Diabetes practice questions
- 1 16 year old with NHL aspirations
- 2 9-year old with high blood sugars in the morning
- 3 3-year old picky eater
- 4 Ultralente insulin man
- 5 The 14 year old girl
- 6 Man who says he's healthy (Type 2 start)
- 7 Irregular menstruation and having a baby
- 8 Next case
- 9 Resources
16 year old with NHL aspirations
A 16 year old student was diagnosed with Type 1 diabetes one month ago. He is otherwise healthy and his diabetic control is now stable. He is taking Humalog insulin before each meal and NPH at bedtime. He is very active in sports and plays Junior B hockey. He is anxious to learn if his diabetes will impact on his life-long goal of playing in the NHL.
1. Should he set his goal on something else?
In theory, he should be able to be a hockey player. However, he should consider doing something more useful with his life.
2. Describe the metabolic changes that occur during exercise.
During exercise, various metabolic changes happen. For one, anaerobic processes kick up, including the Corey cycle. Also, glucose sensitivity will increase and there would be decreased insulin production.
3. Describe the differences that can occur in a diabetic during exercise.
During exercise, a diabetic can easily become hypoglycaemic, especially if they just shot themselves with insulin.
With regards to exercise, he should consider using insulin pump therapy to regulate the insulin input. He will also likely have to drink something sweet during the exercise such as juice or gatorade. For blood glucose monitoring, ideally, he should monitor his blood sugar between periods and occasionally on the bench if he thinks he's in trouble. As for diet, he should eat right.
9-year old with high blood sugars in the morning
A 9-year old girl with Type 1 diabetes for three years is on a twice-daily regimen of Regular (10 units) and NPH (12 units) before breakfast, and Regular (6 units) and NPH (8 units) before supper. She has consistently high blood glucose levels in the range of 12-20 mmol/L before breakfast. She also had some ketones present in the urine before breakfast. The rest of the day her blood sugars are all around 4-7 mmol/L and her ketones are negative.
1. Describe three physiologic or pathophysiologic reasons for her high morning sugars.
It is possible that:
- she is having a hypoglycaemic effect, which gives a physiological rebound and increased sugars in the morning.
- Increased gluconeogenesis at night.
2. What questions about symptoms would you ask to help you determine which of these events is occuring?
Night hypoglaecemia would result in night sweats and rustled sheets and the like.
3. What would you advise her to do if doubts still exist as to the cause?
4. What changes would you recommend to her insulin regimen?
Decrease the insulin at night.
3-year old picky eater
A 3-year old with Type 1 diabetes is a picky eater. Currently he is on Regular (1-3 units) and NPH (6 units) insulin before breakfast; and Regular (0-2 units) and NPH (2 units) before supper. His parents find they just can't predict how much he will eat. Recently he has been having hypoglycaemic reactions 2-3 times a week due to not completing meals.
1. What options are available to the parents to prevent hypoglycaemia in this toddler.
2. List three options for treating hypoglycaemia.
- A glucose tablet or sugar-containing drink by mouth
- Corn syrup
- Glucagon emergency kit (1mg of glucagon given into the muscle or adipose.
- If there is a recurrent pattern, then decreasing the insulin dose might help.
Ultralente insulin man
Mr. Bruce Holt is a 37 year old man with 27 years of Type 1 diabetes. He has recently had coronary artery bypass grafting. His surgeon has placed him on atenolol and he has been having a lot of problems with low blood sugars. He is testing 3-4 times daily and finds at least once a day he is less than 2 mmol/L. His current insulin program is 5 units Regular and 22 units Ultralente at breakfast, and 7 units Regular and 15 units Ultralente at supper.
1. What suggestions do you have for Mr. Holt with regards to:
Tell him to have a more consistent diet with regards to carbohydrates.
b) Blood glucose monitoring
He should keep up his blood glucose monitoring, but perhaps monitor more during times of any activity or when he is at risk of having an episode.
Suggest that he use a faster-release insulin instead of the ultralente, and have it with meals so that he could have better control.
d) Other medications
The 14 year old girl
Man who says he's healthy (Type 2 start)
A 45-year old man presents to your office complaining of dysuria and frequent urination. He has been previously healthy but his last checkup with you was more than 5 years ago. On questioning, he admits to drinking large amounts of juices and soda.
On examination, he is overweight with a BMI of 34. His blood pressure is 145/90, and his pulse is 70. He is afebrile. The remainder of the examination is normal except for predominant abdominal obesity.
Initial laboratory tests show:
- WBC: 8 x 109/L (4-11)
- Urinalysis: White cells, glucose
- Random serum glucose: 15mmol/L
1. What is your diagnosis?
He has glucoseuria, a probable urinary tract infection, and previously undiagnosed Type 2 diabetes.
2. What treatment would you start?
He would probably have to get off the juices to help with the high glucose. As well, he should be treated for his UTI. Since he has higher blood glucose than motivation, he would probably have to be put on some medication.
3. What classes of medication are available for treating type 2 diabetes?
Some of the classes:
- Stimulate insulin release (sulfonurea)
- Increase insulin sensitivity (metforin)
- Inhibit glucose absorption from the gut (acarbose)
- Insulin itself
4. How would you assess cardiovascular risk and what would you monitor long term?
To assess cardiovascular risk, one would check family history, ask about smoking status, check his blood pressure, and check overall blood sugar control.
5. For what other complications of diabetes would you monitor?
He should be examined on a yearly basis for peripheral neuropathy and the like. For his kidney function, one would screen with a microalbumin/creatine ratio. Also, retinopathy should be screened for by an ophthamologist.
Irregular menstruation and having a baby
A 27-year old woman presents to your office complaining of irregular menstrual periods. Her last menstrual period was 6 months ago. She is recently married and wants to start a family.
On examination, she is overweight (BMI 35) with increased abdominal obesity. She has increased facial hair with dark terminal hair over her moustache and side burn region. She has acne on her back and face. She is not hypertensive, but there is a family history of high blood pressure and diabetes.
1. What skin abnormality may she manifest?
2. What laboratory investigations would you order?
A pregnancy test, a random/fasting blood glucose,
3. What is the most likely diagnosis and what is the underlying physiologic mechanism?
4. What treatment would you recommend?
1. He is at high risk due to family history and an abnormal sugar (though he's not in the diabetic range)
2. He is not diabetic, but he has impaired fasting glucose. He probably has a >50% chance of acquiring diabetes.
3. Developing type 2 diabetes is one risk. Another is cardiovascular disease.
4. Exercise; more frequent checkups; glucose tolerance test