Diagnosis and Screening Management, Part 1

Question 1

Condition due to near complete or total absence of circulating insulin

Answer 1

Type I DM

Question 2

Type I diabetics eventually require ___ to survive

Answer 2

insulin

Question 3

What causes type II DM?

Answer 3

insulin resistance, decreased insulin secretion, increased hepatic glucose production
“Ominous Octet”

Question 4

Many signs and symptoms of DM are related to _____, its resultant _____, and ______ associated with diabetes

Answer 4

hyperglyceumia, hyperosmolality, glycosuria

Question 5

What are the 3 polys in diabetes?

Answer 5

Polyuria
Polydipsia
Polyphagia

Question 6

S/S of type I DM

Answer 6

3 polys
Weight loss
Postural hypotension
Weakness
Blurred vision
Peripheral neuropathy
Chronic infections, dry skin, poorly healing wounds
Severe: marked dehydration, ketoacidosis

Question 7

What are risk factors for type I DM?

Answer 7

Family history
Genetics
Geography-further from the equator
4-7 y/o, 10-14 y/o
Low vitamin D, cow’s milk, viral exposure

Question 8

What are s/s of Type II DM

Answer 8

Insidious onset
Polys
Overweight or obese weight
Blurred vision
Peripheral neuropathy
Chronic infections, dry skin, itching, poorly healing wounds
Severe: marked dehydration, hyperglycemic hyperosmolar state

Question 9

What are risk factors for Type II DM?

Answer 9

Family history
Native americans, blacks, latino/a, asians, NHOPI
Overweight or obese
Physical inactivity
Gestational DM, IGT, IFG, or A1C >5.6
Women who delivered baby >9 lbs
Metabolic syndrome, acanthosis nigricans, PCOS, CV disease

Question 10

What are exam findings of DM?

Answer 10

Poorly healing wound/foot ulcer
Candidal vulvovaginitis/balanoposthitis
Rash in intertriginous fold
Acanthosis nigricans

Question 11

why does hypoglycemia occur in DM?

Answer 11

combination of epinephrine and decreased CNS levels of glucose

Question 12

What are s/s of hypoglycemia

Answer 12

Neuro
Autonomic

Question 13

Who should be screened for DM?

Answer 13

Everyone starting at age 45
Any age if overweight or obese, and have 1+ DM risk factors
Gestational DM (1st prenatal visit if risk factors, otherwise at 24-28 weeks)
HIV + patients

Repeat every 3 years

Question 14

How can DM screening be done?

Answer 14

using A1C, FPG, or 2-hr PG after 75 g OGTT

Question 15

What are normal fasting plasma glucose levels? A1C?

Answer 15

70-99 mg/dL, 4-5.6%

Question 16

What is a prediabetic fasting plasma glucose? A1C?

Answer 16

100-125 mg/dL, 5.7-6.4%

Question 17

What is a diabetic fasting plasma glucose? A1C?

Answer 17

126 mg/dL or higher, 6.5% or higher

Question 18

what are indications for fasting, capillary BG?

Answer 18

identification of BG levels
Screening or monitoring DM/prediabetes

Question 19

How does a sample being plasma/whole blood impact the sample?

Answer 19

Plasma will have higher BG than whole blood

Question 20

If a venipuncture/arterial puncture is used to get BG what is something to keep in mind?

Answer 20

arterial samples tend to be 3-5 mg/dL higher than venous samples

Question 21

What factors can cause a elevation in blood glucose?

Answer 21

Major physical stressors
Steroids
Caffeine
Hct
Pregnancy
IV fluids containing sugars

Question 22

What factors can cause a decrease in blood glucose?

Answer 22

Acetaminophen
Alcohol
High uric acid levels
Hct >50%

Question 23

How could you interpret a high blood glucose other than prediabetes or diabetes?

Answer 23

acute stress response, cushing syndrome, pheochromocytoma, pancreatitis, chronic renal failure

Question 24

What are indications of hemoglobin A1C?

Answer 24

diagnosis and monitoring of abnormal glycemic states, primarily prediabetes and DM

Question 25

What can cause hemoglobin A1C to be falsely depressed?

Answer 25

Hemoglobinopathies, in particular high levels of HbF Young RBCs: shortened erythrocyte survival, decreased mean erythrocyte age, IV iron or erythropoietic drugs Abnormally low protein levels

Question 26

What can cause hemoglobin A1C to be falsely elevated other than diabetes?

