Diabetes Mellitus

Diabetes Mellitus A presentation by Meighan O’Connor, POPPF DidacticsOnline.com

Case Presentation CC: 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 75th percentile to the 50th 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 I • Classic new onset—most common presentation • Diabetic 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 Presentation CC: 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.

Objective • Vitals: • 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 II • Prevalence 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 II • Sx: • 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 II • Diagnostic 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 II • Complications: • 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

Treatment • Medical: • 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, Ketoacidosishttp://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

Diabetes Mellitus