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FELIPE GARCIA 57 YEAR OLD REASON FOR
ENCOUNTER HIGHBLOOD PRESSURE
LATEST CASE 2025
What are the ADA's phsycian tasks for diabetes care (5)? - answer-1. work to detect diabetes complications and potential comorbidities
- review previous treatment and risk factor control
- begin patient engagement in the formulation of a care management paln
- review and discuss prevention of complications
- develop a plan for continuing care
Relevant medical history for a patient with diabetes? - answer-
Advantages/Disadvantages of EMR - answer-1. offers template that increases likelihood that pt receive recommended care
- provides tools to evaluate pt care across an entire population
- allows documentation of improved physician performance, which may increase reimbursements by some insurers
- Has been shown to interrupt the physician-pt relationship (screen gaze)
What symptoms of hyperthyroidism complicate diabetes management? - answer-Fatigue, Depression, Dyslipidemia
Type 1 DM is associated with which thyroid diseases? - answer-T1DM is an autoimmune illness and is associated with both Graves disease and Hashimoto disease
DKA in T1DM v. T2DM - answer-Pts with T1DM get DKA
Pts with T2DM more often get HHS
pts with T2DM can develop DKA when over time, T2DM starts to resemble T1DM as pancreatic function dwindles and pts may begin to require insulin. If deficiency is severe enough, a pt with T2DM may produce ketones and develop hyperglycemia.
Ex. a T2DM elderly pt who becomes acutely ill could easily develop DKA
Screening for T2DM ADA Recommendations (11) - answer-1. Overweight or obese patients (BMI ≥ 25 kg/m2 or ≥ 23 kg/m 2 in Asian Americans) who have 1 or more:
-Physical inactivity
-High-risk race/ethnicity (Native American, Pacific Islander, Latino, African American, Asian American)
-1st-degree relative with DM
-8% of Asian Americans
-12.1% of Hispanics
-12.7% of non-hispanic blacks
-15.1% of american indians/alaska natives
What are rates of diabetes among hispanics from different regions? - answer-- 8.5% for Central/South Americans
-9% Cubans
-12% Puerto Ricans
-13.8% Mexican Americans
How does laser photocoagulation treatment help with retinopathy? - answer- Slows the progression of retinopathy and reduce vision loss, but doesn't restore lost vision.
Important to identify and treat patients early since retinopathy is asymptomatic in early course and the treatment is aimed at preventing vision loss
What findings should one see in severe, non-proliferative retinopathy? - answer-1. retinal hemorrhages- dark blots with indistinct borderst that indicate partial obstruction and infarction
- Cotton wool spots- white spots with fuzzy borders and they indicate areas of previous infarction. Accompany hemorrhages
What is the hallmark of proliferative retinopathy? - answer-neovascularization. Growth of new new blood vessels is prompted by retinal vessel occlusion and hypoxia
What is the optimal range for blood glucose? - answer-1. Fasting BG should be 80-120mg/dl
- Postprandial BG between 1-2 hours after a meal should be <180mg/dl
What conditions contribute to hyperglycemia (5) - answer-1. Overeating
- missing doses of medication
- dehydration
- infection and illness
- stress
What is the leading cause of death in pts with diabetes? - answer-ASCVD (coronary heart disease and stroke)
What factors should be considered in management of ASCVD risk (5)? - answer-1. Smoking cessation
- Hypertension
- Dyslipidemia
- Lifestyle modification
- Lifestyle control
People with diabetes are 2-4x more likely to have heart
disease or stroke than people without.
Patients with DM who have an MI have
worse outcomes than patients without, and a dx of DM is considered equivalent in risk to
having had a previous
MI.
Management of cardiovascular risk factors so commonly found in
diabetes is therefore essential in preventing morbidity and mortality in these patients.
What is the most common cause of new cases of blindness among adults of working age? - answer-DM. ages 20-74y
5yrs after dx of T2DM, pts w/ more severe or uncontrolled disease that requires insulin have a 40% prevalence of retinopathy while those on oral hypoglycemic agents have a 24% prevalence.
After 15yrs of DM, almost all pts with T1DM and 2/3 of patients with T2DM have background retinopathy.
