🤔 MEDIUM

I think every medical student appreciates the importance of understanding the principles of diabetes mellitus in the 21st century healthcare environment.  Have a crack at these three patients … good luck! 

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Approach to the Patient with Abnormal Blood Sugar Levels - Part One

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Question 1

Stem 1 of 4

A 9YOF is brought to hospital by her parents because of a half-day history of significant fatigue and regular vomiting. History is notable for increasing thirst, loss of weight, and increased urine output.

NICE states a random plasma glucose, of which figure, to be classed as the metabolic disorder of diabetes mellitus? (units:mmol/L)
A
>8
B
>9
C
>10
D
>11
E
>12
Question 1 Explanation: 
NICE Clinical Knowledge Summary, 2021, describes diabetes as: “Diabetes mellitus is a metabolic disorder characterized by persistent hyperglycaemia (random plasma glucose more than 11 mmol/L) with disturbances of carbohydrate, protein, and fat metabolism resulting from defects in insulin secretion, insulin action, or both.”
Question 2

Stem 2 of 4

Which of the following represents a known microvascular complication of type one diabetes?
A
Cerebrovascular accident
B
Diabetic ketoacidosis
C
Diabetic retinopathy
D
Myocardial infarction
E
Peripheral artery disease
Question 2 Explanation: 
Complications of diabetes can be handedly broken into microvascular, macrovascular, metabolic and psychological. Microvascular triad of complications include: diabetic retinopathy, nephropathy and neuropathy.
Question 3

Stem 3 of 4

Which of the following is not a classic presentation of type one diabetes?
A
Decreased weight
B
Excessive thirst
C
Excessive urination
D
Increased fatigue
E
Increased heart rate
Question 3 Explanation: 
Although the classic type one diabetes tirad of fatigue, weight loss, polyuria and polydipsia in an underweight young adult is the classic presentation, even now, there is change. T1DM diagnoses are becoming more frequent in older, higher BMI individuals with indolent presentations.
Question 4

Stem 4 of 4

What is the current most-common HbA1C threshold for patients with diabetes mellitus type one? (Select TWO which are true)
A
<5%
B
<50mmol/mol
C
<53mmol/mol
D
<6%
E
<60mmo/mol
F
<7%
Question 4 Explanation: 
Glycosylated haemoglobin is used as a proxy for how aggressively you should medically intervene with the patient. It is currently widely accepted that 7% A1C, or <53mmol/mol, is the threshold aimed for, for most adults and children. Also worth keeping an eye on is blood pressure, lipid profile and end-organ damage for eyes, heart and kidneys regularly.
Question 5

Stem 1 of 4

A patient presents for a GP check-up. She has a BMI of 33, diagnosis of poorly controlled primary hypertension, and elevated HbAlC.

Which of the following drugs have the greatest link to type two diabetes?
A
Amiloride
B
Furosemide
C
Indapamide
D
Mannitol
E
Spironolactone
Question 5 Explanation: 
NICE lists several drugs as linked to T2DM acquisition, most notably thiazides and corticosteroids.
Question 6

Stem 2 of 4

On physical examination you note discoloration of the armpit. What is this sign classically called?
A
Acanthosis nigricans
B
Battle sign
C
Cullen/Grey Turner sign
D
Erythema marginatum
E
Erythema nodosum
Question 6 Explanation: 
Acanthosis nigricans, black staining of the skin, is a classic finding of insulin resistance seen in type two diabetes.
Question 7

Stem 3 of 4

What is the most appropriate first line management in this patient?
A
Basal bolus insulin
B
Dietary modifications
C
Metformin
D
Physical activity changes
E
Pioglitazone
Question 8

Stem 4 of 4

The patient returns three months later for a “check up” and is placed on a medication. Three months after the “check up” (six months after initial diagnosis), she returns for a second-line pharmacotherapy agent. She is concerned about her obesity. Which of the following diabetic agents are most likely to cause weight gain?
A
Exenatide
B
Metformin
C
Orlistat
D
Pioglitazone
E
Sitagliptin
Question 8 Explanation: 
Insulin, sulfonylurea and thiazolidinediones medications are the most likely in these classes to cause weight gain. Thiazolidinediones include pioglitazone.
Question 9

Stem 1 of 4

A patient presents to ED with extreme acute abdominal pain (generalised), vomiting copiously and is difficult to rouse. His respiration pattern is described as deep and rapid, with his temperature elevated. His accompanying partner states the patient is a type one diabetic - poorly concordant with his regular medication.

In this patient, which hormone is least likely elevated?
A
A hormone, that when deficient, causes acromegaly
B
A hormone activating glucose utilisation
C
A hormone released from the zona fasciculata
D
Monoamines circulating in the periphery
E
Protein released from pancreatic alpha cells
Question 9 Explanation: 
Acromegaly is caused by growth hormone deficiency, glucose utilisation by insulin, zona fasciculata releases glucocorticoids, monoamines in the periphery include catecholamines and alpha cells of the islet of Langerhans release glucagon.
Question 10

Stem 2 of 4

Which of the following physiological hallmarks is least representative of insulin deficiency?
A
Breakdown (catalysis) of adipocyte
B
Fatty acid oxidation at hepatocytes
C
Formation of beta-hydroxybutyrate
D
Hypoosmolar serum state
E
Release of free fatty acid
Question 10 Explanation: 
In the insulin deficient patient, ie this patient, decreased glucose utilization causes an increase of release of stores of free fatty acids. These undergo lipolysis and beta-oxidation to form ketone bodies (two are named above).
Question 11

Stem 3 of 4

What is the eponymous term for the breathing described in the patient above?
A
Boyles
B
Dalton’s
C
Harry’s
D
Boozman
E
Kussmaul
Question 11 Explanation: 
Boyles, Dalton's and Henry’s are laws of gas exchange, Kussmaul breathing is the breathing described above and is pathognomonic in stems for DKA. Boozman is a R-AR Senator in the United States Capitol as of 2020.
Question 12

Stem 4 of 4

Which of the following is not a first line investigation in DKA?
A
Amylase and lipase
B
Blood glucose
C
Blood ketones
D
Urea and electrolytes
E
Venous blood gas
Question 12 Explanation: 
A VBG is taken as the first line to ascertain the pH and K+ levels of the patient. Blood glucose and ketones are self-explanatory. An amylase and lipase can be considered - but to help decide on pancreatitis in the ddx.
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