Updated: 6/10/2021

Diabetes Mellitus

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Questions
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Snapshot
  • 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 permeable
      • 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% 
      • best single test for diabetes mellitus
    • random blood glucose of > or equal to 200mg/dL AND diabetic symptoms
    • 2 separate fasting glucoses of > or equal to 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 
  • Complications of treatment
    • peripheral neuropathy 
      • duloxetine (serotonin/norepinephrine reputake inhibitor), venlafaxine, tricyclic antidepressants, pregabalin, or gabapentin 
    • diabetic kidney disease
      • ACE-inhibitor 
    • gastroparesis
      • metoclopramide
Prognosis, Prevention, and Complications
  • Macrovascular complications
    • coronary artery disease
      • 4 times more likely in DM patients
    • peripheral vascular disease
    • stroke
  • Microvascular complications
    • 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  
      • abnormal small bowel motility 
        • leads to small intestinal bacterial overgrowth 
      • GI discomfort
      • postural hypotension
    • skin dysfunction
      • necrobiosis lipoidica diabeticorum
        • yellow plaques on legs
    • diabetic foot
      • combination 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

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Questions (12)
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(M1.EC.14.11) 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?

QID: 103804
FIGURES:
1

Figure A

5%

(3/56)

2

Figure B

57%

(32/56)

3

Figure C

7%

(4/56)

4

Figure D

11%

(6/56)

5

Figure E

4%

(2/56)

M 2 D

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(M1.EC.13.115) 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?

QID: 100416
1

Renal failure

16%

(38/245)

2

Myocardial infarction

64%

(156/245)

3

Infection

3%

(7/245)

4

Peripheral neuropathy

2%

(4/245)

5

Coma

14%

(35/245)

M 4 E

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(M1.EC.13.52) 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?

QID: 100353
1

Increased insulin production by beta-cells

6%

(4/68)

2

Self-reactive T-cells

51%

(35/68)

3

Amyloid deposits in pancreatic islet cells

26%

(18/68)

4

Absence of leukocytic infiltrates in the pancreas

1%

(1/68)

5

Hypoglycemia

4%

(3/68)

M 1 D

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(M1.EC.13.91) 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?

QID: 100392
1

Evidence of amyloid deposition in pancreatic islets

25%

(12/48)

2

High T4 and T3 levels

12%

(6/48)

3

Elevated ketone levels

58%

(28/48)

4

Hypoglycemia

2%

(1/48)

5

Hyperinsulinemia

2%

(1/48)

M 2 D

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Evidence (9)
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