DAVAO MEDICAL SCHOOL FOUNDATION, INC.

– COLLEGE OF MEDICINE
Department of Internal Medicine
Name: MEEVIE LOVE D. TOLEDO
Batch/Sec@on: NMD 3 Date: NOVEMBER 28, 2020

DAY 3 ACTIVITY

InstrucFons:
• Strictly use Harrison’s Principles of Internal Medicine 20th ediFon, Bate’s Guide to Physical ExaminaFon and History Taking, or Clinical PracFce Guidelines as your reference in answering this case. You
may also use the official textbooks used by other departments.
• Indicate the name of the book, chapter and page number in the reference column. Failure to write the reference will incur deducFon from the total grade.
Case:

M. M., is 55-year-old male, market vendor, from Agdao, Davao City

Chief complaint: weight loss

The pa@ent was apparently well un@l 8 months prior to consulta@on, he started no@cing that his pants were geCng gradually loose despite his good appe@te. This was associated with weakness. There
was no consulta@on done.
Three months prior to consulta@on, the pa@ent has been having frequent urina@on where he passes large volume of urine, and that he usually wakes up from sleep to urinate. The condi@on was
associated with excessive thirst for which he used to drink plenty of water. The condi@on was tolerated. No consulta@on was done. No medica@ons were taken.
Four weeks prior to consulta@on, the pa@ent noted onset of @ngling sensa@on and numbness of both hands and feet. S@ll, no consulta@on was done. No medica@ons were taken.
Two weeks prior to consulta@on, due to worsening weight loss, the pa@ent decided to weigh himself and noted 62 kilograms weight from 70 kilograms (10 months ago prior to the onset of the
condi@on). The persistence of the condi@on prompted the pa@ent to seek for medical care. Hence, this consulta@on.

Past medical history • claimed that he has no diabetes, no hypertension, no asthma

• no known food and drug allergies
Family history • father is diabe@c and hypertensive
• mother is hypertensive
Personal and social • smokes one pack of cigare]e every day
history • occasionally drinks alcohol
Review of systems • denies history of heat intolerance, tremor, bowel changes
• denies chest pain, orthopnea, PND
• denies cough, hemoptysis, rise of temperature in the a^ernoon

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine

Physical ExaminaFon Findings

General Survey Vital Signs Skin HEENT Neck
BP 110/70
HR 94 bpm Neck supple
PERRLA, pupil diameter 3mm bilaterally
Awake, coopera@ve, coherent RR 16 cpm, not labored Nega@ve for rash or other lesions Trachea midline
Anicteric sclera
Not in respiratory distress T 37.1 C Warm to touch No palpable nodes
No nasal drainage
Good skin turgor and mobility No vein disten@on
Fundoscopy: see image
Ht 5’5’’ No neck mass
Wt 61 kgs

Lungs Heart Abdomen Genitalia/Rectum ExtremiFes Neuro

Equal chest expansion
PMI at 5th ICS, 7cm from
Resonant
the midsternal line
Ausculta@on: see a%ached Normoac@ve bowel sounds DRE reveals good sphincter ton, no
Ausculta@on: see a%ached
file So^, nontender, masses, no tenderness, empty CNs II-XII intact
file No clubbing, cyanosis, nor edema
nondistended rectal vault, and no blood on the Muscle strength = 5/5 all extremi@es
Pulses 2+ bilateral in all extremi@es
No guarding, no rebound examining finger See Babinski examina@on below
Intact ROM
case 21 lung tenderness Normal sized prostate without See DTR below
case 21 heart No bruits, no masses nodules, asymmetry
sounds.mp3
sounds.mp3

Babinski Deep Tendon Reflexes Fundoscopy

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine

2020-08-10-21-56-28.
mp4

Double click the icon to play the short clip

FINAL DIAGNOSIS • DiabeFc neuropathy secondary to Diabetes Mellitus Type 2

BOOK-BASED DISCUSSION based on the primary (main) problem of the patient

REFERENCE
Instructions: Answers should be in bullet format, and the inputs should be the main points or key words only
(Source, page no.)
Harrison’s Principles of
• Genetic susceptibility,
Internal Medicine 20th
Etiology • Environmental factors (such as obesity, poor nutrition, and physical inactivity ed., chapter 396, page
2851
• Risen dramatically over the past two decades, from an estimated 30 million cases in 1985 to 415 million in 2017

• Based on current trends, the IDF projects that 642 million individuals will have diabetes by the year 2040

• The prevalence of type 2 DM is rising much more rapidly, presumably because of increasing obesity, reduced activity levels as countries
Harrison’s Principles of
become more industrialized, and the aging of the population

Epidemiology Internal Medicine 20th

• In 2015, the prevalence of diabetes in individuals aged 20–79 ranged from 7.2–11.4%

(worldwide) ed., chapter 396, pages

• The countries with the greatest number of individuals with diabetes in 2015 are China (109.6 million), India (73 million), the United States
2851-2852
(30.3 million), Brazil (14 million), and the Russian Federation (9 million).

