Diabetes Mellitus

DIABETES MELLITUS

Rationale

Diabetes mellitus is an increasingly prevalent illness in the U.S. and a leading cause of disability and death. It is estimated that 5-9% of American adults are diabetic with the illness appearing at earlier ages in some populations All internists must identify those at risk and institute appropriate management to ameliorate the potentially fatal complications of this illness.

Prerequisites

Basic science instruction in nutrition, biochemistry, immunology, physiology, pathology, pharmacology and behavioral sciences.

Knowledge

Students should be able to define, describe and discuss:

presenting symptoms and signs of type 1 and type 2 diabetes mellitus

presenting symptoms and signs of diabetic ketoacidosis and nonketotic hyperglycemic coma.

major causes of morbidity and mortality in diabetes mellitus – coronary artery disease, peripheral vascular disease, hypoglycemia, diabetic ketoacidosis, nonketotic hyperglycemic coma, retinopathy, neuropathy – peripheral and autonomic, nephropathy, foot disorders, infections.

pathophysiology, genetics, risk factors, and epidemiology of type 1 and type 2 diabetes mellitus.

diagnostic criteria for type 1 and type 2 diabetes mellitus, based on a history, physical examination, and laboratory testing

diagnostic criteria for diabetic ketoacidosis, nonketotic hyperglycemic coma, and hypoglycemic coma.

laboratory tests needed to screen, diagnose, and follow diabetic patients including:

glucose (fingerstick v. serum, fasting v.random)

electrolytes

blood urea nitrogen/creatinine

ketones (serum)

arterial blood gas

glycosylated hemoglobin (HgbA1c)

urine glucose, ketones, albumin/protein, urine microalbumin

non-pharmacologic and pharmacologic treatment of diabetes mellitus necessary to maintain acceptable levels of glycemic control, prevent target organ disease, and other associated complications.

the specific components of the American Diabetes Association Diet dietary recommendations for type 1 and type 2 diabetes mellitus.

key indications for diet therapy, oral hypoglycemic agents, and insulin therapy in diabetes mellitus.

basic management of diabetic ketoacidosis and nonketotic hyperglycemic states, including the similarities and differences in fluid and electrolyte replacement.

the Dawn phenomenon, and the implications of each in diabetes pharmacologic management.

basic management of hypertension in the diabetic patient.

Skills

Students should demonstrate specific skills, including:

History-Taking Skills: Students should be able to obtain, document and present a focused medical history for a diabetic patient that includes:

weight changes, hypo- or hyperglycemic symptoms, medication history (adherence, side effects, other medications), home glucose monitoring results, smoking and alcohol use, immunizations

target organ disease complications (cardiovascular, foot, gastrointestinal, infectious, neurological, sexual, skin, urinary, or vision symptoms)

diet history (total coloric intake, intake of sugar-containing foods, intake of saturated fat and cholesterol, physical activity level, timing of meals)

Physical Exam Skills: Students should be able to perform a focused physical examination on diabetic patients to establish the diagnosis and severity of disease complications that includes mental status (stupor, coma), Kussmaul respirations, fruity breath, signs of autonomic insufficiency and/or volume depletion, skin examination for diabetic dermopathy, furuncles, carbuncles, candidiasis, and necrobiosis lipoidica diabeticorum, foot examination, fundoscopic exam, carotid bruits, peripheral pulses, peripheral neuropathy, dermatophytosis, ulceration.

Differential Diagnosis: Students should be able to generate a prioritized differential diagnosis for hypo- and hyperglycemia and other symptoms and exam findings associated with type 1 and type 2 diabetes.

Laboratory Interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and know how to interpret them, both prior to and after initiating treatment. Recommendations should include consideration of test cost and performance characteristics as well as patient preferences. Laboratory and diagnostic tests should include, when appropriate:

serum glucose (fasting), electrolytes, blood urea nitrogen, creatinine, ketones, arterial blood gas, glycosylated hemoglobin, lipid profile

urine glucose, ketones, albumin, microalbumin, creatinine clearance

CBC with differential

LFT’s

Communication Skills: Students should be able to:

explain the results and significance of above tests to patients, and educate patients on the course and prognosis of diabetes.

counsel patients appropriately on dietary measures, exercise, smoking cessation, medication adherence, and proper foot care.

counsel a patient regarding the basic features of ADA diabetic diet recommendations and how to perform home blood glucose monitoring.

educate a patient on how detrimental the effects of poor glycemic control, obesity, hypertension, hyperlipidemia and infection are on their health.

educate a patient on the availability of community resources such as the ADA hospital and community-based education programs, and support groups to aid the patient in understanding and managing their illness.

Management Skills: Students should be able to develop an appropriate evaluation and treatment plan for patients that includes:

determining when to institute diet therapy, oral hypoglycemic agents, and insulin therapy;

writing appropriate fluid and insulin orders that outline critical steps for the treatment of diabetic ketoacidosis and nonketotic hyperglycemic coma;

calculating an appropriate insulin dose for a diabetic patient;

determining when to involve an endocrinologist in the care of a diabetic patient;

consulting a podiatrist for routine foot care and the proper fitting of specially designed weight-bearing shoes.

Attitudes and Professional Behaviors

Students should be able to:

appreciate the medical, social, and economic impact of diabetes mellitus on the individual, family and American society.

consider the patient’s physical, socioeconomic, and cultural background when designing and implementing nutritional, pharmacologic, exercise, and referral recommendations.

know how to access and utilize appropriate information systems and resources to promote life-long learning about diabetes.

understand and respect the role of team work and non-physician health care providers in the care of diabetic patients.

Resources

Clerkship Articles Week Four:

Type 2 Diabetes Mellitus:Update on Diagnosis, Pathophysiology, and Treatment, Richard J. Mahler, Michael L. Adler, The Journal of Clinical Endocrinology & Metabolism, 1999, Vol. 84, No. 4, 1165-1171.

Evidence-based therapy for type 2 diabetes, Flemmer, Mark C., M.D., Vinik, Aaron I., M.D., Ph.D., Postgraduate Medicine, May 1, 2000, Volume 107, Number 5, pages 27-47.

The Diabetes Control and Complication Trail Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. NEJM 1993;329:977-86. (sign on as “smuser”)

Clerkship Seminar, “Diabetes”, Romesh Khardori, MD

American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care 2005 Vol: 28 Suppl.

Expert Committee on the screening of Diabetes Mellitus. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 2005 vol:28 Suppl. 24.

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