Diabetes Flashcards
History of Present Illness: UR is a 48 year old male with newly diagnosed type 2 diabetes. He presents to the clinic on 10/10 for a comprehensive visit to include initiation of diabetes treatment.
Allergies: NKDA
Past Medical History:
Gout
Diabetes mellitus type 2
Social History:
Married, 2 young children, office job with long periods of sitting, smokes ½ PPD, alcohol socially on weekends and some evenings during the week. Does not exercise or have any active hobbies.
Current Medications:
None
Immunizations History: None since childhood
Vitals:
Height: 5’11” Weight: 182 lbs
BP: 154/96 mmHg HR: 83 BPM RR: 20 BPM Temp: 98.6ºF Pain: 1/10
Labs (fasting):
AST (units/L) = 24 (10 - 40)
ALT (units/L) = 21 (10 - 40)
TC (mg/dL) = 206 (125 - 200)
TG (mg/dL) = 165 (< 150)
HDL (mg/dL) = 34 (> 40)
LDL (mg/dL) = 163 (<100)
GLU (mg/dL) = 264 (100 - 125)
Na (mEq/L) = 141 (135 - 145)
K (mEq/L) = 4.2 (3.5 - 5)
Cl (mEq/L) = 100 (95 - 103)
HCO3 (mEq/L) = 28 (24 - 30)
BUN (mg/dL) = 22 (7 - 20)
SCr (mg/dL) = 1.2 (0.6 - 1.3)
Mg (mEq/L) = 1.9 (1.3 - 2.1)
PO4 (mg/dL) = 4.4 (2.3 - 4.7)
Ca (mg/dL) = 9.5 (8.5 - 10.5)
TSH (mIU/L) = 1.9 (0.3 - 3.0)
Hgb A1C = 10.6 %
Urinary albumin excretion (mg/24 hours) = 20 (< 30)
Question
Which of the following should be recommended for UR at this time? (Select ALL that apply.)
Answer
A Influenza vaccine (live, Flumist) B Influenza vaccine (inactivated, shot) C Pneumococcal polysaccharide vaccine D Hepatitis B vaccine E Hepatitis A vaccine
B Influenza vaccine (inactivated, shot) C Pneumococcal polysaccharide vaccine D Hepatitis B vaccine
The patient is not a candidate for the live influenza vaccine. This is not used in patients with chronic disease and no longer recommended by the CDC for any patient. He should receive the influenza shot (inactivated), the pneumococcal polysaccharide vaccine (Pneumovax 23), and the hepatitis B vaccine.
Why should they receive the PPSV23 and not the Hep A?
History of Present Illness: UR is a 48 year old male with newly diagnosed type 2 diabetes. He presents to the clinic on 10/10 for a comprehensive visit to include initiation of diabetes treatment.
Allergies: NKDA
Past Medical History:
Gout
Diabetes mellitus type 2
Social History:
Married, 2 young children, office job with long periods of sitting, smokes ½ PPD, alcohol socially on weekends and some evenings during the week. Does not exercise or have any active hobbies.
Current Medications:
None
Immunizations History: None since childhood
Vitals:
Height: 5’11” Weight: 182 lbs
BP: 154/96 mmHg HR: 83 BPM RR: 20 BPM Temp: 98.6ºF Pain: 1/10
Labs (fasting):
AST (units/L) = 24 (10 - 40)
ALT (units/L) = 21 (10 - 40)
TC (mg/dL) = 206 (125 - 200)
TG (mg/dL) = 165 (< 150)
HDL (mg/dL) = 34 (> 40)
LDL (mg/dL) = 163 (<100)
GLU (mg/dL) = 264 (100 - 125)
Na (mEq/L) = 141 (135 - 145)
K (mEq/L) = 4.2 (3.5 - 5)
Cl (mEq/L) = 100 (95 - 103)
HCO3 (mEq/L) = 28 (24 - 30)
BUN (mg/dL) = 22 (7 - 20)
SCr (mg/dL) = 1.2 (0.6 - 1.3)
Mg (mEq/L) = 1.9 (1.3 - 2.1)
PO4 (mg/dL) = 4.4 (2.3 - 4.7)
Ca (mg/dL) = 9.5 (8.5 - 10.5)
TSH (mIU/L) = 1.9 (0.3 - 3.0)
Hgb A1C = 10.6 %
Urinary albumin excretion (mg/24 hours) = 20 (< 30)
Question
According to the ADA guidelines, what is the best therapy to start in UR (in addition to lifestyle treatment)?
