DIABETES SEMINAR II

CASE #1

This is the first visit of a 48-year-old obese woman to your office for control of her
diabetes. She complains of the recent onset of polydypsia, polyuria and nocturia
4x/night. She has never been told that she has diabetes, although she recalls being told
she had a fasting blood sugar about 6 yrs ago of 115 mg/dl which was repeated and was
116 otherwise she has not seen a physician in 15 years. She did not follow up on the the
blood tests. On further questioning she also states she has numbness of her legs and
feet and shooting leg pains which are worse at night. She has two children ages 20 and
23 in good health, both of whom weighed over 9 lbs. at birth. Her father has diabetes as
well as an older brother and both her maternal and paternal grandmothers. She notes
that small cuts to her arms and legs do not heal as readily as about 10 years ago. She
has been obese all her adult life: height, 5'4", weight 215 lbs; although her weight has
fluctuated from a low of 175 to a high of 250. She denies chest pain on exertion and pain
in her legs on walking.

On physical examination she is an obese woman appearing older than her stated age in
no acute distress. BP 130/80; P = 86. reg. Neuro exam: decreased sensation to
monofilament over feet and legs; decreased vibratory sensation over both external
malleoli; position sense intact; Neurological exam of the upper extremity is normal.

1. Does this patient have type 1 or type 2 diabetes? What features of her history and
physical exam point to the diagnosis? What are the criteria for diagnosing
diabetes? How would you have classified her 6 years ago?

2. Does your patient have insulin deficiency, insulin resistance, or both? What is the
pathophysiology of her metabolic state?

3. What are the roles of weight reduction, food choices in terms of carbohydrate, fat, and
fiber, and exercise in the management of this patient?

4. What are the roles of oral hypoglycemic agents, insulin, and a combination of an oral
hypoglycemic agent and insulin in the treatment of this patient?

a. What would be the advantages and disadvantages of a biguanide?

b. Why and when would you use a sulfonlyurea?
c. What other medications would be considered if your first intervention
did not work?
d. Which agents would be most beneficial for weight loss for this patient?
CASE #2

A 56-year-old male with a past medical history of Type 2 diabetes for > 5 years comes to
you for evaluation. He has been taking 5 mg of glipizide (an oral sulfonylurea agent) per
day for the last 4 years. He has not seen a physician in the last 3 years and has been
obtaining his medication from his brother-in-law, a pharmacist. He does not perform
home blood glucose monitoring. He does exercise but has reduced his frequency and
duration due to dyspnea with exertion after about 20 minutes for the last 5-6 months. He
recently decreased his cigarette smoking from 1 pack/day to 1 pack/week.

Physical exam revealed:

A moderately obese male in no acute distress

Blood pressure: 150/100, Heart rate: 84, Respirations: 12

The exam was remarkable only for a fundoscopic exam with background diabetic
retinopathy with signs of early proliferative changes, and diminished Dorsalis Pedis and
Posterior Tibial pulses.

Laboratory data:

Na+ 139 Glucose 301 Cholesterol 268 Microalbumin 122 g/g creatinine (nl < 30)
K+ 4.2 BUN 18 HDL 32 EKG - NSR 80/min
Creatinine 1.1 Triglycerides 300 No abnormalities noted
LDL-Chol 176
Hemoglobin A1c 12.0% (4.1-6.5)

QUESTIONS:

1. What complications is the patient presently exhibiting which may be related to his
diabetes?

2. What factors in the patient's history and lab data may be playing a role in the
development and progression of the complications he is exhibiting?

3. How might you manage his complications?