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 is 223 ml/dL. Her hemoglobin A1c is 9.2. Introduction Type 1 diabetes immune-mediated destruction of β-cells and loss of insulin production by pancreas may also have antibodies against insulin 10% of diabetes cases classically occurs in thin people younger than 30 sudden onset (after about 90% β-cells destroyed) result of self-reactive T-cell destruction of β-cells not necessary to have a family history associated with HLA-DR3 and -DR4 also seen concurrently with other autoimmune diseases (e.g., Graves', Hashimoto, etc.) Type 2 diabetes insulin insensitivity in peripheral organs requiring increased insulin production pancreas cannot produce enough insulin 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 amyloid deposition in β-cells Complications are due to poor glycemic control if diabetic maintains glucose in normal range prognosis is good damage mediated by non-enzymatic glycosylation which makes vessels more permiable increased synthesis of type IV collagen in basement membrane osmotic damage which is secondary to glucose conversion to sorbitol by aldose reductase cause of cataracts and neuropathy Presentation Symptoms type I polyuria polydipsia polyphagia fatigue weight Loss DKA type II blurry vision candidal infections (especially vaginitis) hyperosmolar nonketotic coma acanthosis nigricans: a velvety hyperpigmentation of the skin and found in body folds Evaluation Labs: 4 options hemoglobin A1c > or equal to 6.5% random blood glucose of > 200mg/dL AND diabetic symptoms 2 separate fasting glucoses of > 126 mg/dL (fasting means no intake for > 8 hours) 2-hour postprandial glucose (glucose tolerance test) of > or equal to 200 mg/dL Treatment See Diabetes pharmacology Complication treatment peripheral neuropathy duloxetine (serotonin/norepinephrine reputake inhibitor), pregabalin, or gabapentin diabetic kidney disease ACE-inhibitor gastroparesis metoclopramide Prognosis, Prevention, and Complications Macrovascular complications coronary arery disease 4 times more likely in DM patients peripheral vascular disease stroke Microvascular complication nephropathy arteriosclerosis leading to hypertension nodular sclerosis Kimmelstiel-Wilson nodules progressive proteinuria chronic renal failure 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 sense central neuropathy 3rd nerve palsy sparing the pupil also CN IV and VI autonomic dysfunction impotence bladder retention and incontinence gastroparesis GI discomfort postural hypotension skin dysfunction necrobiosis lipoidica diabeticorum yellow plaques on legs diabetic foot combintion of vascular and nerve disease higher likelihood of infection, pressure ulcers can lead to amputation infectious disease urinary tract infections due to increased glucose in urine rhinocerebral mucormycosis Pseudomonas malignant external otitis
QUESTIONS 1 of 9 1 2 3 4 5 6 7 8 9 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + (M1.EC.115) An 18-year-old Caucasian female presents to your clinic because of a recent increase in thirst and hunger. Urinalysis demonstrates elevated glucose. The patient's BMI is 20. Which of the following is the most common cause of death in persons suffering from this patient's illness? Review Topic QID: 100416 1 Renal failure 15% (29/188) 2 Myocardial infarction 64% (120/188) 3 Infection 3% (5/188) 4 Peripheral neuropathy 2% (3/188) 5 Coma 14% (27/188) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.EC.11) A 36-year-old obese African American female presents to her primary care physician complaining of blurry vision and increased fatigue. Aside from obesity, her past medical history includes multiple candidal infections in the past six months. Her physician sends her for laboratory testing, with the following results: hemoglobin 12.0 g/dL, glucose tolerance test of 212 mg/dL at 2 hours, sodium 137 mEq/L, potassium 4.1 mEq/L, and creatinine 0.9 mg/dL. Which of the following findings would be the most likely be found on physical exam? Review Topic QID: 103804 FIGURES: A B C D E 1 Figure A 23% (3/13) 2 Figure B 69% (9/13) 3 Figure C 0% (0/13) 4 Figure D 0% (0/13) 5 Figure E 8% (1/13) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.EC.52) A 14-year-old Caucasian male of normal weight presents for a well-child checkup. During physical examination, his parents state that their son has been frequenting the bathroom more often than usual and his weight has decreased despite an increase in his caloric intake. Which of the following is most consistent with their son's symptoms? Review Topic QID: 100353 1 Increased insulin production by beta-cells 7% (3/42) 2 Self-reactive T-cells 38% (16/42) 3 Amyloid deposits in pancreatic islet cells 33% (14/42) 4 Absence of leukocytic infiltrates in the pancreas 2% (1/42) 5 Hypoglycemia 5% (2/42) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.EC.91) A 19-year-old Caucasian college student is home for the summer. Her parents note that she has lost quite a bit of weight. The daughter explains that the weight loss was unintentional. She also notes an increase in thirst, hunger, and urine output. Her parents decide to take her to their family physician, who suspects finding which of the following? Review Topic QID: 100392 1 Evidence of amyloid deposition in pancreatic islets 42% (5/12) 2 High T4 and T3 levels 17% (2/12) 3 Elevated ketone levels 42% (5/12) 4 Hypoglycemia 0% (0/12) 5 Hyperinsulinemia 0% (0/12) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 3
The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Researc Endocrine - Humanitarian N. Engl. J. Med.. 1993 Sep;329(14):977-86. PMID: 8366922 (Link to Abstract)
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