Updated: 9/9/2020

Diabetes Mellitus

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Snapshot
  • A 46-year-old obese woman presents to the family practice clinic for her yearly exam. She reports that over the past few weeks, she has had some increased urinary frequency and thirst and recently went to an urgent care center for a urinary tract infection. She denies any fevers or chills. A random blood glucose level is 235 mg/dL and her hemoglobin A1c comes back at 10.0.
Introduction
 
Type I vs Type II Diabetes

Type I Diabetes
Type II Diabetes
Pathogenesis
  • Immune-mediated destruction of beta cells leading to ↓ insulin production
  • Sensitive to insulin
  • ↑ End-organ resistance to insulin, leading to pancreatic beta cell defects
  • Not sensitive to insulin

Demographics

  • Onset at younger age
  • Onset at older age
Associated with
  • HLA-DR3 and HLA-DR-4
  • Other autoimmune diseases (e.g., Celiac disease (most common) or autoimmune thyroid disorders) 
    • Consider screening for these (e.g., anti-tissue transglutaminase or TSH, respectively)
  • Obesity
  • Hypertension
  • Metabolic syndrome, defined as at least 3 out of 5 of: 
    • Abdominal obesity (waist circumference ≥40 inches in men, ≥35 inches in women)
    • Fasting glucose ≥100-110 mg/dL
    • Serum triglycerides ≥150 mg/dL
    • Serum HDL cholesterol <40 mg/dL in men or <50 mg/dL in women
    • Blood pressure ≥130/85
Histology if biopsied
  • Leukocytic infiltrate
  • Amyloid polypeptide deposition
 
Presentation
  • Classic symptoms
    • polyuria
      • in children, can present as nocturnal enuresis 
    • polydipsia
    • polyphagia
    • weight loss
    • fatigue
    • blurry vision
 
Symptoms and Physical Exam in Type I vs Type II Diabetes

Type I Diabetes
Type II Diabetes
Classic symptoms
  • Common
  • Not as common

Acute manifestations

  • Diabetic ketoacidosis
  • Hyperosmolar hyperglycemic state
Signs of complications
  • Candidal infections
  • Acanthosis nigricans  
  • Vascular disease examination
    • cold, hairless lower extremities with diminished pulses
  • Fundoscopic examination
    • hemorrhages, exudates, and neovascularization
  • Neuropathy
    • cranial nerve III ischemia
 
Studies
  • Diagnostic testing
    • studies
      • hemoglobin A1c ≥ 6.5 
        • indicates glucose levels from the previous 8-12 weeks
      • ↑ blood glucose
    • all adults 40 - 70 years who are overweight or obese should be screened
  • Diagnostic criteria
    • 1 of the following
      • hemoglobin A1c ≥ 6.5%
      • 2 separate fasting plasma glucose ≥ 126 mg/dL
      • 2-hour oral glucose tolerance test ≥ 200 mg/dL
      • random glucose ≥ 200 mg/dL along with classic symptoms (polyuria, polydipsia, and polyphagia)
Differential
  • Glucagonoma
    • distinguishing factor
      • presents with hyperglycemia as there is overproduction of glucagon, which increases glycogenolysis and gluconeogenesis
      • also presents with necrolytic migratory erythema, weight loss, hypercoagulable state, and depression
      • treatment is octreotide or surgery
Treatment
  • Management approach
    • strict glycemic control to prevent microvascular complications
    • lifestyle modifications and management of hypertension or hyperlipidemia to prevent macrovascular complications
  • Type I diabetes
    • first-line
      • insulin
    • does not respond to lifestyle changes
  • Type II diabetes
    • first-line
      • lifestyle changes
        • diet
        • exercise
        • weight loss
      • insulin
      • oral agents
        • metformin
          • first-line, especially in patients with obesity
          • contraindicated with
            • renal insufficiency
            • use of contrast for imaging
Complications
  • Complications of diabetes
    • macrovascular
      • coronary artery disease
      • peripheral artery disease
      • stroke
    • microvascular
      • diabetic retinopathy
      • diabetic nephropathy  
        • diagnosis
          • urine albumin-to-creatinine ratio testing is the most sensitive test to detect moderately elevated levels of urinary albumin excretion
        • treatment
          • angiotensin-converting enzyme inhibitors  
          • angiotensin II receptor blockers
      • diabetic neuropathy
        • treatment
          • duloxetine, gabapentin, pregabalin, and NSAIDs
      • autonomic dysfunction
        • gastroparesis
          • treatment
            • lifestyle modifications 
            • metoclopramide or erythromycin
          • complications
            • small bowel bacterial overgrowth (diarrhea)
              • treat with rifaximin 
      • diabetic foot 
        • treatment
          • debridement and antibiotics
          • amputation
      • neurogenic bladder
        • treatment
          • bethanechol
          • intermittent straight catheterization
 

