DIABETES

MELLITUS
CASE PRESENTATION
Cainta Municipal Hospital
Family and Community Medicine
Jordan T. Garcia MD
OBJECTIVES
 Screening and diagnosis of diabetes

 Screening and prevention of complications

 Treatment (pharmacologic and non-pharmacologic) of diabetes

 Acute complications of diabetes

GENERAL INFORMATION
 B. J., 36 y/o male
 Muslim
 Works as an entrepreneur
 Born at Cotabato City
 Currently residing at Cainta, Rizal
 Ht: 5’6
 Wt: 78kg

 CC: body weakness

HISTORY OF PRESENT ILLNES
 Patient is a known diabetic (unrecalled years) prescribed with Metformin (uncompliant)
 2days PTA> (+) bloatedness, (+) body weakness, (+) fever, (+) nausea, no consult done, self-
medicated with concoction of 1 tab of Ibuprofen 200mg tab + Paracetamol 500mg tab, 1 tab
Paracetamol 500mg tab , 1 tab Paracetamol + Chlopheniramine Maleate +
Phenylpropanolamine tab. Sought consult at a private institution. Laboratory workups were
done. Patient was hooked on PNSS 1L x 8. Patient was eventually discharged on that day
 Still with above symptoms, now with difficulty of breathing, patient sought consult at our
institution hence admission (Dec. 17, 2020)
PAST MEDICAL HISTORY
 (-) Hypertension

 (-) Bronchial asthma

 (-) Previous surgeries

 (-) No known allergies

FAMILY HISTORY
 (+) Hypertension, paternal and maternal side

 (+) Diabetes mellitus, maternal side

FAMILY GENOGRAM
Balawag Family
Feb. 17, 2019

- Diabetes
- Hypertension
PERSONAL AND SOCIAL
HISTORY
 (+) Occasional alcohol beverage drinker
 (-) Smoker
 (-) Substance abuse
 Patient works as a market vendor/lala move rider
 Daily regular exercise includes 15minute walk
 Patient lives with his family on a well-ventilated bungalow house
REVIEW OF SYSTEMS
 General survey: (-) weight loss
 HEENT: (-) cough, (-) headache, (+) odynophagia
 Pulmonary: (-) wheezes, (-) crackles, (-) rales
 Cardiovascular: (-) chest pain
 Gastrointestinal: (-) abdominal pain, (-) change in bowel movement
 Musculoskeletal: (-) muscle pain, (+)joint pains
PHYSICAL EXAMINATION
 Vital Signs: BP – 120/70 mmHg, CR – 82 bpm, RR – 30 bpm, Temp – 37.9 ˚C
 Conscious, lethargic, ambulatory
 (+) Redness on soft palate, (+) oral ulcers
 Adynamic precordium, normal rate and regular rhythm
 Symmetrical chest expansions, clear breath sounds, (+) tachypnea
 Flabby abdomen, soft, non-tender
 Full and equal pulses on all extremities, parched skin
SALIENT FEATURES
 36y/o male

 Known diabetic but uncompliant with medications

 Occasional alcohol beverage drinker

 Presented with difficulty in breathing, bloatedness, malaise, fever, nausea, odynophagia,and

joint pains
ADMITTING DIAGNOSIS

Diabetes Mellitus, t/c Diabetic

Ketoacidosis, ATP
COURSE IN THE ER
 HGT-high (500above)

 Patient was hooked to PNSS 1200ml to run for 1hr

 CBC, UA + ketones, ABG, blood chemistry, chest X-ray, HbA1C were requested

 Insulin HR 10units SC and 2units IV were given

 HGT monitoring q1

 Started on Ceftriaxone 1gm q12, Paracetamol 300mg PRN for fever

DIABETES MELLITUS
 Refers to a group of common metabolic disorders that share the phenotype of hyperglycemia
(reduced insulin secretion, decreased glucose utilization, increased glucose production)

 Classification according to etiology:

 Type 1 DM – result of complete or near-total insulin deficiency
 Type 2 DM – characterized by variable degrees of insulin resistance, impaired insulin secretion, and
increased glucose production
 Type 3 DM – include specific genetic defects in insulin secretion or action, metabolic abnormalities,
and a host of conditions that impair glucose tolerance
 Type 4 DM – gestational diabetes mellitus
CRITERIA FOR THE
DIAGNOSIS OF DIABETES
MELLITUS
 Symptoms of diabetes plus random blood glucose concentration ≥11.1mmol/L (200mg/dL)
 Fasting plasma glucose ≥7.0mmol/L (126mg/dl)
 A1C >6.5%
 Two-hour plasma glucose ≥11.1mmol/L (200mg/dl) during an oral glucose tolerance test
 • Testing should be considered in all adults >40 yo
 • Consider earlier testing if with at least one other risk factor as follows:
 o History of IGT or IFG
 o History of GDM or delivery of a baby weighing 8 lbs or above
 o Polycystic ovary syndrome (PCOS)
 o Overweight: Body Mass Index (BMI)2 of >23 kg/m2 or Obese: BMI of >25 kg/m2 , or
 o Waist circumference >80 cm (females) and >90 cm (males), or Waist-hip ratio (WHR) of >1 for
males and >0.85 for females
 o First degree relative with Type 2 diabetes
 o Sedentary lifestyle
 o Hypertension (BP >140/90 mm Hg)
 o Diagnosis or history of any vascular diseases including stroke, peripheral arterial occlusive disease,
coronary artery disease
 o Acanthosis nigricans
 o Schizophrenia
 o Serum HDL 250 mg/dL (2.82 mmol/L)
PHARMACOLOGIC
TREATMENT
 Patient with HbA1C <9% and FBS <250- Monotherapy or Combination therapy
 Patient with HbA1C ≥9% and FBS ≥250- Combination therapy or Insulin therapy

