CCFP Review PART 2 (largest)
with Complete Solutions
when target not met w/ lifestyle change, metformin and other orals OR if in
HHS/DKA or very symptomatic hyperglycemia (remain on metformin, not
combined w/ most other orals)
often start long acting at hs, ~10u of glargine (or detemir)
go until am FBG <7
can add rapid acting (aspart or lispro) to 10 mins prior to meals (decr hypo
compared to short acting) - ANSWER-When to use insulin in DM2
How to add to DM2 regimen
BS >14mmol/L, presence of urinary or plasma ketones, pH <7.3 and serum
bicarbonate <18mmol/L
Absence of insulin = decr glucose utilization = incr'd triglyceride breakdown
to free FAs = ketone production - ANSWER-DKA dx criteria and mechanism
,T1DM
T2DM w/ african american/latino, male, middle aged, overweight/obese, FHx
DN, new Dx
Poor adherence, depression, wt control, money issues
Not monitoring BS - ANSWER-RF for DKA
Viral studies - rarely done
Stool gram stain, culture & sens - if immunocompromised, IBD, bloody
diarrhea or persistent diarrhea
Ova, cyst and parasites - travel hx, persistent diarrhea
C diff toxin - recent Abx or persistent diarrhea - ANSWER-Investigations for
acute diarrhea
Fever --> salmonella, shigella, campylobacter , enteric viruses, clostridium
difficile, entamoeba histolytica
Blood --> Escherichia coli, entamoeba histolytica, campylobacter, salmonella
- ANSWER-Which microrgansims are involved when diarrhea is accompanied
by fever?
,With bloody diarrhea?
If no red flags
Rehydration and supportive care
Avoid solid food or dairy
BRAT diet (banana, rice, apple sauce, toast)
Abx in the following circumstances:
- severe traveller's diarrha (>4 unformed stools/d, fever and blood, pus or
mucous in the stool)
- >8 stools/d
- sx >1 wk
- immunocompromised
- hospitalized patients
Probiotics
Loperamide if no fever or bloody stool - ANSWER-Tx of acute diarrhea
Infection (UTI, PNA, sepsis) ~30%, EtOH, psych stress, pregnancy, CV events
(CVA.MI), trauma, Rx (steroids, thiazide), Cushing's, acute GI illness,
idiopathic in ~40% - ANSWER-Precipitants of DKA
, polyuria or polydipsia, fatigue, lethargy, decr appetite, h/a, n/v, abdo pain
decr skin turgor, decr sweat, postural hypoTN, kussmaul breathing, fruity
smelling breathing
ALWAYS LOOK FOR PRECIPITANT - ANSWER-Sx/signs of DKA
Ketosis -
starvation ketosis - G close to n
EtOH ketoacidosis - N/decr gluc, osmolar gap
pseudo ketosis - N gluc, N gap
rhabdomyolysis - N gluc, ketones
Acidosis -
lactic
salicylate - N/decr gluc
methanol - low ket, blurry vision, osmolar gap
ethylene glycol - N ket, osmolar gap
