Fam med case 6

Which of the following statements are true regarding hyperosmolar hyperglycemic state (HHS)? Select all that apply. A. Metabolic acidosis is the primary disturbance. B. Dehydration is a common finding. C. Plasma glucose levels are commonly >600 mg/dL. D. Ketones are absent or mildly elevated. E. The mortality rate is extremely low.

B, C, D.

What is the leading cause of death in patients with diabetes?

Cardiovascular disease, including both coronary heart disease and cerebrovascular disease

What are the primary precipitants of HHS?

Infections, like pneumonia and urinary tract infections, accompanied by a decreased fluid intake are the most common underlying causes of HHS. Other acute conditions like stroke, MI or pulmonary embolism may also precipitate HHS.

What are optimal ranges for blood glucose? (Fasting and postprandial)

fasting blood glucose should be 80 -120 mg/dl postprandial blood glucose between 1-2 hours after a meal should be < 180 mg/dl

What are the vaccination recommendations for patients with diabetes?

1) Influenza vaccine annually. 2) Pneumococcal 23-valent polysaccharide (Pneumovax) and a one-time revaccination if over 64 years of age and the vaccine was first received greater than five years ago. Patients should also receive the re-vaccination if they have nephrotic syndrome, chronic renal disease or are immunocompromised. There is also the Pneumococcal 13-valent conjugate (Prevnar), which can be given at least one year after Pneumovax in patients 65 and over. Patients can then receive the additional Pneumovax at least one year after the original Prevnar dose. 3) Hepatitis B vaccine

Who should be screened for diabetes according the the American Diabetes Association?

1. Healthy people over 45yo or 2. body mass index 25 kg/m2 with one of the following: -Physical inactivity; -Race/ethnicity (e.g., Native American, Pacific Islander, Latino, African American, Asian American); -First-degree relative with diabetes; -Previously diagnosed impaired fasting glucose (100-125 mg/dL) or impaired glucose tolerance (2-hour plasma glucose > 140 mg/dL following a 75 gram glucose load); -Hypertension (Blood pressure > 140/90 mmHg); -HDL cholesterol < 35 mg/dL and/or triglycerides > 250 mg/dL (2.83 mmol/L); -History of gestational diabetes mellitus, or delivering a baby > 9 lbs; -Polycystic ovarian syndrome; -History of cardiovascular disease; -A1C ≥5.7%, impaired glucose tolerance, or impaired fasting glucose on previous testing -Other clinical conditions associated with insulin resistance (e.g., acanthosis nigricans, severe obesity)

What is the diagnostic criteria for DM?

1. Random glucose of 200 mg/dL or above, plus symptoms 2. A fasting plasma glucose of greater than or equal to 126 mg/dL (sx or repeat needed) 3. A hemoglobin A1C greater than or equal to 6.5% (sx or repeat needed) 4. Oral Glucose Tolerance Test (OGTT) (sx or repeat needed)

Why is it important to order lab tests at a diabetes follow-up visit?

1. monitoring diabetic control; 2. assessing end organ damage; 3. monitoring side effects of treatment; 4. uncovering management complications.

What BP measurement is classified as "pre-hypertensive" in patients older than 18yo?

120 - 139 / 80-89

In the absence of risk factors, at what age should screening for diabetes begin?

45yo

What ethnicities in the US have the highest rates of DM?

7.6% of non-Hispanic whites 9.0% of Asian Americans 12.8% of Hispanics 13.2% of non-Hispanic blacks 15.9% of American Indians/Alaska natives

Which of the following elements may comprise a comprehensive foot examination for a diabetes patient? Select all that apply. A. Evaluate the feet for sensation to touch and vibration B. Elicit patellar reflexes bilaterally C. Palpate dorsalis pedis and posterior tibial pulses bilaterally D. Measure the surface temperature of the feet bilaterally E. Assess the skin for color and temperature changes, hair loss and scaling F. Inspect the feet for abrasion, callus formation ulceration, infection G. Inspect the feet for bony abnormalities H. Elicit Achilles reflexes bilaterally

A, C, E, F, G, H (All but B and D); A. Evaluate the feet for sensation to touch and vibration C. Palpate dorsalis pedis and posterior tibial pulses bilaterally E. Assess the skin for color and temperature changes, hair loss and scaling F. Inspect the feet for abrasion, callus formation ulceration, infection G. Inspect the feet for bony abnormalities H. Elicit Achilles reflexes bilaterally