By the time the patient's vision is affected, substantial retinal damage may have already occurred. Proliferative retinopathy is prevalent in 25% of the diabetic population with 25 or more years of DM.
Neuropathy Classification - answer-Classified
according to the nerves affected:
- focal
- diffuse
- sensory
- motor
- autonomic
How is the prevalence of neuropathy defined? How does it increase with disease longevity? - answer-The prevalence of neuropathy defined by loss of ankle jerk reflexes is 7% at 1 year
increasing to 50% at 25 years for both T1DM and T2DM
How many people with DM develop diabetic nephropathy? - answer-20-40% of people with diabetes develop diabetic nephropathy.
Diabetes was
listed as the primary cause of kidney failure in 44% of all new cases in 2014.
Is hyperthyroidism an end result of diabetes? - answer-No, but this hypermetabolic state can unmask underlying flucose intolerance, and adversely affect glucose control and lipid management in patient with diabetes
This includes most men or women
with DM ≥50 years w/ at least 1 additional major risk factor (fhx of premature
at ASCVD, HTN, smoking, dyslipidemia, or albuminuria) and are not at
increased risk of bleeding. (Level of Evidence C)
- In absence of risk factors, screening should begin at 45
- If normal, repeat testing at least q3y depending on risk status and initial results.
USPSTF DM Screening Recommendations - answer-Adults 40-70y who are overweight or obese, screen for abnormal BG as part of
CV risk assessment.
Clinicians should offer or refer pts with abnormal BG to
intensive behavioral counseling interventions to promote a healthful diet and physical activity.
Rating: "B"
recommendation.
Diagnostic Criteria for DM - answer-1. Random BG 200 mg/dL or above + sx of hyperglycemia (polyuria, unexplained
wt loss, hyperglycemic crisis)
- Fasting plasma BG > or = to 126 mg/dL; fasting = no caloric intake for at
least 8 hours.
- HbA1c > or = 6.5%.
- 2hr plasma BG≥ 200 mg/dL (11.1 mmol/L) during an OGTT.
Fasting glucose, OGTT and A1C need to be confirmed on a different day unless the patient has
unequivocal or unquestionable symptoms of hyperglycemia.
Prevalence of diagnosed and undiagnosed DM in US all ages 2015 - answer- Total: 30.3 million (9.4% of population)
Diagnosed: 23 million
Undx: 7.2 million (23.8% of population)
Aspirin should not be recommended for atherosclerotic cardiovascular disease prevention for adults with
diabetes at low atherosclerotic cardiovascular disease risk (10-year atherosclerotic cardiovascular disease
risk <5%), such as in men or women with diabetes aged <50 years with no major additional atherosclerotic
cardiovascular disease risk factors, as the potential adverse effects from bleeding likely offset the potential
benefits. (Level of Evidence C)
LEARN model - answer-Berlin and Fowkes- simple way to remember the imporance of two-way dialogue with your pt about understanding their illness.
Where can you get a tool to help facilitate communication with patients from various cultural and linguistic backgrounds? - answer-Office of Minority Health of US Dept of HHS
"think cultural health offers a guide to providing effective communication and language assistance services"
How often and why should Diabetics get foot exams? - answer-annually
Up to 50% of diabetic peripheral neuropathy (DPN) may be asymptomatic but leave patients at risk of foot
ulceration
- nonDM neuropathies may be present in patients with diabetes and may be treatable
- while specific tx for the underlying nerve damage is currently not available, other than improved
glycemic control, which may slow progression but not reverse neuronal loss -- effective symptomatic
treatments are available for some manifestations of DPN.
Why does foot ulceration happen? - answer-Foot ulceration is the result of impaired sensation (distal symmetric polyneuropathy) and impaired perfusion (diabetes vasculopathy and peripheral vascular disease), both of which are independent annd strong risk factors for foot ulceration and amputation
What should Diabetic foot exam include? - answer-1. testing for loss of protective sensation (Sensory testing should be conducted with a 10g monofilament PLUS any one of the following:
- vibration using 128Hz tuning fork
- pinprick sensation
- ankle reflexes (achilles necessary but patellar not needed))
- Assessment of pedal pulses (dorsalis pedis and posterior tibial arteris; assessing the arterial supply to the lower limbs and feet is essential in evaluation for peripheral vascular disease, the strongest risk factor for delayed ulcer healting and amputation in DM patients.
