GO! Diabetes Train the Trainer Program

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GO! DiabetesTrain the Trainer Program
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Case Study Compilation and Questions
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Case Study 1

• 28 year-old Mexican American female was noted to
  have a random glucose of 125 mg/dL on a
  chemistry panel obtained as part of an annual
  health fair by her employer. No symptoms or
  prior history of abnormal glucose (screening OGTT
  during pregnancy 4 years ago was negative)
• PMH
• Negative
• Medications
• None
• FHx
• Mother and brother have type 2 diabetes
• Mother has a history of retinal laser treatments,
  proteinuria and foot ulcer

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Case Study 1

• Social Hx
• She has smoked 1ppd since age 19 years
• She and her husband own a convenience store
• They have two children, ages 4 and 6 years
• ROS
• Frequent yeast infections
• PE
• Height 64" Weight 200 lb BP 142/92, 92
• Waist 38" Skin tags Trace edema
• Further exam normal
• Labs
• A1C 6.3 (normal 4-6)
• 1-hour postprandial glucose 133 mg/dL
• Questions Diabetic? How would you counsel her?

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Case Study 2

• 32 year-old Caucasian female with a history of
  gestational diabetes presents for confirmation of
  pregnancy (LMP 10 weeks ago). Recent home
  pregnancy test was positive. Asymptomatic except
  for nocturia without dysuria or fatigue
• PMH
• She has two children, ages 3 years and 26 months
• Previous gestational diabetes requiring insulin
  therapy during both previous pregnancies
• Glucose tolerance test 6 weeks post-partum
  normal
• FHx
• No diabetes or vascular disease

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Case Study 2

• Social Hx
• No tobacco or EtOH
• Power-walks 30 minutes 5-7 days a week
• Follows standard nutritional guidelines
• Weight stable for past 4 years
• PE
• Height 64" Weight 110 lb BP 110/62, 66
• Afebrile Further exam negative
• Labs
• Urine beta-HCG positive
• A1C 9.4
• Glucose 277 mg/dL (3 hr pc) yesterday at PCP
  295 mg/dL (4h pc)
• Questions Diabetic? Type 1 or Type 2?

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Case Study 3

• 78 year-old nursing home resident presents for
  evaluation of recurrent episodes of severe
  hypoglycemia. Diabetes diagnosed at age 65 years
  during routine insurance exam
• Current treatment includes insulin 70/30 14 units
  qam glargine 10 units qhs and sulfonylurea
• Fingerstick glucose logs (4-6 readings per day)
  reveal levels from 30s to mid 500s for past two
  weeks
• Severe hypoglycemia usually occurs during the
  afternoon or early morning
• The average measurement is 196 mg/dL (SD 130
  mg/dL)
• PMH
• Otherwise unremarkable
• FHx
• No vascular disease

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Case Study 3

• Social Hx
• Denies tobacco or EtOH use
• PE
• Height 61" Weight 98 lb
• BP 138/66, 82 Further exam normal
• Labs
• A1C 8.6
• Creatinine 1.3
• Total Cholesterol 150 mg/dL
• HDL 70 mg/dL
• LDL 70 mg/dL
• Triglycerides 50 mg/dL
• Questions Diabetic? Type 1 or Type 2?

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Case Study 4

• 32 year-old African American male presents for
  evaluation of poorly controlled diabetes. His
  diabetes was diagnosed after presenting with DKA
  at age 22 years during rehabilitation from a MVA
  with spinal cord injury that ended football
  career
• Current medications include insulin 70/30 65
  units bid
• Glucose levels are generally in the mid 200s
• Glucometer download reveals average 3.1 readings
  per day and mean glucose 246 mg/dL (SD 55 mg/dL)
• Recent implementation of MNT, though states it
  doesnt seem to make a difference
• Not currently exercising
• PMH Full recovery from spinal cord injury
• FHx Early vascular disease

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Case Study 4

• Social Hx
• No EtOH
• Smokes 1 ppd
• Works as a dispatcher for a trucking firm
• Married and has 3 children
• ROS
• Nocturia Feet always cold
• Blurred vision Denies numbness and
  dysesthesias
• PE
• Height 70" Weight 245 lb BP 162/92, 102
• Waist 44" Chest/cor normal Hypertrophic
  
• Normal pulses Skin tags present
  diffusely
• Hyperpigmented rash on nape of neck
• Questions Diabetes? Type 1 or Type 2?

