke
  • Microvascular complication
    • nephropathy
      • arteriosclerosis leading to hypertension
      • thickening of the glomerular basement membrane 
      • nodular glomerular sclerosis - hyaline deposited in glomerulus -- this is pathognomonic for a diagnosis of diabetes
        • Kimmelstiel-Wilson nodules
      • diffuse glomerular sclerosis
      • basement membrane thickening
      • progressive proteinuria as a result of an increased GFR 
        • screen for microalbuminuria 
        • if protein comes up as positive on a urine dipstick, the patient has already progressed from microalbuminuria (30-300 mg/24 h) to outright proteinuria
      • chronic renal failure (ESRD)
    • ocular
      • retinopathy
        • proliferative changes involve neovascularization of retina
        • nonproliferative changes involve microaneurysms
      • cataracts
      • glaucoma
      • blindness
    • peripheral neuropathy  
      • numbness and paresthesias
      • burning sensation
      • ↓ deep tendon reflexes
      • ↓ vibration and temperature sense
      • can mask the symptoms of PVD or of developing ulceration/infection of foot
    • central neuropathy
      • 3rd nerve palsy sparing the pupil - pain, double vision, ptosis; cannot ADduct the eye
      • also CN IV and VI
    • autonomic dysfunction
      • impotence
      • neurogenic bladder - urinary retention and incontinence
      • gastroparesis  
        • nausea & vomiting, early satiety
        • should be evaluated with upper endoscopy to rule out obstructing mass 
        • confirm diagnsis with gastric emptying study
      • GI discomfort - constipation and/or diarrhea
      • postural hypotension
    • skin dysfunction
      • necrobiosis lipoidica diabeticorum
        • yellow plaques on legs
    • diabetic foot 
      • combination of vascular and nerve disease
        • largest risk factor = presence of neuropathy 
      • higher likelihood of infection, pressure ulcers
      • can lead to amputation
    • infectious disease - increased susceptibility to infection
      • impaired/delayed wound healing
      • UTIs
        • due to increased glucose in urine
      • Rhinocerebral mucormycosis
      • Pseudomonas malignant external otitis


Qbank (12 Questions)

(M3.EC.20) A 62-year-old female with a history of type II diabetes presents to her primary care physician for an annual check-up. Her long-term medications include glyburide, metoprolol, and sertraline. She is afebrile. Blood pressure is 140/90 mmHg, pulse is 82/min, and respiratory rate is 16/min. Fasting glucose is recorded as 160 mg/dL. Serum cholesterol is 150 mg/dL and serum creatinine is 0.9 mg/dL. BMI is 31 kg/m^2. On physical exam, erythema is present at the fifth metatarsal-phalangeal joint of the right foot and the patient has decreased sensation over the affected area. Which of the following would most likely decrease the incidence of future neuropathy in this patient? Topic Review Topic

1. Add atorvastatin
2. Add hydrochlorothiazide
3. Right-sided femoral-popliteal bypass
4. Tight glycemic control
5. Discontinue sertraline

(M3.EC.44) A 53-year-old gentleman presents to your office with a two-month history of abdominal pain. Of note, the patient is a long-time patient of yours that you have been treating for uncontrolled diabetes. In the office today, his blood sugar is 322 mg/dL. Otherwise, the patient appears non-toxic and his vital signs are stable. Upon further questioning, the patient endorses daily nausea, occasional vomiting, and a feeling of post-prandial fullness. What is the most appropriate next step in the patient's care? Topic Review Topic

1. Radioisotope gastric-emptying scan
2. Upper endoscopy
3. Treatment with metaclopromide; follow up in 3 months
4. Barium radiographic study
5. Hospital admission, nasogastric tube, no PO intake, fluid resuscitation, and anti-emetics

(M3.EC.47) A 57-year-old female presents to her primary care physician with complaints of nausea, vomiting, abdominal pain, and bloating that have increased in severity over the past several months. She reports that she occasionally vomits after eating; the emesis contains undigested food particles. Additionally, the patient states that she often is satiated after only a few bites of food at meals. Her medical history is significant for hypertension and type II diabetes mellitus that was first diagnosed 10 years ago. Gastric emptying scintigraphy is conducted and shows gastric retention of 80% at 2 hours and 40% at 4 hours. Which of the following is the best first step in management of this patient's condition. Topic Review Topic

1. Dietary modification
2. Metoclopramide
3. Erythromycin
4. Botulinum toxin injection into pylorus
5. Total parenteral nutrition

(M2.EC.9) A 32-year-old male with type 1 diabetes presents to his primary care physician concerned about the long-term consequences of high blood sugar. You discuss the effects of his condition on the major organ systems. Specifically relating to the kidneys, which of the following is the earliest renal abnormality seen in diabetic patients? Topic Review Topic

1. Azotemia
2. Potassium hypofiltration
3. Na+/H2O retention
4. Secondary hyperparathyroidism
5. Glomerular hyperfiltration

(M2.EC.13) A 62-year-old woman presents to the urgent care clinic complaining of vision changes, headaches, and leg pain while walking that is relieved by rest, which has been progressing over many years. She cannot remember the last time she visited the doctor and she takes no medications. On physical exam, she is found to have a blood pressure of 175/95. Her basic metabolic panel is as follows:
Na 132
K 3.8
Cl 102
HCO3 23
BUN 70
Cr 4.2
Glu 360