• The prevalence of type 2 DM and its harbinger, IGT, is highest in certain Pacific islands and the Middle East and intermediate in countries
such as India and the United States

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine
The prevalence of diabetes mellitus in the Philippines for the last 10 years according to the National Nutrition and Health Survey is as
follows:

1998 2003 2008

Philippine Practice
FBS >125 3.9 3.4 4.8

Guidelines for the

Epidemiology DM based on history —— 2.6 4.0

Diagnosis and
(Philippines) FBS or OGTT or History —— 4.6 7.2

Management of
Diabetes; page 6
• This figure balloons to 17.8% or nearly 20% after adding those who have pre-diabetes (impaired fasting glucose or impaired glucose
tolerance or both) which has a prevalence of 10.6%.

• One out of every 5 Filipino could potentially have diabetes mellitus or pre-diabetes.
Harrison’s Principles of
Epidemiology
• The countries with the greatest number of individuals with diabetes in 2015 are China (109.6 million), India (73 million), the United States Internal Medicine 20th
(India or in your (30.3 million), Brazil (14 million), and the Russian Federation (9 million). ed., chapter 396, pages
country of origin) 2851
Harrison’s Principles of
Internal Medicine 20th
Non-modifiable ed., chapter 396, page
• Family history of diabetes (i.e., parent or sibling with type 2 diabetes)

2852-2853

risk factors OR • Race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander)

predisposing • Age

ADA Standards of
factors • Gender
Medical Care in
Diabetes - 2020 page
S18 & S20-S21
• Overweight or obese (BMI ≥25 kg/m2, ≥23 kg/m2 in Asian Americans, or other ethnically relevant definition for overweight)

Harrison’s Principles of
• Physical inactivity

Internal Medicine 20th

• Previously identified with IFG, IGT, or an hemoglobin A1c of 5.7–6.4%

Modifiable risk ed., chapter 396, page

• History of GDM

2853

factors OR • Hypertension (blood pressure ≥140/90 mmHg)

precipitating • HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L

ADA Standards of
factors • Polycystic ovary syndrome or acanthosis nigricans

Medical Care in
• History of cardiovascular disease

Diabetes - 2020 page

• Smoking

S18
• Alcohol use
• Impaired insulin secretion

Harrison’s Principles of
• Insulin resistance

Internal Medicine 20th

Pathophysiology • Excessive hepatic glucose production

ed., chapter 396, pages

• Abnormal fat metabolism

2851 and 2856

• Systemic low-grade inflammation

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine
• Recent Changes In Weight

• Family History Of Dm And Its Comlications

• Risk Factors For Cardiovascular Disease

• Sedentary Lifestyle

• Smoking Status

• History Of Pancreatic Disease

• Ethanol Use

• Polyuria

• Polydipsia

Harrison’s Principles of
• Weight Loss

Internal Medicine 20th

History • Fatigue

ed., chapter 396, page

• Weakness

2858
• Blurry Vision

• Frequent Superficial Infections (Vaginitis, Fungal Skin Infections)

• Slow Healing Of Skin Lesions After Minor Trauma

• Types Of Therapies Tried

• The Nature Of Any Intolerance To Previous Therapies

• Prior Hba1C Levels

• Self-Monitoring Blood Glucose Results

• Frequency Of Hypoglycemia (<3.0 Mmol/L, <54 Mg/Dl)

• Presence Of Dm-Specific Complications

Harrison’s Principles of
• From overweight or obese to normal or underweight

Internal Medicine 20th

• Hypertensive

PE Findings ed., chapter 396, pages

• With complications: weak peripheral pulses, non-proliferative/proliferative retinopathy, macular edema, mono-/polyneuropathya and
2858-2859 and chapter
autonomic neuropathy
398 page 2875
Diagnostic tests • Symptoms of diabetes plus random blood glucose concentration ≥11.1 mmol/L (200 mg/dL); or
Harrison’s Principles of
to request and its • Fasting plasma glucose ≥7.0 mmol/L (126 mg/dL); or
Internal Medicine 20th
expected findings • Hemoglobin A1c ≥ 6.5%; or
ed., chapter 396, page
or results • 2-h plasma glucose ≥11.1 mmol/L (200 mg/dL) during an oral glucose tolerance test 2852