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The threshold fasting plasma glucose level
recommended for confirming the diagnosis of
diabetes mellitus is __________ mg/dL
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Which of the following medications can cause
hyperglycemia? (Mark all that are true.)A)
Nicotinic acidB) Clozapine (Clozaril)C)
PrednisoneD) SpironolactoneE) Ramipril
(Altace)
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Which of the following lipid-lowering agents can
worsen glycemic control?(Mark all that are
true.)A) Colestipol (Colestid)B) Ezetimibe
(Zetia)C) Gemfibrozil (Lopid)D) Nicotinic acid
(Niacin)E) Atorvastatin (Lipitor)
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Endocrinopathies associated with diabetes
mellitus include which of the following? (Mark
all that are true.)A) Cushing's syndromeB)
AcromegalyC) PheochromocytomaD)
HyperparathyroidismE) Glucagonoma
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Mark all options below that are true regarding
diabetes screening, according to current American
Diabetes Association guidelines.A) A 2-hour
glucose challenge test is the recommended
screenB) Screening at 3-year intervals is
recommended in individuals with a BMI gt
25.0 kg/m2, beginning at age 45C) Screening
should be considered in all women who have
delivered a baby weighing over 9 lbD) Community
screening for diabetes is felt to be valuable
and cost-effectiveE) Measurement of hemoglobin
A1c has no role in screening for diabetes
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List three conditions included in the
differential diagnosis of a high anion gap
metabolic acidosis1. _______________2.
_______________3. _______________
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A 16-year-old male has a 1-week history of
polyuria, polydipsia, and polyphagia. On
laboratory evaluation he is found to have a serum
glucose level of 270 mg/dL, a serum bicarbonate
level of 9 mEq/L (N 2226), a serum pH of 7.0,
and a serum potassium level of 4.0 mmol/L
(N3.55.0).Which one of the following most
accurately describes this patient's total body
potassium?A) Mild total body potassium
excessB) Normal total body potassium storesC)
Mild total body potassium deficiencyD) Severe
total body potassium deficiency
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A 58-year-old obese male comes to your office
with a 2-week history of fatigue associated with
polyuria, polydipsia, and weight loss. You
suspect he has type 2 diabetes. This diagnosis
would be corroborated by a random glucose level
greater than or equal to ________ mg/dL
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A 63-year-old handyman is brought to the
emergency department unconscious. His temperature
is 38.1 C (100.6F) rectally, blood pressure
90/70 mmHg, pulse 128 beats/min, and respirations
13/min. The examination is otherwise
unremarkable except for very dry skin and mucous
membranes.Laboratory FindingsSerum sodium
............................. 150 mmol/L (N
135-145)Serum potassium .........................
.. 3.2 mmol/L (N 3.5-5.0)Serum chloride
............................ 107 mmol/L
(N100-108)CO2 ...................................
.............. 22 mmol/L (N 24-30)Serum glucose
...............................................
1080 mg/dLSerum creatinine ......................
....... 4.0 mg/dL (N 0.6-1.5)BUN
..................................................
.. 70 mg/dL (N 8-25)Serum ketones
................................. small amount
presentAdjusting for the hyperglycemia, what is
the patient's corrected serum sodium level?
____________ mmol/L
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A 16-year-old female is admitted to the hospital
with a 1-week history of polyuria, polydipsia,
and polyphagia. Examination reveals a lethargic,
volume-depleted female with the smell of acetone
on her breath. Her blood pressure is 96/70 mm Hg,
her pulse rate is 120 beats/min, and she has
Kussmaul respirations at a rate of
32/min.Laboratory FindingsSerum glucose
................................................
525 mg/dLSerum sodium ...........................
... 122 mEq/L (N 135145)Serum potassium
........................... 3.1 mmol/L (N
3.55.0)Chloride ................................
....... 95 mmol/L (N 100108)CO2
..................................................
. 7 mmol/L (N 2430)Arterial blood gasespH
..................................................
. 7.10 (N 7.357.45)pCO2 ........................
..................... 15 mm Hg (N 3545)pO2
.............................................. 98
mm Hg (N 80100)After initiation of intravenous
fluid therapy, which one of the following should
be done next?A) Initiation of insulin therapyB)
Potassium replacementC) Bicarbonate therapyD)
Phosphate therapyE) Dexamethasone therapy
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At a routine health maintenance visit, a
42-year-old obese male is found to have a fasting
plasma glucose level of 118 mg/dL. Which one of
the following is the most appropriate initial
intervention for preventing or delaying the
development of diabetes in this patient?A)
Lifestyle modificationB) Metformin
(Glucophage)C) A thiazolidinedioneD) An oral
sulfonylurea agentE) An ACE inhibitor
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Mark all options below that are true regarding
the use of thiazolidinediones (TZDs).A) The
full hypoglycemic effect is seen 2 weeks
after the initiation of a given doseB) The
hypoglycemic effect is comparable to that of
metformin (Glucophage) or a sulfonylureaC)
Monitoring of liver enzymes is recommendedD)
Weight gain and edema are commonly
associated with their useE) Their mechanism of
action is enhancement of insulin
sensitivity
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A 62-year-old female is diagnosed with type 2
diabetes on the basis of consecutive fasting
plasma glucose levels of 138 mg/dL and 143 mg/dL.