- Inspection: skin changes such as hair loss and temperature changes may signal vascular insufficiency. Since foot ulceration is usually caused by breaks in the skin d/t accidental trauma or poorly fitted footwear, at each visit, the patient's feet should be inspected for breaks in the skin, pressure calluses that precede ulceration, existing ulceration and infection, and bony abnormalities that lead to abnormal pressure distribution and ulceration. The patient's footwear should also be inspected for abnormal patterns of wear and appropriate sizing
How to request a referral? - answer-INclude:
-pertinent pt information
-clear request or question to be addressed
What is the commonly prescribed dose of ASA in the US? - answer-81mg
Lowering A1c below 7% prevents what types of complications - answer- microvascular
-retinopathy
-nephropathy
Lowering A1c below what percent prevents microvascular complications? - answer-<7%
Does lowering A1c below 7% prevent macrovascular AND microvascular complications? - answer-Unclear about macrovascular.
Pt may have difficulty making health care decisions without consulting family
--Refrain from interpreting indecisiveness as ambivalence or apathy; ask pt if he/she would like
to include family members in decision making.
How does respeto/simpatia play a role in facilitating or hindering communication with health care providers? - answer-Special respect should be shown to elders and authority figures
Hispanic pts tend to avoid overt disagreement or confrontation and prefer communication based on politeness and respect
Latino women may refrain from asking questions about a dx or tx plan or even monitoring s/e to not appear disrespectful
Pts may nod but not necessarily agree
How does personalismo play a role in facilitating or hindering communication with healthcare providers? - answer-Latino patients value warm, friendly relationships over impersonal or institutional formality; this should be balanced with respeto, however when it comes to addressing pts, don't address latino pts by their first name. Be friendly , but respectful. "Ms. Sanchez, it is good to see you. How is your sister?"
How does fatalismo play a role in facilitating or hindering communication with healthcare providers? - answer-Holding to a belief that control over one's diabetes is external to self latino patiens may express that nothng can be done to improve their diabetes or health. Common phrases may be, "It is out of my hands," or "everyone has to die from something."
Fatalismo is not unique to the Latino culture. Some DM education programs have addressed the philosophy with other common Latino beliefs like, "help yourself, and god will help you"
- Physical limitations regarding drawing up insulin
- Pt's perception that insulin actually causes the comorbidities associated with diabetes
- Physicians may lack the time and support staff to teach patients
How do you respond to this:
Mindset that insulin is a medication of last resort and that initiating equals failure - answer-This is not true. Remember that good glucose conrol is more important than the means used to achieve it
How do you respond to pt fear of injecting insulin with a needle? - answer- Most pts are surprised at how easy administering insulin, and often share that it is less painful than fingerstick glucose monitoring
How do you respond to the issue of physical limitations regarding drawing up insulin? - answer-Presents an impediment for some pts due to poor vision or poor dexterity; insulin pens make it easy to "draw up" the correct amount of insulin
How do you respond to the issue of pt perception that insulin actually causes the comorbidities associated with DM? - answer-Many pts have family members or friends with DM who were placed on insulin late in the progression of their disease. When complications occurred, the insulin was blamed for the poor outcomes
How do you respond to the issue of physicians lacking the time and support staff to teach patients? - answer-Pts need to be educated about administering, storing, and dosing insulin, and monitoring blood glucose
Are pts who cut back on smoking likely to see cardiovascular benefit? - answer- No, pts should QUIT (level of evidence A), not just cut back.
Advising all pts to simply cut back on smoking has not been shown to improve CVD.
What is the most important modifiable cause of premature deaht in pts with ASCVD? - answer-Smoking.
Strong and convincing evidence for a causal link between cigarette smoking and health risk.
Why is smoking especially bad in pts with DM and ASCVD? - answer-Pts with DM who smoke have a higher risk of premature development of microvascular complications, CVD, and premature death.
Is smoking cessation counseling helpful? - answer-A number of large RCTs have demonstrated efficacy and cost-effectiveness of smoking cessation counseling in changing smoking behavior
