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GO! Diabetes Train the Trainer Program

GO! Diabetes Train the Trainer Program. Case Study Compilation and Questions. Case Study #1.

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GO! Diabetes Train the Trainer Program

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  1. GO! DiabetesTrain the Trainer Program

  2. Case Study Compilation and Questions

  3. 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

  4. 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?

  5. 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

  6. 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?

  7. 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 30’s to mid 500’s 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

  8. 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 • QuestionsDiabetic? Type 1 or Type 2?

  9. 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 200’s • 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 doesn’t seem to make a difference” • Not currently exercising • PMH Full recovery from spinal cord injury • FHx Early vascular disease

  10. 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?

  11. The threshold fasting plasma glucose level recommended for confirming the diagnosis of diabetes mellitus is __________ mg/dL

  12. Which of the following medications can cause hyperglycemia? (Mark all that are true.)A) Nicotinic acidB) Clozapine (Clozaril)C) PrednisoneD) SpironolactoneE) Ramipril (Altace)

  13. 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)

  14. Endocrinopathies associated with diabetes mellitus include which of the following? (Mark all that are true.)A) Cushing's syndromeB) AcromegalyC) PheochromocytomaD) HyperparathyroidismE) Glucagonoma

  15. 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 > 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

  16. List three conditions included in the differential diagnosis of a high anion gap metabolic acidosis:1. _______________2. _______________3. _______________

  17. 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 22–26), a serum pH of 7.0, and a serum potassium level of 4.0 mmol/L (N3.5–5.0).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

  18. 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

  19. A 63-year-old handyman is brought to the emergency department unconscious. His temperature is 38.1° C (100.6°F) rectally, bloodpressure 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 Findings:Serum 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

  20. 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 135–145)Serum potassium ........................... 3.1 mmol/L (N 3.5–5.0)Chloride ....................................... 95 mmol/L (N 100–108)CO2 ................................................... 7 mmol/L (N 24–30)Arterial blood gasespH ................................................... 7.10 (N 7.35–7.45)pCO2 ............................................. 15 mm Hg (N 35–45)pO2 .............................................. 98 mm Hg (N 80–100)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

  21. 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

  22. 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

  23. 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

  24. 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)

  25. 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)

  26. 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

  27. 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

  28. 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

  29. 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)

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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

  35. 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

  36. 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

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