This document discusses diagnosing and managing diabetes. It presents the case of a 45-year-old female who presented with numbness and weakness in her lower extremities. Her initial impression was type 2 diabetes mellitus based on her family history, symptoms of polydipsia and polyuria, and weight loss. The document then reviews diabetic complications, treatment options, and guidelines for managing blood glucose, blood pressure, lipids, and other risk factors.

1. Diagnosing DiabetesJoseliza de la Cruz, M.D.Tiffany Chu, RN

2. S.B. 45 y/o F from SampalokCC: numbness over lower extremities 3 days PTC weakness with easy fatigability no chest pain, epigastric pain or back pain self medicated with Paracetamol and No consult done 1 day PTC weakness persisted numbness over lower extremities “karayomnatumutusok” no blurring of vision Consult

3. ROS: (-) cough, colds, fever(-) SOB, orthopnea, PND(+) occ. Palpitations, (-) chest pain(+)polydipsia (10-12 glass of water and soda)(-) epigastric pain, vomiting, change in appetite(-) lbm, constipation(+) polyuria (8x/day) , (-) dysuria, oliguria(+) wt loss PMH: TB 1999 treated for 6 months with no ff up(-) asthma, HPN, Diabetes or kidney dse(-) cancer

4. Ob-Gyne History: G2P2 (2-0-0-2)History of delivering large babies via CSHistory of elevated BS during pregnancyFH: diabetes – father and 2 siblingsHPN – mother (-) CA, Kidney dse, AsthmaPSH: non-smoker, non-alcoholicWorks as a Caterer

5. PE: conscious, coherent, ambulatoryHt: 5’3” Wt: 150 lbs BMI: 26.6BP 150/90 HR 92 RR 18 Temp 37CPink palpebral conjunctivae, anictericscleraeSupple neck, no palpable lymph nodes, neck veins not distendedSymmetrical chest expansion, no retractions, clear breath soundsAdynamicprecordium, normal rate, regular rhythm, no murmursFlabby abdomen with midincisional scar in the hypogastric area, NABS, soft nontenderPulses full and equal, no edema

6. Neurological examGCS 15 CN intact (no ptosis, no facial asymmetry, tongue midline)No motor or sensory deficitsNo babinski

7. Subjective data45 y/o female caterernumbness over lower extremities “karayomnatumutusok”weakness with easy fatigabilitypolydipsia, polyuria, wt loss no chest pain, blurring of visionStrong family history of diabetesHistory of delivering large babies

8. Objective dataBMI: 26.6BP: 150/90 HR92Pink palpebral conjunctivaeClear breath soundNormal rate regular rhythmNo edemaEssentially normal neuro exam

9. Initial impression: DM2Plans: Stat Hgt – 202Instructed TCB in AM with CBC, U/A, FBS, Bun, Crea, Lipid profile, Na, KEKGOphthalmology referral if labs suggestive of DMRx: Paracetamol 500mg/tab prn for pain/ numbness

13. polydipsia, polyuria, wt lossHgt: 202

14. IFG – d/t increased hepatic glucose uptakeInc Hgt – decreased peripheral usage of glucose

15. Complications Acute DKA and HNSChronic Vascular, Nonvascular and Others

16. Table 338-7 Chronic Complications of Diabetes MellitusMicrovascular Eye disease Retinopathy (nonproliferative/proliferative) Macular edema Neuropathy Sensory and motor (mono- and polyneuropathy) Autonomic NephropathyMacrovascular Coronary artery disease Peripheral arterial disease Cerebrovascular diseaseOther Gastrointestinal (gastroparesis, diarrhea) Genitourinary (uropathy/sexual dysfunction) Dermatologic Infectious Cataracts and Glaucoma Periodontal disease

17. Mechanisms of ComplicationsInc intracellular glucose -> AGEsSorbitol pathway - aldosereductase - redox potential DAG - PKC - alters endothelial cells and neuronal structures Hexosamine pathway -F6P in glycosylation and proteoglycan production - altering gene expression of TGF or PAI-1Growth factors VEGF-A - diabetic proliferative retinopathy TGF - diabetic nephropathy - (+) BM production of collagen and fibronectin by mesangial cells Hyperglycemia leads to increased production of reactive oxygen species or superoxide in the mitochondria.

