Diabetes Day 1
Case 1:
Darin is a 46-year-old male who was referred to your clinic by Dr. Kemp, a physician with
whom you work routinely. Darin saw Dr. Kemp two days ago for a routine physical and
her note says that Darin has gained 25 pounds in the last year, and now has a BMI of
36.8 (meeting the definition obesity). He does not exercise other than walking in
general around his office and admits that he likes to eat a meat and potato or pasta-
based diet and loves chocolate chip cookies and brownies. He also drinks regular pop 3
cans per day. He has experienced a little bit of increased thirst recently, but otherwise
denies any other symptoms. He has a family history significant for his brother and
father with type 2 diabetes. His mother had a heart attack at age 67 but recovered and
has hypertension and osteoporosis. He does not smoke and drinks 1 beer per week.
He did fast for these tests, renal fxn WNL. Out of range ones listed below:
Today’s value Normal ranges per
Michigan Medicine (MM)
Glucose 210 70-180 mg/dL
LDL 109 <130 mg/dL
HDL 32 > 40 mg/dL
Triglycerides 301 < 150 mg/dL
Cholesterol 252 < 200 mg/dL
A1c 8.8 4.2-5.6%
UACR 38 ≤30 mg/g
BP today was 142/74 and weight of 279 pounds.
Which of the following best represents your assessment and topics you plan to discuss.
A. His A1c and history are consistent with type 2 diabetes; his A1c goal
will be < 7%; recommend weight loss, moderate carbohydrate intake,
focus on protein intake, minimal sweets, minimal regular pop, increase
vegetables, add metformin XR 500 mg daily, add lisinopril 10 mg daily
B. His A1c and history are consistent with type 2 diabetes; his A1c goal is < 7%;
continue to eat lean proteins, a moderate amount of carbohydrate foods,
decrease consumption of cookies and brownies and regular pop, increase
vegetables, encourage weight loss, and exercise by working up to walking 3
times per week, add metformin IR 500 mg daily and losartan 50 mg daily
a. IR causes IMMEDIATE and INCREASED GI SE’s
C. His A1c and history are consistent with type 2 diabetes; his A1c goal will be
< 7.5%; start metformin XR 1000 mg daily, start amlodipine 5 mg daily,
continue eating protein, eat a moderate amount of carbohydrates, do not eat
any chocolate chip cookies or brownies, stop drinking regular pop and
replace with lemonade
Diabetes Day 1
D. His A1c and history are consistent with type 1 diabetes; his A1c goal will be <
7.5%; he needs to start insulin daily, start chlorthalidone 12.5 mg daily, eat a
moderate amount of carbohydrates, stop eating all sweets and regular pop
E. His A1c and history are consistent with type 1.5 diabetes (LADA); his A1c
goal will be < 7%; he needs to start insulin at this time, cut out potatoes and
rice from his diet, eat minimal sweets, walk 1 time per week, continue to
monitor blood pressure
Case 2:
IF BETWEEN AGES 40-75 W/ DIAGNOSED T2DM – ALL SHOULD BE ON AT
LEAST A MOD INTENSITY STATIN REGARDLESS OF ANY TG / LDL / HDL LEVELS
Dr. Chan, a physician in your clinic, refers the following patient to you to initiate
medication therapy (you have a collaborative practice agreement). Paul is a 54-year-
old African American male diagnosed with type 2 diabetes about 3 years ago (A1c =
7.6% at diagnosis). He has been managing his diabetes through diet and exercise
alone, but on his visit earlier this week his A1c increased despite these efforts. Paul
also has hypertension, which is treated to goal; otherwise, past medical history is
nonsignificant. Paul’s mother passed away from a MI 3 years ago at the age of 79.
Patient denies any symptoms of polyuria, polydipsia or polyphagia, but does say he
has been a little fatigued lately. Patient notes that the medical assistant mentioned
an indication of kidney disease, while taking his blood pressure. He also states he
has heard from his friends some tablets are excreted in stool, and some give you
“bad” diarrhea; he wants to avoid those medications.
Social History
Smoking Status Smokes ½ ppd
Alcohol Use Beer once per week
Lifestyle
Diet Struggled with diet for the last 6-8 months, with more
carbohydrate foods/sweets, but knows he needs to get back on
track
Exercise Was going walking/jogging outside 2-3 days per week, but with
colder weather hasn’t been working out as much
Medications
Aspirin 81 mg daily
Diabetes Day 1
Multivitamin 1 tablet daily
Lisinopril/HCTZ 20 mg/12.5 mg 1 tablet daily
Acetaminophen ES 2 tablets as needed for arthritis pain
Allergies: None known
Adherence/side effects/Cost: Patient reports rarely missing medications. He
denies any tolerance issues with his current medications. But does note that he
often experiences side effects to medications when they are initially started. He has
great prescription insurance and is able to afford his copays.
Vitals at today’s Clinic Visit Notes
Blood Pressure/ 126/64 76
Pulse
Weight and Height 228 pounds 5’8” up from 199 pounds 8 months ago
Labs
Today’s value Normal ranges per (MM)
Sodium 143 136-146 mmol/L
Potassium 4 3.5-5.1 mmol/L
Chloride 104 98-108 mmol/L
CO2 27 22-31 mmol/L
Urea Nitrogen 19 8-20 mg/dL
Creatinine 1.4 (0.9 – 4 months ago) 0.7-1.3 mg/dL
Glucose 198 70-180 mg/dL
LDL 68 <130 mg/dL
HDL 40 >40 mg/dL
Triglycerides 156 < 150 mg/dL
Cholesterol 147 < 200 mg/dL
A1c 8.5 (6.9% – 6 months ago) 4.2-5.6%
EGFR 59 (63 – 6 months ago) > 59 mL/min
Urine Microalbumin/ 16 (15 - 2 months ago) 0 – 30 mg/gm
Creatinine Ratio
BMI 34.7 (31.2 – 8 months ago)
Foot exam 7/21/24
Eye exam 8/23/22
Which of the following is the best recommendation for Paul today?