Answer
A Metformin + pioglitazone B Metformin + exenatide C Metformin + glimepiride D Basal insulin + mealtime insulin E Metformin + basal insulin + sulfonylurea.
D
Basal insulin + mealtime insulin
Combination injectable therapy should be considered in patients with severe hyperglycemia, defined as a BG ≥ 300 mg/dL or A1C ≥ 10%.
What is the mechanism of action of the thiazolidinediones?
Answer
A
They act on PPAR-gamma receptors as an antagonist.
B
They stimulate insulin secretion from the pancreas.
C
They improve insulin sensitivity in the muscle cells.
D
They act as an incretin mimetic.
E
They decrease glucagon secretion from the pancreas.
C
They improve insulin sensitivity in the muscle cells.
They are actually PPAR-gamma receptor agonists.
A physician wants to prescribe exenatide to his patient. He calls the pharmacy to ask if there are any precautions to the use of this medication. The pharmacist should relay that the drug may not be safe to use in the following situations: (Select ALL that apply.)
Answer
A Creatinine clearance less than 30 mL/minute B Decreased bone mineral density C Liver disease D Alopecia E History of pancreatitis
Byetta A Creatinine clearance less than 30 mL/minute E History of pancreatitis
A patient gave the pharmacist a prescription for Soliqua 100/33. Which of the following is the generic for this drug?
Answer
A Insulin glargine + liraglutide B Insulin glargine + lixisenatide C Metformin + saxagliptin D Metformin + canagliflozin E Empaglifllozin + linagliptin
B
Insulin glargine + lixisenatide
KS is picking up a new prescription for glipizide. What are possible side effects from this medication? (Select ALL that apply.)
Answer
A Pancreatitis B Hypoglycemia C Bladder cancer D Thyroid cancer E Weight gain
B
Hypoglycemia
E
Weight gain
A patient with type 2 diabetes is beginning therapy with pramlintide. Choose the correct statement:
Answer
A
The mealtime insulin dose should be decreased by 50% when beginning pramlintide.
B
The basal insulin dose should be increased by 25% when beginning pramlintide.
C
This medication is injected after meals and with any food intake up to 250 kilocalories.
D
This medication has a boxed warning for thyroid cancer and weight gain.
E
This medication can only be used for treating type 1 diabetes.
A
Incorrect
Pramlintide has a boxed warning for severe hypoglycemia; the mealtime insulin dose must be decreased by 50% when starting therapy.
A patient is using propranolol for migraines. She has just begun therapy with glipizide. The patient may not be able to recognize the following symptoms of hypoglycemia: (Select ALL that apply.)
Answer
A Shakiness B Anxiety C Hunger D Sweating E Palpitations
A Shakiness B Anxiety E Palpitations Incorrect Beta blockers can block shakiness, anxiety and palpitations brought on by hypoglycemia. Sweating and hunger may still be present.
Plan: CT scan of the abdomen with iodinated contrast (scheduled for 9/22) to check for abdominal abscess; hold metformin and start sliding scale insulin to control blood glucose. Start cefepime 2 grams IV Q24H, levofloxacin 500 mg PO daily and metronidazole 500 mg PO TID. Patient may eat a regular diet beginning on the afternoon of 9/22 after CT scan has been completed.
Question
Based on the plan documented, which type of insulin will be added to PQ’s medication profile?
Answer
A Insulin regular B Insulin NPH C Insulin detemir D Mixed insulin 75/25 E Mixed insulin 70/30 .
A
Insulin regular
Incorrect
Regular (short-acting) or rapid-acting insulins are used for sliding scales and correction doses. When the blood glucose is elevated, it is best to get it controlled right away. Long-acting insulins have a slow onset of action
Plan: CT scan of the abdomen with iodinated contrast (scheduled for 9/22) to check for abdominal abscess; hold metformin and start sliding scale insulin to control blood glucose. Start cefepime 2 grams IV Q24H, levofloxacin 500 mg PO daily and metronidazole 500 mg PO TID. Patient may eat a regular diet beginning on the afternoon of 9/22 after CT scan has been completed.