Which of the following should be prescribed as
part of her initial management? (Mark all that
are true.)A) Lifestyle interventionB)
Metformin (Metformin)C) An oral sulfonyureaD) A
thiazolidinedioneE) Pramlintide
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Hypoglycemia is a possible side effect of which
of the following diabetes agents? (Mark all that
are true.)A) InsulinB) Pioglitazone (Actos)C)
Metformin (Glucophage)D) SulfonylureasE)
Repaglinide (Prandin)F) Acarbose (Precose)
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A 29-year-old female with polycystic ovary
syndrome asks if you can correct her
oligomenorrhea and infertility. Her fasting
glucose level is 100 mg/dL and she has a normal
glycosylated hemoglobin level. Which of the
following diabetes medications have been found to
address these problems? (Mark all that are
true.)A) Glyburide (Micronase, DiaBeta)B)
Metformin (Glucophage)C) Pioglitazone (Actos)D)
Miglitol (Glyset)E) Repaglinide (Prandin)
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Mark all options below that are true regarding
the use of metformin (Glucophage).A) Its
efficacy as a hypoglycemic agent is comparable
to that of sulfonylureasB) It has a lower
secondary failure rate than sulfonylureasC) Its
hypoglycemic effect is additive to the action of
sulfonylureasD) Gastrointestinal side effects
cause 20-30 of patients to discontinue its
useE) It is contraindicated in patients with a
serum creatinine exceeding 1.5 mg/dL for males or
1.4 mg/dL for females
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Which of the following oral agents should be
used with caution in patients with advanced heart
failure? (Mark all that are true.)A)
ThiazolidinedionesB) Metformin (Glucophage)C)
SulfonylureasD) MeglitinidesE)
Alpha-glucosidase inhibitors
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At a routine health maintenance visit, a
42-year-old obese male is found to have a fasting
plasma glucose level of 118 mg/dL. Which one of
the following is the most appropriate initial
intervention for preventing or delaying the
development of diabetes in this patient?A)
Lifestyle modificationB) Metformin
(Glucophage)C) A thiazolidinedioneD) An oral
sulfonylurea agentE) An ACE inhibitor
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Hypoglycemia is a possible side effect of which
of the following diabetes agents? (Mark all that
are true.)A) InsulinB) Pioglitazone (Actos)C)
Metformin (Glucophage)D) SulfonylureasE)
Repaglinide (Prandin)F) Acarbose (Precose)
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Which one of the following oral agents is most
likely to produce weight loss in the diabetic
patient?A) ThiazolidinedionesB) Metformin
(Glucophage)C) SulfonylureasD) MeglitinidesE)
Alpha-glucosidase inhibitors
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Which one of the following types of insulin
should never be mixed with any other form of
insulin?A) LenteB) UltralenteC) Insulin
glargineD) NPHE) Insulin lispro
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A 42-year-old female with a body mass index
(BMI) of 31 kg/m2 has a 3-week history of
polyuria and polydipsia, accompanied by a 10-lb
weight loss. Her fasting plasma glucose level is
320 mg/dL, and her hemoglobin 1c A level is
11.1. Initial treatment with which one of the
following will reverse glucose toxicity and
improve glycemic response?A) Metformin
(Glucophage)B) Pioglitazone (Actos)C) Glipizide
(Glucotrol)D) Acarbose (Precose)E) Insulin
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Patients must eat within 15 minutes of
administration of which one of the following
types of insulin?A) LenteB) Insulin
glulisineC) Insulin glargineD) NPHE) Insulin
lispro
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A 58-year-old male with type 2 diabetes is
started on a twice-daily insulin regimen
consisting of 20 units of NPH/10 units of regular
insulin in the morning and 10 units of NPH/4
units of regular insulin in the evening before
dinner. His fasting glucose levels have generally
been in the 140-180 mg/dL range, as have his
glucose levels just before lunch and dinner.He
complains of frequent midmorning hypoglycemic
episodes requiring midmorning snacks, as well as
hypoglycemic episodes just before bedtime, also
requiring snacks.Which one of the following
adjustments is most likely to be effective?A)
Reduce the regular insulin dosageB) Reduce the
NPH dosageC) Have the patient eat later in the
morning and eveningD) Have the patient increase
meal sizes at breakfast and dinnerE) Change the
patient's regimen to insulin glargine in the
evening and insulin lispro for each meal
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Mechanisms of action of exenatide (Byetta)
include which of the following? (Mark all that
are true.)A) Enhanced insulin secretionB)
Suppression of glucagon secretionC) Enhanced
insulin sensitivity of muscleD) Slowing of
gastric motilityE) Reduction of the rate of
polysaccharide digestion in the small
intestine
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Matt is a 19 year old type 1 diabetic who is in
college. He is on insulin glargine 25 units
daily. He uses insulin glulisine at meals in a 1
unit to 10 grams carbohydrate ratio. His most
recent HbA1C was 7.1. He is in college and you
are his primary care physician. He expresses
frustration to you because he is having frequent
hypoglycemia. In fact, he recently had to be
transported to an ER because his college found
him unresponsive. His blood glucose was 22 mg/dl
when paramedics arrived.His problem times
include mornings when he sleeps in and often with
exercise. Outside of those times his fasting
glucoses are between 120 and 150 mg/dl. He
wonders what his options are. Which of the
following is the best recommendation to help
him a) lower the insulin glargine dosage b)
lower the insulin to carbohydrate ratio c)
consider an insulin pump d) set his alarm when
he plans on sleeping