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(M2.EC.17.4768) A 78-year-old male presents to the emergency department with dysuria for two days. He also endorses increased urinary frequency and urgency, but denies hematuria. His past medical history is significant for hypertension and coronary artery disease, but he has been lost to follow up for many years. On physical exam, he has mild suprapubic pain without costovertebral angle tenderness. Urinalysis is positive for nitrites and leukocyte esterase with few white blood cells, large protein, and no blood. Urine culture grows Escherichia coli. The patient is diagnosed with a urinary tract infection and treated with levofloxacin as an outpatient. He is scheduled for an appointment with a nephrologist due to his urinalysis results and eventually undergoes kidney biopsy, which can be seen in Figure A.

Which of the following is most likely associated with this patient’s renal disease?
Tested Concept

QID: 109068
FIGURES:
1

HIV infection

7%

(2/29)

2

Insulin resistance

79%

(23/29)

3

Light chain dyscrasia

10%

(3/29)

4

Malignancy

0%

(0/29)

5

Upper respiratory infection

0%

(0/29)

M 6 C

Select Answer to see Preferred Response

(M2.EC.17.95) A 76-year-old female with a past medical history of obesity, coronary artery disease status post stent placement, hypertension, hyperlipidemia, and insulin dependent diabetes comes to your outpatient clinic for regular checkup. She has not been very adherent to her diabetes treatment regimen. She has not been checking her sugars regularly and frequently forgets to administer her mealtime insulin. Her Hemoglobin A1c three months ago was 14.1%. As a result of her diabetes, she has developed worsening diabetic retinopathy and neuropathy. Based on her clinical presentation, which of the following is the patient most at risk for developing? Tested Concept

QID: 104420
1

Stress incontinence

0%

(0/1)

2

Overflow incontinence

0%

(0/1)

3

Uterine prolapse

0%

(0/1)

4

Rectal prolapse

0%

(0/1)

5

Hemorrhoids

0%

(0/1)

M 8 C

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(M3.EC.15.44) A 53-year-old man presents to your office with a 2 month history of abdominal bloating. He states that he feels full after eating only a small amount and has experienced bloating, diarrhea, and occasionally vomiting when he tries to eat large amounts. He states his diarrhea has now become more profuse and is altering the quality of his life. One week ago, the patient was given antibiotics for an ear infection. He states he is trying to eat more healthy and has replaced full fat with fat free dairy and is reducing his consumption of meat. His temperature is 99.0°F (37.2°C), blood pressure is 164/99 mmHg, pulse is 85/min, respirations are 14/min, and oxygen saturation is 98% on room air. Laboratory values from a previous office visit are notable for a hemoglobin A1c of 13%. Which of the following is the best treatment of this patient's diarrhea? Tested Concept

QID: 103534
1

Better glycemic control

0%

(0/0)

2

Elimination of dairy from the diet

0%

(0/0)

3

Metoclopramide

0%

(0/0)

4

Rifaximin

0%

(0/0)

5

Vancomycin

0%

(0/0)

M 10 E

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(M3.EC.15.47) A 57-year-old woman 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. She states that 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. Initial laboratory values are notable only for a hemoglobin A1c of 14%. Which of the following is the best initial treatment for this patient? Tested Concept

QID: 102676
1

Dietary modification

54%

(7/13)

2

Erythromycin

23%

(3/13)

3

Metoclopramide

15%

(2/13)

4

Myotomy

8%

(1/13)

5

Surgical resection

0%

(0/13)

M 11 E

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(M2.GN.15.46) A 40-year-old woman presents to her family physician for a wellness appointment. The patient states that she feels well and has no current complaints. She has been drinking more water lately and has started eating a mostly corn diet for the past week in an attempt to lose weight. She does not smoke, is not sexually active, and has been urinating more frequently recently. The patient has also stopped using shampoo in an attempt to make her hair thicker. Her temperature is 97.6°F (36.4°C), blood pressure is 133/74 mmHg, pulse is 84/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is notable for the finding in Figure A. Laboratory studies are ordered and are currently pending. Which of the following is most likely to be found in this patient? Tested Concept

QID: 104257
FIGURES:
1

Beta-cell destruction

1%

(1/69)

2

Insulin resistance

6%

(4/69)

3

Niacin deficiency

19%

(13/69)

4

Poor hygiene

68%

(47/69)

5

Visceral malignancy

3%

(2/69)

M 6 E

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POSTS (2)
Topic COMMENTS (31)
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