06 DM2

Question 1

RF T2DM

Answer 1

overweight or obese pts :
physical inactivity
race (NA, PI, latino, AA, Asian)
first degree relative
impaired fasting glucose (100-125) or impaired glucose tolerance (2-hr > 140 after 75 gm)
HTN
HDL < 35 or TGs > 250
Hx GDM or baby > 9 lbs
PCOS
Hx CVD
A1c > 5.7%
Other clinical conditions associated with insulin resistance

Question 2

Screening recs (ADA)

Answer 2

if no RF, start at 45 and repeat q 3 or more often

Question 3

USPSTF recs

Answer 3

screen in asx pts with sustained bp greated than 135/80

Question 4

dx criteria DM

Answer 4

random glucose of 200 +, plus sxs of hyperglycemia like polyuria or unexplained weight loss or hyperglycemic crisis

fasting glucose higher than 126

A1c >= 6.5%

OGTT

confirm on a diferent day unless unequivocal or unquestionable sxs

Question 5

fundoscopic exam severe nonproliferative retinopathy

Answer 5

retinal hemorrhages
cotton wool spots
microaneurysms

Question 6

optimal range for blood glucose

Answer 6

fasting 80-120

postprandial 1-2 hours < 180

Question 7

LEARN model

Answer 7

Listen to pt's perception
Explain your perception and strategy for tx
Acknowledge differences
Recommend tx 
Negotiate agreement

Question 8

Annual foot exam

Answer 8

testing for loss of protective sensation
assessment pedal pulses
inspection

Question 9

familismo

Answer 9

family is primary source of support. may not make decisions without cnsulting famiyl

Question 10

respeto/simpatia

Answer 10

special respect to elders and authority figures, including health care providers

Question 11

personalismo

Answer 11

value warm friendly relationships over impersonal or institutional formalty - balance iwth preseto

Question 12

fatalismo

Answer 12

nothing can be done to improve their health

Question 13

management of ASCVD RF in DM

Answer 13

smoking cessation
HTN > 140/90
Use of statins in prevention - measure annually and tx if LDL 70-189
moderate in 40-75 yo with DM
High intensity in 40-75 yo with > 7.5 ASCVD risk

ASA as if they didn’t have DM (those with inc risk, > 10%)
weight loss, exercise

Question 14

first tier tx DM

Answer 14

Step 1:
Dx = HbA1c > 6.5% = lifestyle changes + metformin

Step 2: HgbA1c > 8 = above + either SUR or basal insulin or insulin detemir or NPH

Step 3: If HGb A1c > 8 = lifestyle changes + metformin + basal insulin or intensify insulin
d/c SUR

Question 15

2nd tier tx DM

Answer 15

rapid acting insulin with meals
thiazolidinediones (actos or avandia - glitazones)
meglitinides 
GLP-1 analogs (exenatide, liraglutide)
DPP-4 inhibitors (sitagliptin)
amylin analog (pramlintide)
alpha-glucosidase

Question 16

major issues with glitazones

Answer 16

can increase risk HF, edema, bone fractures

Question 17

vaccine recs for dm

Answer 17

influenza
Pneumovax (23)to all pts iwth DM over 2 yo, revaccinate after 64 if first time was over 5 years ago
can give prevnar (13) 1 year later
Hep B

Question 18

refer to ophtho

Answer 18

type 1 5 years after dx

type 2 right away

Question 19

follow up labs for DM

Answer 19

A1c
foot exams 
Creatinine/urine albumin/creatinine ratio
B12 if neuropathy or on metformin 
TSH yearly 
fasting lipids

Question 20

HHS

Answer 20

pH > 7.3, bicarb > 15
glucose > 600
no/few ketones

severe dehydration
infections/stroke/mi/pe precipitate

Question 21

DKA

Answer 21

ph < 7.30
low glucose ie 250
ketosis