The patient is diagnosed with end-stage renal failure and started on dialysis. Screening for which of the following would have been most appropriate to detect this patient's progressing renal failure? Topic Review Topic

1. Hematuria
2. Leukocyturia
3. Urine nitrites
4. Leukocyte esterase
5. Microalbuminuria

(M2.EC.19) A 65-year-old man with a history of diabetes mellitus type II presents to his primary care physician for routine care. His only medication is metformin. His vital signs are:

Temperature: 37.1
Pulse: 80
Blood Pressure: 150/95
Respiratory Rate: 16
SaO2: 99%

He is found to be excreting albumin in his urine at a rate of 150 mg per 24 hours, compared with 50 mg per 24 hours 3 months ago. What is the most appropriate next treatment in the care of this patient? Topic Review Topic

1. Watchful waiting
2. Decreased protein intake
3. Lisinopril
4. Glyburide
5. Insulin

(M2.EC.58) A 57-year-old with a 30-year-history of type I diabetes presents to general medical clinic with a lesion on his foot (Figure A). Although he was advised to wear orthotics by his podiatrist, he decided to keep wearing his dress shoes and reports that he observed this lesion when his sock was stained with blood yesterday morning. His vital signs are temperature of 37 degrees Celsius, heart rate 75/minute, blood pressure 145/90 mmHg, respiratory rate 12/minute, and oxygen saturation 99% on room air. Physical examination reveals a diminished response to the monofilament test. What is the most significant risk factor for development of this condition? Topic Review Topic
FIGURES: A          

1. Peripheral vascular disease
2. Female sex
3. Duration of diabetes mellitus
4. Smoking
5. Neuropathy

(M2.EC.59) A 58-year-old gentleman comes in to his primary care physician's office complaining of "tingling in my fingers and toes". He states that this has occurred more frequently over the past 3-4 weeks and figured it was about time to see his doctor. On physical examination he is noted to be obese and denies any attempts to exercise. A random blood glucose is found to be 223 mg/dL and his hemoglobin A1c is 9.2. What is the most likely diagnosis? Topic Review Topic

1. Autonomic neuropathy
2. Compression mononeuropathy
3. Symmetrical distal polyneuropathy
4. Proximal neuropathy
5. Focal neuropathy

(M2.EC.60) A 63-year-old woman with a history of poorly-controlled diabetes mellitus presents to your office to review labs and her blood glucose record. Her hemoglobin A1C is 9.4%. In addition, her blood glucose records demonstrate poor control with numerous spikes and lows throughout the day. Of note, it takes > 1 hr after meals for her blood glucose to rise. She is also complaining of a decreased appetite, nausea, reflux, and early satiety. What is the most appropriate treatment for her current symptoms? Topic Review Topic

1. Increasing the dose of her short acting insulin
2. Loperamide
3. Metoclopramide
4. Ondansetron
5. Gabapentin

(M2.EC.61) A 55-year-old male with a medical history significant for type II diabetes mellitus, hypertension, and benign prostatic hypertrophy (BPH) presents to your office with worsening urinary retention. He was started on tamsulosin for his BPH one year ago, and had immediate improvement of his urinary symptoms. However, his urinary symptoms returned and began to worsen after he was started on several new medications at an annual checkup three months ago. The medications started at that time included hydrochlorothiazide for his hypertension, and a combination of amytriptyline and gabapentin for severe diabetic neuropathy. What is the likely culprit of this patient's worsening urinary retention? Topic Review Topic

1. Hydrochlorothiazide
2. Amitriptyline
3. Gabapentin
4. Tachyphylaxis of tamsulosin
5. Progression of his BPH

(M2.EC.63) A 52-year-old man comes to your clinic for his annual physical exam. He is overweight (BMI=31) and is currently on captopril for hypertension. He reports increased urinary frequency and thirst but is otherwise feeling generally well. He does not exercise and describes his diet as consisting mainly of fast or frozen food. Which of the following values would be sufficient to diagnosis this patient with diabetes? Topic Review Topic

1. Random blood glucose of 185 mg/dL
2. 2 separate fasting glucoses of 130 and 120 mg/dL
3. 2 hour postprandial glucose (glucose tolerance test) of 180 mg/dL
4. Hemoglobin A1c (HbA1c) of 6.8%
5. The presence of diabetic symptoms only

(M2.EC.4754) A 63-year-old male presents to the emergency department complaining of worsening nausea. He reports that the nausea began several months ago and is accompanied by occasional bloating and heartburn. He reports that he frequently feels full even after eating only a little at each meal, and occasionally he will vomit if he eats too much. The vomit is non-bloody and contains bits of undigested food. A review of systems is notable for occasional headaches, tingling in his distal extremities, and constipation. His medical history is significant for Parkinson’s disease diagnosed 3 years ago, hypertension diagnosed 8 years ago, and type II diabetes mellitus diagnosed 10 years ago. The patient reports that he was given prescriptions for both his blood pressure and diabetes medications, but he has not taken either for months because one of them was causing erectile dysfunction. He reports he regularly takes his levodopa. An endoscopy is performed, which rules out cancer. In addition to restarting medications for his hypertension and diabetes, what of the following is most appropriate treatment for the patient’s symptoms? Topic Review Topic

1. Ondansetron
2. Metoclopramide
3. Scopolamine
4. Proton-pump inhibitor
5. Erythromycin

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