Dr. Wilson asks you: Which of the following are common manifestations of end-organ damage caused by diabetes? Select all that apply. A. Coronary heart disease B. Cerebrovascular disease C. Inflammatory bowel disease D. Hyperthyroidism E. Retinopathy F. Neuropathy G. Nephropathy H. Primary pulmonary hypertension

A. Coronary heart disease B. Cerebrovascular disease E. Retinopathy F. Neuropathy G. Nephropathy

For a patient who has not been seen for her diabetes for over a year. Which of the following diagnostic tests are appropriate with respect to her diabetes? Select all that apply. A. Hemoglobin A1c B. 24-hour urine protein and glucose C. Spot urine albumin/creatinine ratio D. Fingerstick blood glucose E. Serum creatinine and calculated GFR F. Serum B12 levels G. Thyroid-stimulating hormone (TSH) H. Fasting lipid profile (total cholesterol, LDL- and HDL-cholesterol and triglycerides)

Answer: A, C, E, F, G, H (All but B and D)

The American Diabetes Association and the United States Preventative Services Task Force recommend very different screening criteria for DM. (USPSTF recommends much less screening). How can two organizations, both well respected, come up with such different recommendations about screening? Select all that apply. A. Drug companies support the work of one of the organizations, but not the other. B. One of the organizations uses expert opinion, but the other analyzes research. C. One of the organizations has a subspecialist orientation, and the other a primary care perspective. D. The missions of the two organizations differ.

Answer: All are possible options-- B and C most likely.

Which of the following interventions have evidence of improving cardiovascular disease outcomes that matter to patients with diabetes? Select all that apply. A. Advising all patients to simply cut back on their smoking B. Lowering blood pressure in patients with blood pressure > 140/90 mmHg C. Screening asymptomatic diabetes patients for coronary heart disease (CHD) D. Adding a moderate-intensity statin for patients 40-75 yrs old with LDL-c >70 mg/dl E. Adding a high-intensity statin for patients 40-75 yrs old with LDL-c >70 mg/dL and ≥ 7.5% estimated 10-year ASCVD risk F. Treating dyslipidemia through lifestyle modification: diet and exercise G. Using aspirin as secondary prevention in diabetes patients with a history of CVD H. Controlling glucose as close to normal range as possible (A1C 4 to 6%)

Answer: B, D, E, F, G (all but A, C, H)

What is an important side effect of metformin to consider when doing a comprehensive exam (physical + labs) on a diabetic patient?

During clinical trials, up to 7% of patients receiving metformin developed asymptomatic subnormal serum vitamin B12 levels. In the setting of neuropathy, too, serum B12 levels would be a very reasonable diagnostic test to order.

If diabetes screening for a 45yo with no risk factors comes back normal, when should the next screening take place?

Every 3 years

What is a key physical finding of Hyperglycemic Hyperosmolar Syndrome?

HHS is characterized by severe dehydration. A profound fluid deficit is usually present, in excess of 9 L on average in adults. Serum osmolality usually exceeds 320 mOsm/kg. Fluid replacement is a key component of treatment.

Does hyperosmolar hyperglycemic state or DKA have higher plasma glucose levels?

HHS. Plasma glucose levels are usually >600 mg/dL. In DKA, plasma glucose levels are normally around 250.

What is the mortality rate in hyperosmolar hyperglycemic state?

Increases with increasing age and serum osmolality. The average mortality rate in many studies is 15%, but can be as high as 20-30% in the presence of significant infection.

What type of acute diabetic compensation exists in type I and type II diabetes?

In patients with type 1 diabetes, without sufficient insulin, blood sugar runs high, and diabetic ketoacidosis (DKA) can develop. Type 2 patients with hyperglycemia more often develop hyperosmolar hyperglycemic state (HHS). (DKA can develop if DM II has progressed to resemble DM I) .

What is the serum pH for diabetic ketoacidosis?

Metabolic gap acidosis associated with a pH <7.30.

What is the mortality rate for DKA?

Mortality rate is roughly 2% for patients under 65 years old, but as high as 22% for patients over 65 years old.

What is the difference between proliferative and non-proliferative retinopathy?

Neovascularization is the hallmark of proliferative retinopathy. The growth of new blood vessels is prompted by retinal vessel occlusion and hypoxia.

