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A continuation of last week's case study John Eckersly is a 61 year-old man who is a new patient. He works as a researcher and his only complaint is that he has gained 20 lbs over the past 25 months. He is single and eats out for most of his evening meals. He is relatively sedentary at his job. He spends most evenings watching TV or surfing the Internet. He has 2 grown daughters who live nearby.

Part Four: A continuation of last week's case study: John Eckersly is a 61 year-old man who is a new patient. He works as a researcher and his only complaint is that he has gained 20 lbs over the past 25 months. He is single and eats out for most of his evening meals. He is relatively sedentary at his job. He spends most evenings watching TV or surfing the Internet. He has 2 grown daughters who live nearby.

A continuation of last week's case study (Part C): John Eckersly is a 61 year-old man who is a new patient. He works as a researcher and his only complaint is that he has gained 20 lbs over the past 25 months. He is single and eats out for most of his evening meals. He is relatively sedentary at his job. He spends most evenings watching TV or surfing the Internet. He has 2 grown daughters who live nearby.

A continuation of last week's case study, Part B: John Eckersly is a 61 year-old man who is a new patient. He works as a researcher and his only compliant is that he has gained 20 lbs over the past 25 months. He is single and eats out for most of his evening meals. He is relatively sedentary at his job. He spends most evenings watching TV or surfing the Internet. He has 2 grown daughters who live nearby.

John Eckersly is a 61 year-old man who is a new patient. He works as a researcher and his only compliant is that he has gained 20 lbs over the past 25 months. He is single and eats out for most of his evening meals. He is relatively sedentary at his job. He spends most evenings watching TV or surfing the internet. He has 2 grown daughters who live nearby.

Type 2 diabetes in dogs is just as prevalent as in humans.

A 25-year-old man who has had Type 1 diabetes for 10 years is evaluated for increased frequency of hypoglycemia and fatigue. Hypoglycemic episodes have particularly occurred during the late afternoon and night.

A 12-year-old black boy undergoes his annual physical examination. He has no symptoms, does not participate in any sports, and has a sedentary lifestyle, but he performs well at school. His mother and both maternal grandparents have a history of Type 2 diabetes. His body mass index is 27.6, which is more than the 95th percentile for age and sex. His blood pressure is 110/72 mm Hg. Dark, velvety pigmentation is noted over the back of his neck. The remainder of his physical examination shows no abnormalities. QUESTION: In addition to diet and exercise counseling, which of the following is the most appropriate next step in the evaluation of this patient? A. Measure fasting blood glucose. B. Measure islet cell antibodies. C. Measure 24-hour urinary cortisol. D. Perform a 2-hour oral glucose tolerance test. E. Screen the patient for diabetes when he is age 16 years

A 62-year-old recently retired female school teacher who was diagnosed with Type 2 diabetes 18 years ago comes for a routine evaluation. Her medications include maximum dosages of rosiglitazone, metformin, and repaglinide. She tells you she is very careful about what she eats and walks 30 to 45 minutes 5 or 6 days weekly. She lives with her husband, who is also a retired teacher. Her body mass index is stable at 27, and her hemoglobin A1c value is 9.9%, up from 9.6% 3 months ago. When the physician suggests that insulin is the next step in her treatment program, she reacts very negatively and says, “I have a morbid fear of needles.” QUESTION: Which of the following is the most appropriate response to this patient? A. Tell her that the newer needles are less painful than the older ones. B. Tell her that if her A1c value and body mass index decrease, she will not need insulin. C. Provide as much information about the safety of insulin as possible. D. Ask her what specifically is frightening to her about needles.