Mechanism of Action Dosage, Route, &

Drug Drug Classification Common Side Effects
(Brief description) Frequency
Decrease hepatic glucose Weight loss, GI upset,
production and slightly Vitamin B12 deficiency,
Metformin Biguanides 500-2000 mg/d PO
improves peripheral glucose metallic taste, lactic
utilization acidosis
Insulin secretagogues - Hypoglycemia Weight
Gliclazide Increase insulin secretion 30-120 mg/d PO
Sulfonylyureas gain

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine
Insulin secretagogues - Hypoglycemia Weight
Repaglinide Increase insulin secretion 0.5-16 mg/d PO
Non-sulfonylureas gain
Alpha-glucosidase Inhibits intestinal absorption of Weight loss, diarrhea,
Acarbose 25-100 mg TID PO
inhibitors sugars flatulence
Edema, weight gain, Good and Gilman’s The
Medical treatment Pioglitazone Decrease insulin resistance, Pharmacological Basis
Thiazolidinediones 15-45 mg OD PO osteoprosis, anemia,
(include the drug increases glucose utilization
CHF of Therapeutics pages
classification, 884-885
mechanism of Urinary and vaginal
action, dosage, infections, dehydration

Increase urinary glucose Harrison’s Principles of

Dapagliflozin SGLT2 inhibitor 5-10mg OD PO
route, and excretion Internal Medicine 20th
Risk of fractures
frequency) (canagliflozin) ed., chapter 397, pages
2865-2869
Binds to bile acids in
Binds bile acids in intestinal
intestinal tract,
tract, increasing hepatic bile
Colesevelam Bile acid sequestrants 3.75 g/d PO increasing hepatic bile
acid & decreasing hepatic
acid & decreasing
glucose production
glucose production
Activates dopaminergic
receptors and modulates Dizziness, nausea,
Bromocriptine Dopamine 2 agonists 0.8-4.8 mg/d PO
hypothalamic regulation of fatigue, rhinitis
metabolism
Prolongs endogenous GLP-1 Headache, nasopharyn
Sitagliptin DPP-IV inhibitors 25-100 mg OD PO
action gitis
Prolongs endogenous GLP-1 Skin irritation after
Exenatide GLP-1 agonists 5-10 mcg BID SC
action injection, nausea
• Metabolic (also referred to as bariatric) surgery for obese individuals with type 2 DM has shown considerable promise, sometimes with Harrison’s Principles of
dramatic resolution of the diabetes or major reductions in the needed dose of glucose-lowering therapies.
Internal Medicine 20th
Surgical treatment • The ADA clinical guidelines state that metabolic surgery should be considered in individuals with type 2 DM and a body mass index >30 ed., chapter 397, page
kg/m2 if hyperglycemia is inadequately controlled despite optimal medical therapy. 2869

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine
• Lifestyle management in Diabetes care

o Diabetes self-management education and support

o Nutrition therapy
Harrison’s Principles of
Nonpharmacologi o Physical activity
Internal Medicine 20th
cal treatment o Psychosocial care
ed., chapter 397, pages
• Monitoring the level of glycemic control
2859-2862
o Self-monitoring of blood glucose

o Assessment of long-term glycemic control

Complications Management (Brief discussion)
• Intensive glycemic and blood pressure control: most effective therapy for diabetic
retinopathy is prevention.

• Prophylactic laser photocoagulation: when initiating intensive therapy

Diabetic Retinopathy (nonproliferative/

• Fenofibrate: reduce the progression of retinopathy

proliferative)
• Regular, comprehensive eye examination

• Laser photocoagulation and/or anti-VEGF therapy: treatment of proliferative

retinopathy or macular edema for preserving vision
• The optimal therapy for diabetic nephropathy: prevention by control of glycemia

• Interventions effective in slowing progression of albuminuria:

• mproved glycemic control

• strict blood pressure control

Diabetic Neuropathy
• administration of an ACE inhibitor or ARB

• Dyslipidemia should also be treated

• The ADA suggests a protein intake of 0.8 mg/kg of body weight/ day in individuals
with diabetic kidney disease. Harrison’s Principles of
• Prevention of diabetic neuropathy is critical through improved glycemic control.
Internal Medicine 20th
Complications ed., chapter 398, pages
• Lifestyle modifications (exercise, diet) has some efficacy in DSPN in type 2 DM

• Hypertension and hypertriglyceridemia should be treated.