Answer 26

Old RBCs (splenectomy) Prolonged or recurrent acute stress response

Question 27

What are interpretations of high A1C?

Answer 27

Diabetes Prediabetes Nondiabetic hyperglycemia Splenectomy

Question 28

What are interpretations of low A1C?

Answer 28

hemolytic anemia chronic blood loss chronic renal failure

Question 29

What are indications for glucose tolerance testing?

Answer 29

assist with DM diagnosis, assist with hypoglycemia evaluation

Question 30

How is glucose tolerance testing done?

Answer 30

Glucose load is administered to patients and glucose measured at start of test and at 30 min, 1 hr, 2 hr, 3 hr, 4 hr Ideally in AM

Question 31

What are side effects of glucose tolerance testing?

Answer 31

May cause dizziness, tremors, anxiety, sweating, or fainting

Question 32

What are patient education points prior to glucose tolerance testing?

Answer 32

Low carb diets can interfere with insulin release and cause abnormal results Should avoid physical activity and smoking until test is complete

Question 33

What are interfering factors with glucose tolerance testing?

Answer 33

acute stress response endocrine disorders exercise fasting or reduced dietary intake prior to test smoking vomiting

Question 34

What are indications for C-peptide and C-peptide/insulin ratio

Answer 34

evalutation of beta-cell function; identify causes of hypoglycemia; evaluation of insulinomas

Question 35

Why might measuring c-peptide be helpful?

Answer 35

If patient has anti-insulin antibodies Factitious hypoglycemia Patient on exogenous insulin Unknown if patient is a type 1 or type 2 diabetic

Question 36

If a patient has increased c-peptide, what could that means?

Answer 36

Renal failure; sulfonylureas, pancreas transplant

Question 37

If a patient has decreased c-peptide, what could that means?

Answer 37

destruction of all or part of the pancreas

Question 38

What are indications for ketones testing?

Answer 38

evaluation for the presence of ketosis either in urine or serum

Question 39

What are general goals of treating DM?

Answer 39

achieve glycemic control Reduce or eliminate long-term complications Maintain quality of life and overall wellbeing: DMSES

Question 40

What are goal levles for patients with DM/

Answer 40

Hemoglobin A1C <7 Preprandial capillary glucose 80-130 mg/dL Postprandial capillary glucose <180 mg/dL Check A1C every 3-6 months

Question 41

Consider a lower target A1C if

Answer 41

shorter diabetes duration long life expectancy T2DM tx with lifestyle or metformin only No significant CVD/vascular complications

Question 42

Consider a higher target A1C if

Answer 42

severe hypoglycemic history Severe disease Long-term DM patients

Question 43

How are pediatric glycemic control guidelines different?

Answer 43

A little less stringent, A1C <7.5

Question 44

At every visit what should you ask about?

Answer 44

Hypoglycemic episodes Advise patients to carry glucose tablets/gel Can give glucagon if at risk for severe hypoglycemia

Question 45

If a patient is conscious what can you do for hypoglycemia?

Answer 45

Give 15-20 g of glucose orally

Question 46

If a patient is unconscious, what can you do for hypoglycemia?

Answer 46

IV glucose, injectable or nasal glucagon kit

Question 47

If hypoglycemia is frequent, severe, or no s/s

Answer 47

re-evaluate therapy to reduce hypoglycemia incidence if pre-exercise glucose is <100 mg/dL, consider ingesting carbs

Question 48

Self monitoring

Question 49

What are diet therapy guidelines?

Answer 49

Medical nutrition therapy for all DM patients Preferred to use a diabetes educator or dietitian who is experienced with DM patients

Question 50

What are goals of MNT?

Answer 50

Healthful eating pattern to improve overall well-bieng Achieving goals for glycemic control, weight, BP, and lipids Delay or prevent DM complications

Question 51

What are exercise guidelines for DM?

Answer 51

Regular exercise for weight control, improved insulin sensitivity, improved CV health at least 150 min/week of moderate aerobic exercise divided over 3+ days No more than 2 consecutive days without exercise Resistance training 2+ days/week Try to spend no more than 30-90 minutes at a time in a sedentary position

Question 52

What are risk of exercise?

Answer 52

hypoglycemia, cardiovascular complications, and injury

Question 53

What are immunization guidelines for DM?

Answer 53

All patients should receive routine vaccinations Influenza vaccine Pneumococcal vaccine Hepatitis B vaccine COVID19 vaccine