 Initiate treatment with metformin unless with contraindications or intolerant of its ADE’s such
as the development of diarrhea, severe nausea or abdominal pain
 Ideally, all patients who are on insulin or will be started on insulin should be under the care of
diabetes specialists (endocrinologists and diabetologists). These are patients who are
inadequately controlled on oral anti-diabetic agents or who have medical conditions which
necessitate insulin administration e.g., those needing surgery, presence of infections or
pregnant diabetics
NON-PHARMACOLOGIC
TREATMENT
 People with Type 2 DM should undertake aerobic physical activity at least 150 min per week,
of moderate to vigorous intensity, spread out 3 days over the week with no more than 2
consecutive days between bouts of activity
ACUTE COMPLICATIONS OF
DM
 Diabetic ketoacidosis

 Hyperglycemic hyperosmolar state

LABORATORY VALUES IN DIABETIC
KETOACIDOSIS (DKA) AND HYPERGLYCEMIC
HYPEROSMOLAR STATE (HHS)
MANIFESTATIONS OF
DIABETIC KETOACIDOSIS
 Symptoms:
 Nausea/vomiting, thirst/polyuria, abdominal pain, shortness of breath

 Precipitating events
 Inadequate insulin administration, infection (pneumonia/UTI/gastroenteritis/sepsis), infarction
(cerebral, coronary, mesenteric, peripheral), drugs (cocaine), pregnancy
 Physical findings
 Tachycardia, dehydration/hypotension, tachypnea/Kussmaul respirations/respiratory distress,
abdominal tenderness, lethargy/obtundation/ cerebral edema/ possibly coma
MANAGEMENT OF DIABETIC
KETOACIDOSIS
 Confirm diagnosis (^plasma glucose, positive serum ketones, metabolic acidosis)
 Admit to hospital; intensive-care setting may be necessary for frequent monitoring or if pH
<7.00 or unconscious
 Assess: serum electrolytes (K+, Na+, Mg2+, Cl-, bicarbonate, phosphate)/ acid-base status—
pH, HCO3-, PCO2, ß-hydroxybutyrate/ renal function (creatinine, urine output)
 Replace fluids: 2-3L of 0.9% saline over first 1-3h (15-20ml/kg per hour); subsequently,
0.45saline at 250-500ml/h; change to 5% glucose and 0.45% saline at 150-25-ml/h when
plasma glucose reaches 200mg/dL (11.2mmol/L)
 Administer short-acting insulin: IV (0.1units/kg), then 0.1units/kg per hour by continuous IV
infusion, increase two-to threefold if no response by 2-4h. If the initial serum potassium is
<3.3mmol/L (3.3meq/L), do not administer insulin until the potassium is corrected. If the
initial serum potassium is >5.2mmol/L (5.2meq/L), do not supplement K+ until the potassium
is corrected
 Assess patient: what precipitated the episode (noncompliance, infection, trauma, infarction,
cocaine)? Initiate appropriate workup for precipitating event (cultures, CXR, ECG).
 Measure capillary glucose every 1-2h; measure electrolytes (especially K+, bicarbonate,
phosphate) and anion gap every 4h for first 24h
 Monitor blood pressure, pulse, respirations, mental status, fluid intake and output every 1-4h
 Replace K+: 10meq/h when plasma K+ <5.0-5.2meq/L (or 20-30meq/L of infusion fluid),
ECG normal, urine flow and normal creatinine documented; administer 40-80 meq/h when
plasma K+ ,3.5meq/L or if bicarbonate is given
 Continue until patient is stable, glucose goal is 8.3-13.9mmol/L (150-250mg/dL), and acidosis
is resolved. Insulin infusion may be decreased to 0.05-0.1units/kg per hour
 Administer long-acting insulin as soon as patient is eating. Allow for overlap in insulin
infusion and SC insulin injection
THANK YOU!!!

 Sources: Compendium of Philippine Medicine 16 th Edition 2014

Harrison’s Principles of Internal Medicine 20 th Edition