Question
On the morning of 9/22, the pharmacist recommends an adjustment to PQ’s insulin therapy as she is hyperglycemic despite using 18 units of sliding scale insulin since admission. Which of the following is an acceptable recommendation?
Answer
A
Double the doses of the sliding scale insulin regimen.
B
Insulin glargine 20 units SC daily.
C
Start glipizide 10 mg PO daily 30 minutes before breakfast.
D
Insulin regular 6 units Q4H while awake.
E
Humalog Mix 70/30 SC BID before the morning and evening meal.
Incorrect
B
Insulin glargine 20 units SC daily.
Sliding scale insulins alone are no longer recommended to manage hyperglycemia in hospitalized patients. Per the 2017 ADA guidelines, patient’s with poor oral intake (this patient is not eating a regular diet until later in the day after her CT scan), a basal insulin regimen with bolus correction doses (aka sliding scale insulin) is recommended. Short- or rapid-acting insulins and agents that cause hypoglycemia (such as sulfonylureas) should not be scheduled in a patient that is not eating regular meals.
Which of the following are correct regarding diabetes? (Select ALL that apply.)
Answer
A
Type 1 diabetes must be treated with insulin.
B
Type 2 diabetes is due to both insulin resistance and insulin deficiency.
C
Prediabetes can be treated with glipizide.
D
The C-peptide test can be used to determine if a patient is producing insulin.
E
Insulin is a hormone that conversion of glucose to glycogen
A
Type 1 diabetes must be treated with insulin.
B
Type 2 diabetes is due to both insulin resistance and insulin deficiency
D
The C-peptide test can be used to determine if a patient is producing insulin.
E
Insulin is a hormone that conversion of glucose to glycogen
HJ needs better control of his type 2 diabetes. His last A1C was 8.2% and he is compliant with his metformin 1,000 mg BID. He states he does not want to gain weight and refuses to take any kind of injectable medication. Which medication option would be most appropriate for HJ, based on his personal preferences?
Answer
A Canagliflozin B Glimepiride C Exenatide D Nateglinide E Pioglitazone
A
Canagliflozin
Canagliflozin causes weight loss and comes as an oral formulation. The other agents listed cause weight gain or are only available as an injectable product.
MK’s mother has been hospitalized and put on insulin therapy. The mother is discharged with a prescription for Novolog FlexPen. Her insurance plan does not cover this option. Choose an acceptable alternative:
Answer
A Humulin N B Humulin R C Humalog KwikPen D Novolin R ReliOn E Levemir FlexTouch
C
Humalog KwikPen
Novolog FlexPen is insulin aspart, a rapid acting insulin. The only other rapid-acting insulin shown is Humalog KwikPen which is insulin lispro.
History of Present Illness: KT is a 23 year-old female being seen in clinic on 2/10 for diabetes management. Of note, KT was hospitalized 2 months ago because she stopped taking her medications for a few days. Since then, she has attended a diabetes education class and met with her dietitian. She feels some tingling in her feet for which she takes gabapentin. She does not smoke and drinks alcohol only on special occasions.
Allergies: NKDA
Current Medications (2/10): Levemir 21 units QHS Insulin lispro 7 units TID before meals Gabapentin 300 mg TID Paxil 40 mg daily
Past Medical History:
Type 1 diabetes
Depression
Peripheral neuropathy
Vitals (2/10):
Height: 5’10” Weight: 155 lbs
BP: 128/77 mmHg HR: 85 BPM RR: 20 BPM
Temp: 98.6ºF Pain: 1/10
12/11 to 2/10 Blood Glucose Value Ranges (self-monitored): Before breakfast: 95 - 120 mg/dL After lunch: 110 - 125 mg/dL After dinner: 200 - 225 mg/dL At bedtime: 130 - 150 mg/dL
2/10 Labs (fasting): AST (units/L) = 23 (10 - 40) ALT (units/L) = 25 (10 - 40) GLU (mg/dL) = 107 (100 - 125) Na (mEq/L) = 141 (135 - 145) K (mEq/L) = 4.2 (3.5 - 5) Cl (mEq/L) = 100 (95 - 103) HCO3 (mEq/L) = 28 (24 - 30) BUN (mg/dL) = 18 (7 - 20) SCr (mg/dL) = 0.9 (0.7 - 1.3) Mg (mEq/L) = 1.9 (1.3 - 2.1) PO4 (mg/dL) = 4.4 (2.3 - 4.7) Ca (mg/dL) = 9.5 (8.5 - 10.5) TSH (mIU/L) = 1.9 (0.3 - 3.0) Hgb A1C = 7.8% Urinalysis = albumin (-) and ketones (-)
2/10 Tests: Eye exam with normal findings
12/9 Labs (hospital admission): GLU (mg/dL) = 390 (100 - 125) Hgb A1C = 8.5% Urinalysis = albumin (-) and ketones (+) pH = 7.24 (7.35-7.45) pCO2 (mmHg) = 25 (35 - 45) pO2 (mmHg) = 92 (80 - 100)
6/14 Labs (clinic visit 8 months prior):
GLU (mg/dL) = 113 (100 - 125)
Hgb A1C = 7.9%
Urinalysis = albumin (-) and ketones (-)
Question
When KT was in the hospital on 12/9 she was started on an insulin drip. What would the initial rate (units/hr) of her infusion have been?
