Family Medicine: Diabetes

Front 1

Pt is asymptomatic and is wondering when he should begin diabetes screening?

Back 1

Testing for diabetes should be considered in all individuals at age 45 years and above and, if normal, it should be repeated at 3-year intervals.

Front 2

What patients should get diabetes screening at a younger age?

- 8 answers

Back 2

are overweight (BMI 25 kg/m2)
• have a first-degree relative with diabetes
• are members of a high-risk ethnic population (e.g., African-American, Latino, Native
American, Asian-American, Pacific Islander)
• have delivered a baby weighing >9 lb or have been diagnosed with GDM
• are hypertensive (140/90 mmHg)
• have an HDL cholesterol level <35 mg/dl (0.90 mmol/l) and/or a triglyceride level
>250 mg/dl (2.82 mmol/l)
• on previous testing, had IGT or IFG
• have other clinical conditions associated with insulin resistance (e.g. PCOS or
acanthosis nigricans)

Front 3

What children should be tested for type 2 diabetes?

Back 3

Overweight (BMI >85th percentile for age and sex, weight for height >85th
percentile, or weight >120% of ideal for height)
Plus any two of the following risk factors:
 Family history of type 2 diabetes in first- or second-degree relative
 Race/ethnicity (Native American, African-American, Latino, Asian-American,
Pacific Islander)
 Signs of insulin resistance or conditions associated with insulin resistance
(acanthosis nigricans, hypertension, dyslipidemia, or PCOS)
 Age of initiation: age 10 years or at onset of puberty, if puberty occurs at a
younger age

Front 4

What are 4 ways to diagnose DM?

Back 4

1. A1C -6.5%. The test should be performed in a laboratory using a method that is NGSP
certified and standardized to the DCCT assay.*
OR
2. FPG -126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.*
OR
3. 2-h plasma glucose -200 mg/dl (11.1 mmol/l) during an OGTT. The test should be
performed as described by the World Health Organization, using a glucose load containing
the equivalent of 75 g anhydrous glucose dissolved in water.*
OR
4. In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random
plasma glucose -200 mg/dl (11.1 mmol/l).
*In the absence of unequivocal hyperglycemia, criteria 1–3 should be confirmed by repeat testing.

Front 5

What does the USPSTF say about checking for DM in patients with HTN? What about those without HTN?

Back 5

The USPSTF recommends screening for type 2 diabetes in asymptomatic adults with
sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg.

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for type 2 diabetes in asymptomatic adults with blood pressure of 135/80 mm Hg or lower

Front 6

What does the USPSTF say about screening diabetes and complications?

Back 6

The USPSTF found convincing evidence that intensive glycemic control in persons with clinically detected (as opposed to screening-detected) diabetes can reduce progression of microvascular disease.

However, the benefits of tight glycemic control on
microvascular clinical outcomes, such as severe visual impairment or end-stage renal disease, take years to become apparent. There is inadequate evidence that early
diabetes control as a result of screening provides an incremental benefit for
microvascular clinical outcomes compared with initiating treatment after clinical
diagnosis.

Front 7

What are ways a patient with DM2 can present?

Back 7

Most patients are asymptomatic. Common presentations at diagnosis are weight loss, fatigue,
excessive thirst, recurrent fungal infections, visual changes, periodontal absess, nocturia, polyuria, and burning, tingling, or numbness in the extremities.

Front 8

What are the 3 annual tests a patient with DM get?

Back 8

Physical examination annually
 Dilated eye examination annually
 Foot examination annually; more often in patients with high-risk foot conditions

Front 9

How often do you take A1c?

Back 9

Quarterly if treatment changes or patient is not meeting goals.
Twice per year if stable

Front 10

What labs do you order with a DM pt?

Back 10

Glycated hemoglobin also called hemoglobin A1C
Quarterly if treatment changes or patient is not meeting goals
Twice per year if stable
 Fasting plasma glucose (optional)
 Fasting lipid profile annually, (including HDl, LDL, total cholesterol, total triglyceride)
 Microalbumin measurement annually (if indicated)

Front 11

List patient variables that are considered in the management of type 2 diabetes.

