A presentation by Meighan - PowerPoint Presentation

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A presentation by Meighan O’Connor, POPPFDidacticsOnline.com

Diabetes Mellitus

Case PresentationCC: fatigue and abdominal pain

HPI: 7 y/o male reports above

sx

for past 3 months. Mother says he has been less active, taking more naps and wetting his bed, which he stopped doing 2 years prior.

Pmhx

,

Pshx

,

Famhx

: unremarkable

ROS: Pertinent positives include weight drop from the 75

th

percentile to the 50

th

percentile despite report from mother that his food and drink intake has increased.

Objective

Labs to be ordered:

WBC count, Urinalysis, Glucose level

Labs return:

WBC: 11,400/mm^3

BUN: 14 mg/

dL

,

Creatinine

: 1.2 mg/

dL

, Sodium: 132

mEq

/L, Potassium: 5.0

mEq

/L, Chloride: 100mEq/L

Glucose: 350 mg/

dL

General: child appears lethargic but AOx3

Skin: Appears dehydrated, no

erythema

or lesions

HEENT, Heart, Lungs, Abdomen: negative findings

Osteopathic Structural Exam: T7-9ERrSr with hypertonic

paraspinals

, CRI slow, decreased

Assessment and Plan

Diabetes Mellitus Type I

Family and patient is trained in how to administer insulin, check blood glucose levels, check for

ketonuria

, recognize hypoglycemia and how to treat it.

Family and patient is counseled on nutrition and timing of carbohydrates and how to measure, rotate and adjust insulin doses depending on the time of day, physical activity and food/drink intake.

F/U in two weeks.

Eventually F/U appointments need to be made every 6 mo. to check weight, BP, eyes, extremities. Future concerns include ETOH intake and depression/mental illness.

Type I

Type IA diabetes is suggested by reduced insulin and the presence of pancreatic (islet)

autoantibodies

.

Type IA vs. type IB

Type I diabetes also is usually suggested by reduced insulin and c-peptide levels.

Uncertain etiology

Peak onset bimodal:

4-6 and 10-14 years of age

Prevalence in US:

2/1000 non-Hispanic whites

Slightly lower in other ethnic

groups

Type IClassic new onset—most common presentationDiabetic

ketoacidosis

—very severe

Deep, rapid breathing

Dry skin and mouth

Flushed face

Fruity smelling breath

Nausea and vomiting

Stomach pain

Incidental finding—take thorough

hx

of all patients, no matter how young.

Case PresentationCC: new pt, physical exam HPI: 30 y/o African American female presents for PE. Claims to be in good health but mentions she is urinating more frequently and has had several UTIs in the past year.

Meds:

Metoprolol

Pmhx

: HTN;

Pshx

: unremarkable

Famhx

: Father and

Gmother

+ heart attacks, Mother, Aunt, Sister + diabetes.

ObjectiveVitals: BP: 125/90 right arm; RR: 14 breaths/min; HR: 85 beats/min

PE:

General: Morbid obesity at BMI of ~48 kg/m2

Heart, Lungs, Abdomen: negative findings

Urine dipstick: 2+

glucosuria

Random plasma glucose: 240 mg/

dL

Osteopathic Structural Exam:

Hypertonic pelvic and abdominal diaphragm, hypertonic

paraspinals

T7-9, and diminished CRI

Assessment and Plan

Diabetes Mellitus type II

Diet, exercise

 weight reduction

Oral hypoglycemic agent

Avoidance of macro/

microvascular

complications

F/U in 2 weeks and

eventually every 6

months to check

weight, BP, eyes

extremities and

renal function.

Type IIPrevalence in the US:

0.18 per 1000 non-Hispanic white youth 10-19 years old

1.06 and 1.45 per 1000 African-American and Navajo youth, respectively.

All ages: 25.8 million people, or 8.3% of the U.S

Risk factors:

Positive family history

Obesity

Female gender

Pregnancy

Type IISx:

Commonly asymptomatic

Increased thirst, increased frequency of urination, blurred vision

Glucose testing

Random blood glucose test

Fasting blood glucose test

Hemoglobin A1C level

Oral glucose tolerance test

Type IIDiagnostic Criteria:

Sx

of diabetes and a random blood sugar of 200 mg/

dL

(11.1

mmol

/L) or higher

A fasting blood sugar level of 126 mg/

dL

(7.0

mmol

/L) or higher

A blood sugar of 200 mg/

dL

(11.1

mmol

/L) or higher two hours after an oral glucose tolerance test.

An A1C of 6.5 percent or higher

The blood tests must be repeated on another day to confirm the diagnosis of diabetes.

Type IIComplications:

Macrovascular

Heart disease

Stroke

Peripheral vascular disease

Microvascular

Retinopathy

Nephropathy

Neuropathy

Infections

Staph infection at injection site

Fungal infections involving oral mucosa, genitals, skin and nails

TreatmentMedical:

Type I:

Short acting insulin=

lispro

or insulin

Intermediate acting= NPH

Long acting:

Lente

or

Ultralente

Type II:

Biguanides

:

Metformin

, mc first line

Sulfonylureas

:

Tolbutamide

,

Chlorpropamide

,

Glipizide

Glitazones

:

Pioglitazone

,

Rosiglitazone

Alpha-

glucosidase

Inhibitors:

Acarbose

,

Miglitol

Treatment

Osteopathic:

We can directly improve circulation which indirectly enhances hormone release, cellular uptake and cellular response and helps the patient avoid infection.

Pancreas T7-9:

Treat

paraspinals

, somatic dysfunctions

Abdominal and pelvic diaphragm release and rib raising

To improve circulation and lymphatic flow

Treat legs and feet

Remove restrictions and SD, improve and maintain ROM thereby helping the pt stay active and proactive in their own health

Cranial

Improve CRI=improve flow of blood, nutrients from the CSF and

lymphatics

Compile exercise and nutrition/diet program or refer to specialists

References

First Aid, Case Reports for the USMLE Step 1

Pub Med,

Ketoacidosis

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001363/

CDC, Prevalence of Diabetes Mellitus in US

http://www.cdc.gov/diabetes/projects/cda2.htm

Up To Date, Diabetes Mellitus I and II

http://www.uptodate.com.ezproxylocal.library.nova.edu

American Diabetes Association Home Page

www.diabetes.org

Rediscovering the classic osteopathic literature to advance contemporary patient-oriented research: A new look at diabetes mellitus

.

John C

Licciardone

.

http://www.om-pc.com/content/2/1/9

An osteopathic approach to type 2 diabetes mellitus

.

Shubrook

JH

Jr

, Johnson AW.

Common crossroads in diabetes management

.

Michael

Valitutto