Updated: 6/12/2018

Diabetes Mellitus

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  • 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
 

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Questions (9)
Lab Values
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/L
Female: 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/mL
Female: 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/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative 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/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 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/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 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/min
Female: 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 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 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

(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%

(28/183)

2

Myocardial infarction

63%

(116/183)

3

Infection

3%

(5/183)

4

Peripheral neuropathy

2%

(3/183)

5

Coma

15%

(27/183)

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(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:
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)

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(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)

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(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

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