Diabetes mellitus
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Transcript Diabetes mellitus
Diabetes Mellitus
A PRESENTATION BY
MEIGHAN O’CONNOR, POPPF
DIDACTICSONLINE.COM
Case Presentation
CC: fatigue and abdominal pain
HPI: 7 y/o male reports above sx for past 3 months.
Mother says he has been less active, taking more
naps and wetting his bed, which he stopped doing 2
years prior.
Pmhx, Pshx, Famhx: unremarkable
ROS: Pertinent positives include weight drop from
the 75th percentile to the 50th percentile despite
report from mother that his food and drink intake
has increased.
Objective
Labs to be ordered:
WBC count, Urinalysis, Glucose level
Labs return:
WBC: 11,400/mm^3
BUN: 14 mg/dL, Creatinine: 1.2 mg/dL, Sodium: 132 mEq/L,
Potassium: 5.0 mEq/L, Chloride: 100mEq/L
Glucose: 350 mg/dL
General: child appears lethargic but AOx3
Skin: Appears dehydrated, no erythema or lesions
HEENT, Heart, Lungs, Abdomen: negative findings
Osteopathic Structural Exam: T7-9ERrSr with
hypertonic paraspinals, CRI slow, decreased
Assessment and Plan
Diabetes Mellitus Type I
Family and patient is trained in how to administer insulin,
check blood glucose levels, check for ketonuria, recognize
hypoglycemia and how to treat it.
Family and patient is counseled on nutrition and timing of
carbohydrates and how to measure, rotate and adjust insulin
doses depending on the time of day, physical activity and
food/drink intake.
F/U in two weeks.
Eventually F/U appointments need to be made every 6 mo. to
check weight, BP, eyes, extremities. Future concerns include
ETOH intake and depression/mental illness.
Type I
Type IA diabetes is suggested by reduced insulin and the
presence of pancreatic (islet) autoantibodies.
Type IA vs. type IB
Type I diabetes also is usually suggested by reduced
insulin and c-peptide levels.
Uncertain etiology
Peak onset bimodal:
4-6 and 10-14 years of age
Prevalence in US:
2/1000 non-Hispanic whites
Slightly lower in other ethnic
groups
Type I
Classic new onset—most common presentation
Diabetic ketoacidosis—very severe
Deep, rapid breathing
Dry skin and mouth
Flushed face
Fruity smelling breath
Nausea and vomiting
Stomach pain
Incidental finding—take thorough hx of all patients,
no matter how young.
Case Presentation
CC: new pt, physical exam
HPI: 30 y/o African American female presents for
PE. Claims to be in good health but mentions she is
urinating more frequently and has had several UTIs
in the past year.
Meds: Metoprolol
Pmhx: HTN; Pshx: unremarkable
Famhx: Father and Gmother + heart attacks,
Mother, Aunt, Sister + diabetes.
Objective
Vitals:
BP: 125/90 right arm; RR: 14 breaths/min; HR: 85 beats/min
PE:
General: Morbid obesity at BMI of ~48 kg/m2
Heart, Lungs, Abdomen: negative findings
Urine dipstick: 2+ glucosuria
Random plasma glucose: 240 mg/dL
Osteopathic Structural Exam:
Hypertonic pelvic and abdominal diaphragm, hypertonic
paraspinals T7-9, and diminished CRI
Assessment and Plan
Diabetes Mellitus type II
Diet, exercise weight reduction
Oral hypoglycemic agent
Avoidance of macro/microvascular
complications
F/U in 2 weeks and
eventually every 6
months to check
weight, BP, eyes
extremities and
renal function.
Type II
Prevalence in the US:
0.18 per 1000 non-Hispanic white youth 10-19 years old
1.06 and 1.45 per 1000 African-American and Navajo youth,
respectively.
All ages: 25.8 million people, or 8.3% of the U.S
Risk factors:
Positive family history
Obesity
Female gender
Pregnancy
Type II
Sx:
Commonly asymptomatic
Increased thirst, increased frequency of urination, blurred
vision
Glucose testing
Random blood glucose test
Fasting blood glucose test
Hemoglobin A1C level
Oral glucose tolerance test
Type II
Diagnostic Criteria:
Sx of diabetes and a random blood sugar of 200 mg/dL (11.1
mmol/L) or higher
A fasting blood sugar level of 126 mg/dL (7.0 mmol/L) or
higher
A blood sugar of 200 mg/dL (11.1 mmol/L) or higher two
hours after an oral glucose tolerance test.
An A1C of 6.5 percent or higher
The blood tests must be repeated on another day to confirm
the diagnosis of diabetes.
Type II
Complications:
Macrovascular
Heart disease
Stroke
Peripheral vascular disease
Microvascular
Retinopathy
Nephropathy
Neuropathy
Infections
Staph infection at injection site
Fungal infections involving oral mucosa, genitals, skin and nails
Treatment
Medical:
Type I:
Short acting insulin= lispro or insulin
Intermediate acting= NPH
Long acting: Lente or Ultralente
Type II:
Biguanides: Metformin, mc first line
Sulfonylureas: Tolbutamide, Chlorpropamide, Glipizide
Glitazones: Pioglitazone, Rosiglitazone
Alpha-glucosidase Inhibitors: Acarbose, Miglitol
Treatment
Osteopathic:
We can directly improve circulation which indirectly enhances
hormone release, cellular uptake and cellular response and helps the
patient avoid infection.
Pancreas T7-9:
Abdominal and pelvic diaphragm release and rib raising
Remove restrictions and SD, improve and maintain ROM thereby
helping the pt stay active and proactive in their own health
Cranial
To improve circulation and lymphatic flow
Treat legs and feet
Treat paraspinals, somatic dysfunctions
Improve CRI=improve flow of blood, nutrients from the CSF and
lymphatics
Compile exercise and nutrition/diet program or refer to specialists
References
First Aid, Case Reports for the USMLE Step 1
Pub Med, Ketoacidosis
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001363/
CDC, Prevalence of Diabetes Mellitus in US
http://www.cdc.gov/diabetes/projects/cda2.htm
Up To Date, Diabetes Mellitus I and II
http://www.uptodate.com.ezproxylocal.library.nova.edu
American Diabetes Association Home Page
www.diabetes.org
Rediscovering the classic osteopathic literature to advance contemporary
patient-oriented research: A new look at diabetes mellitus. John C
Licciardone. http://www.om-pc.com/content/2/1/9
An osteopathic approach to type 2 diabetes mellitus. Shubrook JH Jr,
Johnson AW.
Common crossroads in diabetes management. Michael Valitutto