What percent of patients with diabetes have proliferative retinopathy and what percent have background retinopathy?

Non-proliferative retinopathy: almost 100% DMI (After 15 years of disease), 75% DMII. Proliferative retinopathy: 25% of the diabetes population with 25 or more years of diabetes.

What is the serum pH for hyperosmolar hyperglycemic state?

Not a metabolic acidosis. Serum pH is generally > 7.3, with a bicarbonate > 15 mEq/L (>15 mmol/L)

What are some key conditions that contribute to hyperglycemia?

Overeating, missing doses of medication, dehydration, infection and illness, and stress.

In severe, non-proliferative retinopathy, what do you look for on fundoscopic exam?

Retinal hemorrhages are dark blots with indistinct borders that indicate partial obstruction and infarction. Cotton wool spots are white spots with fuzzy borders and they indicate areas of previous infarction. They accompany hemorrhages. Microaneurysms are more punctate dark lesions that indicate vascular dilatation.

What condition is caused primarily by diabetes?

Retinopathy Diabetes is the most common cause of new cases of blindness among adults of working age.

What BP measurements are classified as "Hypertension Stage 1" and "Hypertension state 2" in patients over 18yo?

Stage 1: >140 / 90; Stage 2: >160 / 100

What is the first tier ADA/EASD consensus algorithm for the management of Type 2 Diabetes?

Step 1: Diagnosis = HbA1C > 6.5 --> Lifestyle changes + Metformin; Step 2: If HbA1C > 8 --> lifestyle changes + Metformin + Add either a sulfonylurea (Glyburide, Glipizide) or Glimepiride or basal insulin Step 3: If HbA1C still > 8 --> Continue lifestyle changes and Metformin + add basal insulin or (if already added) intensify insulin regimen. Consider discontinuing sulfonylurea to avoid hypoglycemia. Step 4: (less well studied) If still uncontrolled, explore other medications and treatment options

A 60-year-old Hispanic female presents to the office complaining of increased frequency of urination and fatigue for the past several months. She denies fevers, dysuria, back pain, diarrhea and abdominal pain. She has noted some weight loss without working on diet or exercise. Her past medical history is significant for hyperlipidemia and hypertension, for which she takes simvastatin and lisinopril. She is a non-smoker and consumes one to two glasses of wine per week. Her vitals are: Heart rate: 70 beats/minute Blood pressure: 130/70 mmHg Body Mass Index: 30 kg/m2 Physical examination reveals increased pigmentation in her axilla bilaterally. Her labs are as follows: Random blood glucose: 205 mg/dL Creatinine: 0.8 mg/dL TSH: 2.1 U/L. What test is needed to diagnose diabetes mellitus? A. The random blood glucose is sufficient B. Fasting blood glucose C. An oral glucose tolerance test D. HgbA1c

The correct answer is (A). Diabetes can be diagnosed with either an HbA1c > 6.5%, a fasting plasma glucose ≥ 126 mg/dl (7.0 mmol/l), a plasma glucose ≥ 200 mg/dL (11/1 mmol/l) two hours after a 75 g glucose load, or symptoms (such as polyuria, polydipsia, unexplained weight loss) and a random plasma glucose ≥ 200 mg/dL (11.1 mmol/l). Answers (B), (C) and (D) are incorrect, as the diagnosis of diabetes can be made based on random blood glucose with symptoms.

A 72-year-old woman with a 30-year history of Type 2 diabetes returns to your office for routine visit. She is taking 20 units of insulin glargine every morning and five units of insulin aspart with meals. The patient notes blurry vision for the past several months and a few days of dark spots in her vision. She denies headaches or nausea. What is true regarding diabetic retinopathy? A. 75% of people with diabetes only develop retinopathy 10 years after diagnosis. B. 40% of people with severe diabetes requiring insulin have retinopathy five years after diagnosis. C. Vision changes are an early sign of retinopathy. D. Primary care physicians should examine the retina on every visit for ongoing diabetes care.