A 48-year-old woman who has had Type 2 diabetes mellitus for several years is seen for a routine follow-up evaluation. Her metabolic control has always been very good, with most hemoglobin A1c values less than 6.5%. Her current treatment is metformin 850 mg twice daily. She self-monitors her blood glucose two to three times daily and usually checks random 2-hour postprandial glucose values at least once daily. She notes that her postprandial glucose levels have been above her target of less than 160 mg/dL (8.88 mmol/L) for several weeks, despite increasing her activity level by walking three or four times weekly after dinner. Her body mass index is 29.2. Her blood pressure is 128/86 mm Hg, and her A1c value is 7.2%. Self-monitored blood glucose values from the past week are noted in her log as follows: BLOOD GLUCOSE VALUE, mg/dL Breakfast Lunch Dinner Day Pre Post Pre Post Pre Post Bedtime Comments Sun 96 109 132 — — — Ate pastry Mon 114 207 — — 97 178 — Walked Tue — — — — 136 217 — — Wed 91 235 — 99 83 — — Walked Thu 89 — 121 118 — 261 — — Fri 76 — — — 78 188 — Walked Sat 79 194 — — 148 — — — Pre = preprandial; post = 2-hour postprandial. QUESTION: Which of the following is the most appropriate change to this patient's treatment regimen? A. Increase metformin to 1000 mg twice daily. B. Initiate preprandial fast-acting insulin on nonexercise days. C. Add glargine at bedtime. D. Add a short-acting secretagogue (either repaglinide or nateglinide).

A 36-year-old woman who has had Type 2 diabetes for 2 years is evaluated because she has just discovered that she is 5 weeks' pregnant. She currently takes glyburide and rosiglitazone. Her most recent hemoglobin A1c value was 8.2%. She says she is not checking her blood sugar level frequently but tells you her fasting glucose concentrations have been in the 140 to 160 mg/dL (7.77 to 8.88 mmol/L) range. She has no known microvascular or macrovascular complications of diabetes. Her body mass index is 39; blood pressure is 120/80 mm Hg. Physical examination shows the presence of acanthosis nigricans. Renal and liver functions are normal. QUESTION: Which of the following is the most appropriate treatment for this patient? A. Add premixed 70/30 insulin before breakfast and dinner. B. Continue glyburide and rosiglitazone, refer to a nutritionist for meal plan revision, and prescribe an exercise regimen. C. Continue rosiglitazone, stop glyburide, and start intensive insulin therapy with preprandial insulin lispro and neutral protamine Hagedorn (NPH) at bedtime. D. Stop glyburide and rosiglitazone and start intensive insulin therapy with preprandial insulin lispro and NPH at bedtime.

A 32-year-old male factory worker is brought to the emergency department after becoming ill at work. On admission, his blood glucose is 468 mg/dL (25.97 mmol/L) with moderate ketones. Intravenous insulin and fluids are administered. He is told his diagnosis of diabetes and is taught to administer insulin and monitor blood glucose levels. On discharge, his blood glucose level is 164 mg/dL (9.1 mmol/L). He is prescribed two injections daily of premixed 70/30 insulin and told to make an appointment for further treatment as soon as possible. In addition to developing a treatment plan, which of the following is the most appropriate first step in the management of this patient? A. Assess how he is coping with the news that he has diabetes. B. Provide detailed information about diabetes. C. Refer him for a dilated eye examination. D. Check his urine for albumin.

A 74-year-old man who has had Type 2 diabetes for 20 years is evaluated for possible initiation of insulin treatment. He takes metformin 1000 mg twice daily and glyburide 10 mg twice daily. He recently began measuring his preprandial blood glucose level; his home blood glucose profile for the past week is as follows: BLOOD GLUCOSE VALUE, mg/dL Breakfast Lunch Dinner Day Pre Post Pre Post Pre Post Bedtime Sun 179 — 212 — 202 — 234 Mon 196 — 234 — 186 — 214 Tue 187 — 199 — 212 — 194 Wed 199 — 187 — 198 — 184 Thu 169 — 156 — 172 — 215 Fri 178 — 177 — 176 — 206 Sat 188 — 190 — 201 — 225 Pre = preprandial; post = 2-hour postprandial. He follows a reasonable meal plan with consistent carbohydrate intake at each meal. His exercise routine is to walk for 20 minutes three times per week. Relevant laboratory data are a hemoglobin A1c value of 9.4% and a serum creatinine concentration of 1.8 mg/dL (159.16 µmol/L). Results of liver function tests are normal. QUESTION: To lower glucose levels to an acceptable target in this patient, which of the following is the most appropriate adjustment of his treatment regimen? A. Continue metformin and glyburide, and start basal insulin at night. B. Continue metformin and glyburide, and start 70/30 premixed insulin before supper. C. Stop metformin, continue glyburide, and add rosiglitazone. D. Stop metformin and glyburide, and start 70/30 premixed insulin twice daily.