19. Diabetic RetinopathyProliferative diabetic retinopathyHallmark features:Neovascularization near the optic nerve and/or macula and rupture easily+/- vitreous hemorrhage, fibrosis, and retinal detachmentNonproliferative diabetic retinopathy late in the first decade or early in the second decade of the disease Features: Retinal vascular microaneurysmsBlot hemorrhagesCotton wool spots Mild nonproliferative retinopathy 1. changes in venous vessel caliber 2. intraretinalmicrovascular abnormalities 3. numerous microaneurysms and hemorrhagesPathophysiologic mechanisms : d/t retinal ischemia 1. loss of retinal pericytes 2. increased retinal vascular permeability 3. alterations in retinal blood flow, 4. abnormal retinal microvasculature

20. DM Nephropathy1st 5 yearsGlomerularhyperperfusion and renal hypertrophy – Inc GFR

21. thickening of the glomerular BM, glomerular hypertrophy, and mesangial volume expansion occur as the GFR returns to normal 5–10 yearsMicroalbuminuria is defined as 30–300 mg/d in a 24-h collection or 30–300 mg/mg creatinine in a spot collection

22. steady decline of GFR 7-10 yearsMacroalbuminuria - BP elevation Tight glycemic control BP control – ACE/ARBsRDA of 0.8g/kg of protein per daywt: 68kilos protein requirement: 55 g/day

23. Diabetic neuropathyPolyneuropathyMononeuropathyAutonomic neuropathySymptoms:Distal symmetrical painAscending discomfort and numbness from LEUE involvement only after LE involvement is sever Treatment:Tight glycemic controlFoot careAntidepressants - tricyclic antidepressants such as amitriptyline, desipramine, nortriptyline, imipramine SSRI – duloxetine Anticonvulsants - gabapentin, pregabalin, carbamazepine, lamotrigine

24. Gastrointestinal Dysfunctiongastroparesis - delayed gastric emptying anorexia, nausea, vomiting, early satiety, and abdominal bloatingconstipation or diarrhea - altered small- and large-bowel motility How to document? Nuclear medicine scintigraphy after ingestion of a radiolabeled meal1. Smaller, more frequent meals that are easier to digest (liquid) and low in fat and fiber2. Metoclopramide 5–10 mg Domperidone 10–20 mg before each meal3. Noninfectious diabetic diarrhea - loperamide and may respond to octreotide (50–75 g three times daily, SC

25. Diabetic autonomic neuropathy Cystopathy - inability to sense a full bladder and a failure to void completelyTreatment: timed voiding self-catheterization Rx: bethanechol2. ED and retrograde ejaculation - one of the earliest signs of diabetic neuropathy Rx: -PDE5: sildenafil

26. Coronary Artery Disease+DM2 – death rate 2x in men and 4x in womenRisk factors:DyslipidemiaHPNACE, ARB, CCA, CAAn, VD

27. BP goal 125/75 BP: 150/903. PVDs (Foot ulcers)

29. Alpha-glucosidase inhibitors - inhibitors block polysaccharide and disaccharide breakdown and decrease postprandial hyperglycemia when administered with food > Acarbose > MiglitolBiguanidesDecreases liver production of glucoseDecreases intestinal absorption of glucoseImproves cell sensitivity to insulin > MetforminCombinationsGlucovance (Glyburide and Metformin)Avandamet (Avandia and Metformin)

30. D-phenylalinine derivatives - acts directly on the pancreatic β cells to stimulate early insulin secretion >Nateglinide (Starlix)Thiazolidinediones - increase insulin sensitivity in muscle, adipose tissue, and liver specifically bind to the PPAR- (peroxisomeproliferator-activated receptor-) nuclear receptor >Pioglitazone (Actos) >Rosiglitazone (Avandia)CI: CHF and Liver dse

31. Sulfonylureas -stimulate insulin secretion by interacting with the ATP-sensitive potassium channel on the beta cell - ideal for recently dxSE: hypoglycemia weight gain increases CV risks

32. Choice of Initial Glucose-Lowering Agent mild to moderate hyperglycemia - FPG < 11.1–13.9 mmol/L (200–250 mg/dLsevere hyperglycemia - FPG > 13.9 mmol/L (250 mg/dL)Can insulin be used as initial therapy in individuals with severe hyperglycemia ?