The correct answer is (B). The patient's symptoms describe diabetic retinopathy. Proliferative retinopathy is prevalent in 25% of the diabetes population with ≥ 25 years of diabetes, but many patients have retinopathy much earlier. Early changes of retinopathy are asymptomatic. Patients need to see an ophthalmologist regularly for a dilated retina exam, not rely on a view of the retina from primary care physicians. Abnormalities seen include macular edema ( a common cause of blurry vision) and new blood vessel formation which can leak and cause dark spots in the vision. Diabetic eye disease often can be treated before vision loss occurs. Glaucoma (causing increased intraocular pressure) is 40% more likely in people with diabetes, but usually causes nausea, headaches, and narrowing of vision or halos around lights.

A patient with newly diagnosed DM II based on sx and random blood glucose 205 has an A1c of 8.9%. What is the best medicine to start at this time? A. A sulfonylurea B. Basal insulin C. Metformin D. Basal-bolus insulin

The correct answer is (C). After a trial of lifestyle changes, metformin is the first-line agent for treatment of Type 2 diabetes. Sulfanylureas are often used as second-line agents. Insulin is generally not used until two other oral medications are insufficient to control the blood sugar, but most people with Type 2 diabetes become insulinopenic over time and require insulin treatment.

A 61-year-old female has recently been diagnosed with Type 2 diabetes. Her fasting glucose was 240 mg/dL and her A1c was 8.9%. Her BP has been 148/90 and 146/86 at two separate office visits. Her home BP measurements have been in a similar range. Her creatinine is 0.9 and she has no known heart disease. She currently takes losartan 100 mg daily for a diagnosis of hypertension. Which of the following would be the most appropriate step in managing this patient's blood pressure? A. Make no changes to her medications as her blood pressure is at goal. B. Start lisinopril daily. C. Start amlodipine daily. D. Start metoprolol daily. Submit

The correct answer is (C). Although the patient is over age 60, and the blood pressure goal is generally 150/90 mmHg, this patient has diabetes. JNC8 indicates a goal blood pressure of 140/90 mmHg for all patients with diabetes, regardless of age. While ACE Inhibitors have been historically the main first-line treatment for patients with diabetes, JNC8 does not make this specification, and allows the choice of any of the first-line treatments for hypertensive diabetic patients. These choices would include ACE inhibitors, angiotensin II receptor blockers (ARBs), thiazides, or calcium channel blockers. Beta blockers are not part of the management of hypertension, unless the patient has another indication (eg. CHF). In this case, lisinopril would not be an appropriate choice because the patient is taking an ARB (losartan) already. The combination of an ACE inhibitor and an ARB is contraindicated due to an increase in renal failure and hyperkalemia.

A 65-year-old male with known Type 2 diabetes mellitus presents to the Emergency Department with altered mental status. The patient experienced no known head trauma. His vitals are: Temperature: 38.1 Celsius Heart rate: 102 beats/minute Respiratory rate: 16 breaths/minute Blood pressure: 90/74 mmHg His mucous membranes appear very dry and he is started on IV fluids. Neurological exam reveals no focal deficits. His plasma glucose is found to be 700 mg/dL. Urinalysis reveals no ketone bodies. What is the most likely diagnosis? A. Thiamine deficiency B. Diabetic ketoacidosis (DKA) C. Cerebrovascular accident D. Hyperosmolar hyperglycemic state (HHS)

The correct answer is (D). HHS is seen typically in patients with Type 2 diabetes. It includes very high sugars > 600; ph > 6.4; dehydration; and lack of ketones in the urine and blood. Diabetic ketoacidosis is more common in Type 1 diabetes, and the patient will have ketone bodies in the urine. Thiamine deficiency can cause Korsakoff syndrome, and is typically seen in alcoholics with severe malnutrition, however, this patient is not a known alcoholic and doesn't appear malnourished. Despite the confusion in this patient, stroke is an unlikely diagnosis in this case given the lack of focal deficits on exam. Cardiac arrhythmia can cause dizziness, but is less likely to cause prolonged altered mental status.

What % of the country has diabetes and what % is undiagnosed?

Total: 29.1 million people (9.3% of the population) have diabetes. Undiagnosed: 8.1 million people (27.8% of the population)

Why is dental care important to diabetics?

When diabetes is not controlled properly, high glucose levels in saliva may help bacteria that attack tooth enamel thrive. Going to the dentist and brushing your teeth helps remove decay-causing plaque which can result in cavities and gum disease. It is also important to go to the dentist regularly because gum diseases and fungal infections appear to be more frequent and more severe among diabetics due to immunosupression. Additionally, periodontal disease can increase the risk of heart trouble.