This document discusses diagnosing and managing diabetes. It presents the case of a 45-year-old female who presented with numbness and weakness in her lower extremities. Her initial impression was type 2 diabetes mellitus based on her family history, symptoms of polydipsia and polyuria, and weight loss. The document then reviews diabetic complications, treatment options, and guidelines for managing blood glucose, blood pressure, lipids, and other risk factors.

1. Diagnosing Diabetes Joseliza de la Cruz, M.D. Tiffany Chu, RN

2. S.B. 45 y/o F from Sampalok CC: numbness over lower extremities 3 days PTC weakness with easy fatigability no chest pain, epigastric pain or back pain self medicated with Paracetamol and No consult done 1 day PTC weakness persisted numbness over lower extremities “karayomnatumutusok” no blurring of vision Consult

3. ROS: (-) cough, colds, fever (-) SOB, orthopnea, PND (+) occ. Palpitations, (-) chest pain (+)polydipsia (10-12 glass of water and soda) (-) epigastric pain, vomiting, change in appetite (-) lbm, constipation (+) polyuria (8x/day) , (-) dysuria, oliguria (+) wt loss PMH: TB 1999 treated for 6 months with no ff up (-) asthma, HPN, Diabetes or kidney dse (-) cancer

4. Ob-Gyne History: G2P2 (2-0-0-2) History of delivering large babies via CS History of elevated BS during pregnancy FH: diabetes – father and 2 siblings HPN – mother (-) CA, Kidney dse, Asthma PSH: non-smoker, non-alcoholic Works as a Caterer

5. PE: conscious, coherent, ambulatory Ht: 5’3” Wt: 150 lbs BMI: 26.6 BP 150/90 HR 92 RR 18 Temp 37C Pink palpebral conjunctivae, anictericsclerae Supple neck, no palpable lymph nodes, neck veins not distended Symmetrical chest expansion, no retractions, clear breath sounds Adynamicprecordium, normal rate, regular rhythm, no murmurs Flabby abdomen with midincisional scar in the hypogastric area, NABS, soft nontender Pulses full and equal, no edema

6. Neurological exam GCS 15 CN intact (no ptosis, no facial asymmetry, tongue midline) No motor or sensory deficits No babinski

7. Subjective data 45 y/o female caterer numbness over lower extremities “karayomnatumutusok” weakness with easy fatigability polydipsia, polyuria, wt loss no chest pain, blurring of vision Strong family history of diabetes History of delivering large babies

8. Objective data BMI: 26.6 BP: 150/90 HR92 Pink palpebral conjunctivae Clear breath sound Normal rate regular rhythm No edema Essentially normal neuro exam

9. Initial impression: DM2 Plans: Stat Hgt – 202Instructed TCB in AM with CBC, U/A, FBS, Bun, Crea, Lipid profile, Na, KEKGOphthalmology referral if labs suggestive of DM Rx: Paracetamol 500mg/tab prn for pain/ numbness

13. polydipsia, polyuria, wt loss Hgt: 202

14. IFG – d/t increased hepatic glucose uptake Inc Hgt – decreased peripheral usage of glucose

15. Complications Acute DKA and HNS Chronic Vascular, Nonvascular and Others

16. Table 338-7 Chronic Complications of Diabetes Mellitus Microvascular Eye disease Retinopathy (nonproliferative/proliferative) Macular edema Neuropathy Sensory and motor (mono- and polyneuropathy) Autonomic Nephropathy Macrovascular Coronary artery disease Peripheral arterial disease Cerebrovascular disease Other Gastrointestinal (gastroparesis, diarrhea) Genitourinary (uropathy/sexual dysfunction) Dermatologic Infectious Cataracts and Glaucoma Periodontal disease

17. Mechanisms of Complications Inc intracellular glucose -> AGEs Sorbitol pathway - aldosereductase - redox potential DAG - PKC - alters endothelial cells and neuronal structures Hexosamine pathway -F6P in glycosylation and proteoglycan production - altering gene expression of TGF or PAI-1 Growth factors VEGF-A - diabetic proliferative retinopathy TGF - diabetic nephropathy - (+) BM production of collagen and fibronectin by mesangial cells Hyperglycemia leads to increased production of reactive oxygen species or superoxide in the mitochondria.