Back 11

 Age
 Gender
 Race
Compare rates of diabetes for ages 40 to 74, in Caucasians (11/2%), Mexican
Americans (20.3%), African Americans (18.2%), and American Indians (ranges
from 33 to 72%!)
 Cultural issues
 Support issues
 Family history
 Insurance status, employment issues, access to care
 Patient motivation

Front 12

Practice obtaining a patient’s view of their illness and treatment using the ETHNIC
mnemonic.

Back 12

Explain. Ask the patient to explain what they believe to be the cause of their illness.
 Treatment. Ask the patient about treatments that they have tried.
 Healers. Ask about the patient’s use of folk healers or other non-allopathic providers.
 Negotiate mutually acceptable options.
 Intervention. Agree on an intervention that is acceptable to the provider and the
patient.
 Collaboration with the patient, family members, and folk healers.

Front 13

Discuss 7 known complications of type 2 diabetes.

Back 13

 Retinopathy
 Nephropathy
 Neuropathy
 Cardiac disease
 Dysmotility
 Dyslipidemia
 Amputation

Front 14

What are ideal blood glucose levels for DM patient

Back 14

hemoglobin A1C < 7%, preprandial
blood glucose between 90 and 130 mg/dl and postprandial (2 hours after initiating a
meal) less than 180 mg/dl.

Front 15

What is the LDL goals for DM

Back 15

Control of cholesterol/TG with aggressive treatment (diabetes poses as great a risk
for having a heart attack in 10 years as does having known heart disease.) LDL
should be less than 100 mg/dl, but a goal of less than 70 mg/dl may be even better.

Front 16

What are 8 things you can do to prevent complications in DM?

Back 16

 Exercise, weight control, and medication to keep hemoglobin A1C < 7%, preprandial blood glucose between 90 and 130 mg/dl and postprandial (2 hours after initiating a meal) less than 180 mg/dl. Ideal is to get as close to normal range as possible without inducing hypoglycemic episodes.
 Self glucose monitoring
 Control of cholesterol/TG with aggressive treatment (diabetes poses as great a risk
for having a heart attack in 10 years as does having known heart disease.) LDL
should be less than 100 mg/dl, but a goal of less than 70 mg/dl may be even better.
 Control of blood pressure - <130/80
 Annual retinal examination
 Consider ACE inhibitors for preservation of renal function and blood pressure control.
 Daily aspirin therapy – 75-325mg
 Annual podiatry visits
 Immunization updates

Front 17

Discuss the benefits of metformin

Back 17

Metformin enhances insulin sensitivity and also improves other factors related to increased cardiovascular risk.

Also induce slight weight loss through its appetite-suppressive action

Metformin should be used cautiously in persons with
renal or liver impairment.

Rosiglitazone recently linked to INCREASED rates of myocardial infarction.

Front 18

Identify the six components of the Chronic Disease Model using diabetes as an example.

Back 18

1. Self-Management
2. Decision Support
3. Clinical Information System
4. Delivery System Design
5. Organization of Health Care
6. Community

Front 19

Why is it difficult to diagnose diabetes in the elderly?

Back 19

Changes such as confusion, incontinence, or complications relating to diabetes are the presenting symptoms.

Because of the normal physiological changes associated with aging (decrease in perception of thirst decreases polydipsia, increased threshold for glycosuria gives negative urine test for glucose), elderly diabetic patients rarely present with the typical symptoms of hyperglycemia.

Front 20

Why is it difficult to manage elderly diabetics?

Back 20

Both insulin-dependent and non-insulin-dependent diabetes occur in the elderly. The
primary impairment in obese elderly diabetic patients is insulin resistance, whereas
lean elderly patients have impaired glucose-induced insulin release
 Counter-regulation involving glucagon, epinephrine, and growth hormone responses
to hypoglycemia are diminished, increasing the incidence of hypoglycemia