Question 11
What are the targets of the following in a middle-aged, otherwise healthy person with diabetes, with no complications, who can detect and treat hypoglycemia?
A1C (based on what trial in T1DM and in T2DM), pre-meal glucose, 2-hr pc glucose:
A1C: <7% (Trials: DCCT for T1DM; UKPDS for T2DM)
Pre-meal glucose: 4-7 mmol/L
2-hr pc glucose: <10 mmol/L
LDL-cholesterol (name one trial this advice is based on):
LDL-cholesterol <2 mmol/L (Trial: HPS; CARDS)
BP (name one trial this advice is based on):
BP <130/80 (Trial: HOT, ABCD)
ACR (male and female):
ACR (male): <2.0
ACR (female): <2.8
Question 12
What antihypertensive agents would you use (in order) to lower blood pressure in a hypertensive patient with diabetes:
With microalbuminuria?
ACE inhibitor, or ARB first line.
Without microalbuminuria?
Any of the following:
- ACE inhibitor
- ARB
- DHP calcium channel blocker
- Thiazide-like diuretic (may need ACEi or ARB for vascular protection)
Question 13
James Band is a 17 year-old young man (previously well) who presents with 8 kg unintentional weight loss, polyuria and polydipsia. He is oriented but drowsy, BP 100/60 HR 88 supine, 80/p, HR 110 standing. Labs: glucose 24 mmol/l, Na 130, K 3.5, Cl 95, HCO3 8, positive serum ketones. The ER doctor has already given him 1 litre of normal saline and 8 units regular insulin i.v. push, and another 8 units iv over the past hour.
What is your biggest concern?
Hypokalemia; potassium should have been given before the insulin.
When would you consider giving sodium bicarbonate?
For arterial pH <7.0; in this case, it would be dangerous, because this would also drop potassium.
What would you monitor to ensure insulin dose is working (glucose, serum bicarbonate, serum anion gap, serum ketones)? What is your rationale?
Anion gap should be used.
Rationale:
- Glucose will fall because of EFCV re-expansion, plus glucose diuresis.
- Serum ketones will become more positive as keotacidosis is treated, because b-OH butyrate (not measured) and Acetoacetate (measured) will be converted to Acetone (measured, but not an acid).
- Serum bicarbonate will level off around 18 mmol/L because ketoacid anions have been lost in the urine with sodium and potassium and thus are not available to regenerate bicarbonate, so ketoacidosis is temporarily replaced with non-harmful non-anion gap metabolic acidosis.
Question 14
What are the five main priorities in the management of diabetic foot ulcer?
- Debride and dress the wound
- Need for antibiotics: Culture: oral meds (mild infection):
- Clindamycin 300 mg qid OR
- Cephalexin (Keflex) 250-500 mg q 6 hr…
- …OR Dicloxacillin 250 mg q 6 hr
- Pressure off-loading
- Revascularization
- Glucose control
Question 15
Anita Blythe is a 24 year-old woman with a 4-month history of amenorrhea and galactorrhea.
List 5 reasons why her prolactin may be elevated.
- Physiologic:
- pregnancy
- breast feeding
- nipple stimulation
- Drug induced:
- Dopamine antagonist
- domperidone
- Endocrine:
- Primary hypothyroidism
- Addison’s disease
- Decreased clearance:
- renal failure
- hepatic failure
- Central:
- prolactinoma
- stalk-effect from pituitary macroadenoma
- Macroprolactin (unlikely, since symptomatic)
What is the primary therapy for a symptomatic prolactinoma?
Dopamine agonists: cabergoline, bromocriptine, or quinagolide.