2877-3881
Diabetic Nephropathy • Avoidance of neurotoxins (alcohol) and smoking, supplementation with vitamins for
possible deficiencies

• Two agents, duloxetine and pregabalin, have been approved by the U.S. Food and
Drug Administration (FDA) for pain associated with diabetic neuropathy
• Aggressive cardiovascular risk modification in all individuals with DM and glycemic
control should be individualized,

• Patients with:

• CHD and type 2 DM: ACE inhibitor (or ARB), a statin, and acetylsalicylic acid
Coronary heart disease
(ASA; aspirin) should be considered

• Diabetes after MI: Beta blockers can be used

• Stable CHF with normal renal function: metformin can be used

• DM + CHD: Antiplatelet therapy reduces cardiovascular events

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine
The optimal therapy for foot ulcers and amputations is prevention through identification
Peripheral arterial disease of high-risk patients, education of the patient, and institution of measures to prevent
ulceration.
• Screening for prediabetes and type 2 diabetes risk through an informal assessment of risk factors

• Refer patients with prediabetes to an intensive behavioral lifestyle intervention program modeled on the Diabetes Prevention Program
(DPP) to achieve and maintain 7% loss of initial body weight and increase moderate-intensity physical activity (such as brisk walking) to
ADA Standards of
at least 150 min/week.

Medical Care in
Prevention • A variety of eating patterns are acceptable for persons with prediabetes.

Diabetes - 2020 page

• Based on patient preference, technology-assisted diabetes prevention interventions may be effective in preventing type 2 diabetes and
S31-S33
should be considered. 
• Given the cost-effectiveness of diabetes prevention, such intervention programs should be covered by third-party payers.

• evaluation for tobacco use and referral for tobacco cessation, if indicated, should be part of routine care for those at risk for diabetes. 
The Diabetes Prevention Program (DPP) demonstrated that intensive changes in lifestyle (diet and exercise for 30 min/d five times/week) in
Harrison’s Principles of
individuals with IGT prevented or delayed the development of type 2 DM by 58% compared to placebo. This effect was seen in individuals
Prognosis or Internal Medicine 20th
regardless of age, sex, or ethnic group. In the same study, metformin prevented or delayed diabetes by 31% compared to placebo. The
outcome ed., chapter 396, pages
lifestyle intervention group lost 5–7% of their body weight during the 3 years of the study; the effects of the intervention persisted for at
2857
least 15 years. Studies in Finnish and Chinese populations noted similar efficacy of diet and exercise in preventing or delaying type 2 DM.

PATIENT-BASED DISCUSSION

Provide a diagram of the pathophysiology of this case of what happened to this pa@ent. This is not a summary of the pa@ent’s case, but rather an explana@on through diagrams on how these symptoms and
physical examina@on findings were manifested by the pa@ent. The diagram should contain and explain the following:
• Predisposing and precipita@ng risk factors OR modifiable and non-modifiable risk factors of the pa@ent
• Symptoms of the pa@ent
• Per@nent ROS reported by the pa@ent
• Per@nent physical examina@on findings present in the pa@ent

To maintain the organiza@on of the diagrams, you may follow one of these op@ons:
• save it as PDF file (recommended);
• write it in a clean white sheet of paper(s), take a picture, then paste it here in the document;
• upload the picture of the wri]en output;
• do a screen shot of your output, paste it back in this document, then crop as needed

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DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine

What is (are) the new information you have learned from • The specific mechanism behind each signs and symptoms associated with Diabetes mellitus

studying this case? • The management of the disease does not end with the treatment; Monitoring for further complications is a must.

What is (are) the most important information you have The history, physical examination, and laboratory findings should be correlated all the time to come up with a prompt
learned from this case that you will never forget? diagnosis and effective therapeutic plan

Will this case or activity be helpful in your future practice Yes because I believe that repetition is one of the best ways of having a long-term memory about a certain topic. This
as a doctor? comprehensive activity provided the basic and detailed knowledge that I needed to learn for my journey as a student and
as a doctor in the future.

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