A 58-year-old woman who has had diabetes for 6 years currently takes metformin 500 mg twice daily. She strictly adheres to her diet and exercise regimen. At a routine evaluation, her blood pressure varies on several readings but remains in the range of 145–150/85–90 mm Hg. Laboratory values are a hemoglobin A1c value of 6.4%, a urine albumin–creatinine ratio of 90 to 120 mg/g on multiple measurements, and a serum creatinine level of 1.0 mg/dL (88.42 µmol/L). Which of the following is now the most appropriate drug therapy for this patient? A. Amlodipine B. Atenolol C. Clonidine patch D. Hydrochlorothiazide E. Valsartan

A 56-year-old woman who has Type 2 diabetes asks her physician to refer her for bariatric surgery. She has had diabetes for 16 years and has been treated with metformin and insulin. She also takes atorvastatin. Her total cholesterol is 170 mg/dL (4.4 mmol/L), LDL cholesterol is 110 mg/dL (2.84 mmol/L), and hemoglobin A1c value is 6.1%. She has gained 1 to 2 kg (2.2 to 4.4 lb) each year since she started taking insulin. Her current body mass index is 36. She says she has been overweight since she was an adolescent and is now “desperate to lose weight.” Which of the following actions should be taken before referral for bariatric surgery? A. Check with the patient's insurer for referral requirements for bariatric surgery coverage. B. Refer for assessment of cardiac risk associated with surgery. C. Refer to a dietitian for medical nutrition therapy. D. Refer for psychological assessment.

A 74-year-old man who has had Type 2 diabetes for 20 years is evaluated for possible initiation of insulin treatment. He takes metformin 1000 mg twice daily and glyburide 10 mg twice daily. He recently began measuring his preprandial blood glucose level. His home blood glucose profile for the past week is as follows: BLOOD GLUCOSE VALUE, mg/dL Breakfast Lunch Dinner Day Pre Post Pre Post Pre Post Bedtime Sun 179 — 212 — 202 — 234 Mon 196 — 234 — 186 — 214 Tue 187 — 199 — 212 — 194 Wed 199 — 187 — 198 — 184 Thu 169 — 156 — 172 — 215 Fri 178 — 177 — 176 — 206 Sat 188 — 190 — 201 — 225 Pre = preprandial; post = 2-hour postprandial. He follows a reasonable meal plan with consistent carbohydrate intake at each meal. His exercise routine is to walk for 20 minutes three times per week. Relevant laboratory data are a hemoglobin A1c value of 9.4% and a serum creatinine concentration of 1.8 mg/dL (159.16 µmol/L). Results of liver function tests are normal. To lower glucose levels to an acceptable target in this patient, which of the following is the most appropriate adjustment of his treatment regimen? Continue metformin and glyburide, and start basal insulin at night. Continue metformin and glyburide, and start 70/30 premixed insulin before supper. Stop metformin, continue glyburide, and add rosiglitazone. Stop metformin and glyburide, and start 70/30 premixed insulin twice daily.

A 58-year-old man who has Type 2 diabetes has excellent glycemic control (hemoglobin A1c value of 6.4%) on diet alone. He exercises and maintains a desirable weight and body mass index. His blood pressure is 110/80 mm Hg. His total cholesterol level is 203 mg/dL (5.25 mmol/L), triglyceride level is 87 mg/dL (0.98 mmol/L), HDL cholesterol level is 64 mg/dL (1.66 mmol/L), and calculated LDL cholesterol level is 122 mg/dL (3.15 mmol/L). Which of the following is the best strategy for managing this patient's disease? Continue current management of diet and exercise. Add a statin. Add metformin. Add Niacin. Add metformin + statin.

Of all the medications dispensed, insulin is the number one product with the most errors. There are a number of things you can do to prevent insulin errors. The best approach to reducing insulin errors with new insulin products is by conducting a: A. Standardization process B. Proactive risk assessment C. Sentinel event review D. Root cause analysis

Test your knowledge issue 477

Test your knowledge issue 476

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