Answer
A 1 unit/hr B 2 units/hr C 5 units/hr D 7 units/hr E 10 units/hr
Incorrect
The initial insulin IV infusion rate is 0.1 units/kg/hr (155 lbs/2.2 lbs/kg X 0.1 units/kg) = 7 units/hr.
History of Present Illness: KT is a 23 year-old female being seen in clinic on 2/10 for diabetes management. Of note, KT was hospitalized 2 months ago because she stopped taking her medications for a few days. Since then, she has attended a diabetes education class and met with her dietitian. She feels some tingling in her feet for which she takes gabapentin. She does not smoke and drinks alcohol only on special occasions.
Allergies: NKDA
Current Medications (2/10): Levemir 21 units QHS Insulin lispro 7 units TID before meals Gabapentin 300 mg TID Paxil 40 mg daily
Past Medical History:
Type 1 diabetes
Depression
Peripheral neuropathy
Vitals (2/10):
Height: 5’10” Weight: 155 lbs
BP: 128/77 mmHg HR: 85 BPM RR: 20 BPM
Temp: 98.6ºF Pain: 1/10
12/11 to 2/10 Blood Glucose Value Ranges (self-monitored): Before breakfast: 95 - 120 mg/dL After lunch: 110 - 125 mg/dL After dinner: 200 - 225 mg/dL At bedtime: 130 - 150 mg/dL
2/10 Labs (fasting): AST (units/L) = 23 (10 - 40) ALT (units/L) = 25 (10 - 40) GLU (mg/dL) = 107 (100 - 125) Na (mEq/L) = 141 (135 - 145) K (mEq/L) = 4.2 (3.5 - 5) Cl (mEq/L) = 100 (95 - 103) HCO3 (mEq/L) = 28 (24 - 30) BUN (mg/dL) = 18 (7 - 20) SCr (mg/dL) = 0.9 (0.7 - 1.3) Mg (mEq/L) = 1.9 (1.3 - 2.1) PO4 (mg/dL) = 4.4 (2.3 - 4.7) Ca (mg/dL) = 9.5 (8.5 - 10.5) TSH (mIU/L) = 1.9 (0.3 - 3.0) Hgb A1C = 7.8% Urinalysis = albumin (-) and ketones (-)
2/10 Tests: Eye exam with normal findings
12/9 Labs (hospital admission): GLU (mg/dL) = 390 (100 - 125) Hgb A1C = 8.5% Urinalysis = albumin (-) and ketones (+) pH = 7.24 (7.35-7.45) pCO2 (mmHg) = 25 (35 - 45) pO2 (mmHg) = 92 (80 - 100)
6/14 Labs (clinic visit 8 months prior):
GLU (mg/dL) = 113 (100 - 125)
Hgb A1C = 7.9%
Urinalysis = albumin (-) and ketones (-)
Question
KT attended the grand opening of a restaurant this past weekend and sampled 8 different dishes. She tested her blood glucose when she got home, which showed 246 mg/dL. KT’s target blood glucose is 120 mg/dL. Calculate her correction dose.
Answer
A 1 unit B 2 units C 3 units D 4 units E 5 units
Incorrect
KT’s correction factor (43) can be calculated using the rule of 1800 since she uses rapid-acting insulin. Her correction dose is (246 -120)/43 = 3 units.
