Type II DM

Question 1

Most important pathophysiologic features in Type 2 DM

Answer 1

1. Insulin resistance
2. Impaired insulin secretion

Question 2

Post-prandial hyperglycemia is due to? (3)

Answer 2

1. Abnormal insulin secretion
2. Impaired regulation of gluconeogenesis
3. Impaired glucose intake into tissues

Question 3

Fasting hyperglycemia is due to? (2)

Answer 3

Gluconeogenesis and glycogenolysis

Question 4

Major sites of insulin resistance (3)

Answer 4

1. Liver
2. Skeletal muscle
3. Adipose tissue

Question 5

What is the most significant morbidity associated with DM neuropathy?

Answer 5

Foot ulceration

Due to: Peripheral neuropathy, excessive plantar pressure, repetitive trauma, peripheral vascular disease, wound-healing disturbances

Question 6

Predominant pathogen in DM ulcer

Answer 6

S. aureus
Aerobic gram (+) cocci

Chronic wounds with prior antibiotic tx: Gram negtive rods
Foot ischemia and gangrene: Obligate anaerobic microorganisms

Question 7

Characterize venous ulcers

Answer 7

Above malleoli
Irregular borders

Question 8

Characterize arterial ulcers

Answer 8

Toes or shins
Pale “punched out” borders
Painful

Question 9

Characterize Diabetic ulcers

Answer 9

Areas of increased pressure or friction

Any ulceration should be unroofed and probed using a blunt-ended rigid sterile probe to determine depth

Question 10

Gold standard for diagnosing lower extremity osteomyelitis in patients with DM foot ulcers

Answer 10

Bone biopsy

Question 11

Glyemic goals in T2DM

Answer 11

Premeal plasma glucose: 80-130mg/dl
Postprandial plasma glucose: <180mg/dl
HBA1c: <7.0%

Question 12

Dose of metformin that may be given for a newly diagnosed diabetic patient in the ED

Answer 12

500mg/day

for GFR greater or equal to 30ml/min/1.73m2

may be increased if needed each week to max 2g/day

Question 13

Define acute severe hyperglycemia

Answer 13

> 300mg/dl + polyuria, weight loss, fatigue, BOV, Neuropathic symptoms

precipitants: glucose altering medications: corticosteroids, sympathomimetics, diuretics, anticonvulsants, salicylates, B adrenergic receptor agonists, Infections , ACS, CVD

Question 14

Therapy for acute severe hyperglycemia

Answer 14

Regular human insulin or lispro

0.1 to 0.15u/kg TIV

Given q1-2hrs if glucose does not fall at least 50mg/dl

Question 15

Acceptable duration of use for the insulin sliding scale

Answer 15

12 to 24 hours

Oral agents should be substituted with insulin

Question 16

Goal Blood Glucose in critically ill patients in the ED

Answer 16

140 to 180mg/dl

stringent control of <110 increases mortality

Question 17

Goal Blood Glucose in non critial patients on SQ insulin

Answer 17

Pre meal glucose: <140mg/dl
Random blood glucose: <180mg/dl

Question 18

Describe insulin regimen for patients with hyperglyemia in the ED for observation

symptomatic hyperglycemia

Answer 18

Basal + prandial dosing, i.e., Long/intermediate acting insulin + short acting insulni

Total dose: 0.2 to 0.5u/kg/day
-half as basal, half as prandial (divided into 3 if able to eat, or every 4-6 hrs if enteral/parenteral)

Question 19

Guidelines for hospital admission for T2DM (6)

Answer 19

1. Life threatening metabolic decompensation (DKA/ HHS)
2. Severe chronic complications of DM, acute comorbidities, inadequate social situations
3. Hyperglycemia (>400mg/dl) with severe volume depletion refractory to interventions
4. Hypoglycemia with neuroglycopenia that does not resolve with correction of hypogly
5. Hypoglycemia from long acting oral hypoglycemia agents or unkown cause
6. Fever without an obvious source

table 224-7

if discharged, follow up in 1 week