Diabetes Super Tuesday Cases

1. An 18-year-old woman is brought to the Emergency Room by her mother

because she is confused and behaving strangely. She has a negative medical
history, but has lost 2 !ounds recently without trying. She has not been
slee!ing well due to getting u! several times at night to urinate. "his morning,
the !atient develo!ed nausea and vomiting. #er mother found her confused and
unaware that today was a school day.
$n e%amination, the !atient was slender, lying on a stretcher. She is res!onsive
to &uestions. She is afebrile, blood !ressure is 12'(8), heart rate is 118 *+,,
res!iratory rate 2) *+,. #er fundosco!ic e%am is normal, oral mucosa is dry,
nec- veins are flat. .ungs are clear, cardiovascular e%am reveals a tachycardic
regular rhythm with no murmur. Abdominal e%am is benign. She is
neurologically intact.
.aboratory studies/ urine drug screen and !regnancy tests are negative.
0rinalysis reveals/ 1 2 glucose, 1 2 -etones, no hematuria or !yuria. 3hest %-
ray is normal.
Renal !anel/ 4a 11 3l 5' *04 )2 glucose '6'
7 '.1 3$2 5 3r 1.1
a. 8hat is the diagnosis9
a. :iabetic -etoacidosis(##S
b. 8hat is the !atho!hysiology9
a. ;nsulin deficiency(resistance
b. <lucagon =S
c. 8hy is her !otassium mildly elevated9
a. ;ncreased !lasma osmolality osmotic #2$ movement out of cells
which !romotes movement of 72 into E3> by 1? #2$ loss
increased cell @72A which favors !assive 72 e%it through 72 channels
and 2? by solvent drag B frictional forces b(w solvent C#2$? and solute
result in 72 being carried out through #2$ !ores in cell mem
b. Also insulin is low and insulin normally !romotes 72 u!ta-e by cells
c. Academia 72(#2 e%change9
d. 8hat are the most im!ortant first ste!s in the acute treatment of this
!rocess9
a. A*3sD mental statusD !!tEing events Ceg ,;, inf%n?D volume status
b. Serum glucose, serum electrolytes w( anion ga!, 3*3 w( diff, 0(A,
!lasma osmolality, serum -etones, A*<, E3<
c. >luid re!lacement C4S?, insulin
e. 8hat are the most common !reci!itating causes of this !rocess9
a. ;nf%n C!neumonia, 0";?D d(cEing or inade&uate insulin thera!y
b. ,;, 3FA, !ancreatitis
c. 4ew onset "1:,
d. <lucocorticoids, high dose thiaGides, sym!athomimetics Cdobutamine,
terbutaline?, 2
nd
gen anti!sychotics
e. 3ocaine
f. Eating disorders
2. A )H-year-old female !resents for her yearly !hysical e%amination. She has
been fine and has no com!laints. #er medical history is notable only for
borderline hy!ertension and moderate obesity. At !rior visits you see that your
!rece!tor has counseled her on a low calorie low fat diet and recommended that
she start an e%ercise !rogram. #owever, the !atient has not made any of these
recommended changes. 8ith her full-time Iob and three children, she finds it
difficult to e%ercise. She admits that her family eats out fre&uently.

#er blood !ressure is 1)(52. #er body mass inde% C*,;? is 1
-ilograms(meters
2
. "he remainder of her e%amination is normal e%ce!t for the
obesity.
Routine laboratory evaluation is unremar-able e%ce!t for a fasting !lasma
glucose of 1) milligrams !er deciliter.
a. 8hat is the most li-ely diagnosis9
a. :iabetes B >+< J12H Cor #bA1c JH.'?, 2hr value in $<"" K2, or
random !lasma @glucoseA K2 in the !resence of S%
b. 3onfirm on a subse&uent day by re!eat test
b. 8hat criteria do you base this u!on9
c. 8hat is the ne%t ste! in the diagnosis9
d. 8hat are the diagnostic criteria for "y!e 2 :iabetes9
f. 8hat are the first ste!s in behavioral modification9
a. 8eight reduction and diet modification, e%ercise
g. ;f medication thera!y is desired, what would be the most a!!ro!riate first
line medication in this !atient9 #ow does it wor-9 8hat is an im!ortant
contraindication to the use of this medication9
a. ,etforminD only effective in !resence of insulinD decreases he!atic
glucose out!ut and increases insulin-mediated glucose use in
!eri!heral tissues, lowers serum >>A conc so less substrate for <4<
and increases intestinal glucose use
h. ;f her glucoses are uncontrolled on the ma%imum dose of this medication,
what are the other second line oral agents and their mechanism of action9
a. 2 insulin
b. 2 sulfonylureas
1. A 'H-year-old male with a 1 year history of "y!e 2 diabetes, insulin- treated for
the !ast ' years, returns for routine follow u!. #is current insulin regimen is
insulin glargine Clantus? H units and !re-meal insulin as!art Cnovolog? of 1 units
with brea-fast, 1 units with lunch, and 1' units with the evening meal.
#is finger stic- blood sugar re!orts from home are as follows/
8 A, fasting/ 1'-2 mg(dl
+rior to the noon meal/ 18-2) mg(dl
+rior to the evening meal/ 18-2) mg(dl
2 hours !ost evening meal/ 2)-1) mg(dl
8hat are the goal >S*S numbers at each of these times of day9
A, fasting/
+re noon meal/
+re evening meal/
2 hours after meals/
Assuming he is following a reasonable low carbohydrate diet, what insulin
changes would you recommend for him9
). "he same !atient above instead has these values/
>asting/ 8-12 mg(dl
+re-noon/ 1)-1H
+re-evening meal/ 1'-16
2 hours after +, meal 2-2)
Assuming he is following a reasonable low carbohydrate diet, what insulin
changes would you recommend for him9