19. Diabetic Retinopathy Proliferative diabetic retinopathy Hallmark features: Neovascularization near the optic nerve and/or macula and rupture easily +/- vitreous hemorrhage, fibrosis, and retinal detachment Nonproliferative diabetic retinopathy late in the first decade or early in the second decade of the disease Features: Retinal vascular microaneurysms Blot hemorrhages Cotton wool spots Mild nonproliferative retinopathy 1. changes in venous vessel caliber 2. intraretinalmicrovascular abnormalities 3. numerous microaneurysms and hemorrhages Pathophysiologic mechanisms : d/t retinal ischemia 1. loss of retinal pericytes 2. increased retinal vascular permeability 3. alterations in retinal blood flow, 4. abnormal retinal microvasculature

23. Diabetic neuropathy Polyneuropathy Mononeuropathy Autonomic neuropathy Symptoms: Distal symmetrical pain Ascending discomfort and numbness from LE UE involvement only after LE involvement is sever Treatment: Tight glycemic control Foot care Antidepressants - tricyclic antidepressants such as amitriptyline, desipramine, nortriptyline, imipramine SSRI – duloxetine Anticonvulsants - gabapentin, pregabalin, carbamazepine, lamotrigine

24. Gastrointestinal Dysfunction gastroparesis - delayed gastric emptying anorexia, nausea, vomiting, early satiety, and abdominal bloating constipation or diarrhea - altered small- and large-bowel motility How to document? Nuclear medicine scintigraphy after ingestion of a radiolabeled meal 1. Smaller, more frequent meals that are easier to digest (liquid) and low in fat and fiber 2. Metoclopramide 5–10 mg Domperidone 10–20 mg before each meal 3. Noninfectious diabetic diarrhea - loperamide and may respond to octreotide (50–75 g three times daily, SC

25. Diabetic autonomic neuropathy Cystopathy - inability to sense a full bladder and a failure to void completely Treatment: timed voiding self-catheterization Rx: bethanechol 2. ED and retrograde ejaculation - one of the earliest signs of diabetic neuropathy Rx: -PDE5: sildenafil

27. BP goal 125/75 BP: 150/903. PVDs (Foot ulcers)

29. Alpha-glucosidase inhibitors - inhibitors block polysaccharide and disaccharide breakdown and decrease postprandial hyperglycemia when administered with food > Acarbose > Miglitol Biguanides Decreases liver production of glucose Decreases intestinal absorption of glucose Improves cell sensitivity to insulin > Metformin Combinations Glucovance (Glyburide and Metformin) Avandamet (Avandia and Metformin)

30. D-phenylalinine derivatives - acts directly on the pancreatic β cells to stimulate early insulin secretion >Nateglinide (Starlix) Thiazolidinediones - increase insulin sensitivity in muscle, adipose tissue, and liver specifically bind to the PPAR- (peroxisomeproliferator-activated receptor-) nuclear receptor >Pioglitazone (Actos) >Rosiglitazone (Avandia) CI: CHF and Liver dse

31. Sulfonylureas -stimulate insulin secretion by interacting with the ATP-sensitive potassium channel on the beta cell - ideal for recently dx SE: hypoglycemia weight gain increases CV risks

32. Choice of Initial Glucose-Lowering Agent mild to moderate hyperglycemia - FPG < 11.1–13.9 mmol/L (200–250 mg/dL severe hyperglycemia - FPG > 13.9 mmol/L (250 mg/dL) Can insulin be used as initial therapy in individuals with severe hyperglycemia ?

36. Thank you for your kind attention.