Diabetes Day 1
a. Patient wants to avoid any medication that could cause diarrhea, so start
another oral medication for diabetes management along with reduced
carbohydrate intake and cut out sweets, restart walking, start simvastatin 10
mg daily, recommend new eye exam and foot exam
a. SIMVASTATIN DOSE IS LOW INTENSITY
b. Start metformin IR 500 mg 2 tablets daily and start walking 3-4 times per
week for 30 minutes along with limiting carbohydrate foods. Add
atorvastatin 80 mg daily. Recommend to check his UACR.
a. STATIN DOSE IS CORRECT FOR HIGH – BUT IR = SE AND PT SAID NO!!
c. Given his prior success with lifestyle, encourage him to get back to exercise.
Set self-management goal to walk for 30 minutes 5 times weekly. Start
lovastatin 40 mg daily. Recommend foot exam.
d. Start metformin XR 500 mg daily. Have patient reduce carbohydrates to
moderate portions and walk 3 times per week for exercise. Start
rosuvastatin 20 mg daily. Recommend eye exam.
a. GOOD ANSWER – ROSU CAUSES LESS MYALGIA
e. Start metformin XR 500 mg daily for 1-2 weeks and if tolerated increase
to 500 mg BID. Advise patient to reduce sweets to 1-2 times per week
and start reading food labels to understand how many carbs he is
eating daily. Add atorvastatin 80 mg daily. Recommend eye exam.
Case 3
Terrance is a 65-year-old male with type 2 diabetes who comes to his physician’s
office for follow-up. He was diagnosed with type 2 diabetes 1.5 years ago. He has a
history of hypertension, GERD, hypothyroidism, and suffered a MI 4 years ago. He is
currently on enalapril 10 mg twice daily, chlorthalidone 25 mg daily, metoprolol XL
100 mg daily, metformin XR 500 mg BID, levothyroxine 50 mcg daily, and
omeprazole 20 mg daily. He denies any symptoms of hyperglycemia, but has been
having burning and numbness in his feet that is quite bothersome. He had recent
labs which can be seen below. He does not follow any specific diet and admits to
eating large portions of carbohydrate foods, mostly at dinner. He eats sweets daily.
He tries to walk on the treadmill once weekly, but often decides not to walk. He
does not smoke and drinks 1-2 beers per week. He drinks regular Pepsi at least 1
glass per day. He does not monitor his home blood sugar.
BP 124/78 Pulse 70 Weight: 237.5 pounds BMI 35.6 (Renal fxn is WNL)
Labs Today’s value Normal ranges per MM
Chloride 107 98-108 mmol/L
Glucose 198 70-180 mg/dL
LDL 97 <130 mg/dL
HDL 36 >40 mg/dL
Diabetes Day 1
Triglycerides 189 < 150 mg/dL
Total cholesterol 210 < 200 mg/dL
A1c 7.8 4.2-5.6%
What would you recommend for Terrance at this time?
a. Decrease carbohydrate intake to a moderate amount, limit sweets and pop,
increase vegetables, increase walking to 3 times per week, change metformin
XR to 1000 mg daily, no need to start monitoring home blood sugar readings,
add atorvastatin 10 mg daily and topical capsaicin for numbness
b. Eat diet moderate to high in carbohydrates, moderate protein, exercise 2-3
times per week with jogging, limit sweets, increase metformin to XR 1000 mg
twice daily, no need for home monitoring, add simvastatin 40 mg daily and
nortriptylline daily
c. Increase exercise and recommended he do the stationary bike or swimming,
reduce regular pop and sweet foods, change metformin XR to IR 500 mg
twice daily, start to monitor home blood sugar readings, add rosuvastatin 20
mg daily and Tylenol 650 mg twice daily for burning in feet
d. Decrease carbohydrate intake, reduce calories by 250-500 calories per day,
increase vegetables, gradually increase exercise to walking 3 times per week
for 30 minutes, increase metformin XR to 1000 mg twice daily, start
monitoring home blood sugar readings, add rosuvastatin 40 mg daily and
pregabalin twice daily
a. NOT CALORIES – CARBOHYDRATES
e. Decrease carb intake to moderate, increase walks to 2-3 times per week for
15-30 minutes, limit sweet foods, reduce intake of regular pop, increase
metformin XR to 1000 mg twice daily, start monitoring home blood sugar
readings, add atorvastatin 40 mg daily and duloxetine (most common used
for neuropathy) daily.
Case 4
Samantha is a 12-year-old female who was just released from the hospital where
she had been admitted for diabetic ketoacidosis and had been diagnosed with type 1
diabetes. She comes to your clinic today, 3 days post discharge with her parents.
She was referred to you for counseling on diabetes and talking about a plan. Sarah
is lean (BMI 20.5) and her mother reports that she had been losing weight and
feeling poorly for at least a week before hospitalization. They report she was
having to go to the bathroom frequently (polyuria), was always thirsty (polydipsia)
and complained of a dry mouth, and always seemed to be very hungry (polyphagia).
Her blood sugar was reported as being over 650 when she was admitted and she
says she felt terrible and really tired all the time. They have started insulin
injections and self-monitoring and have many questions.
1. Mom wonders if this is something that Samantha will grow out of.
Diabetes Day 1
2. Dad wants to know what impact this will have on her ability to continue
playing basketball on her high school team.
3. Mom and dad both want to know what type of goals do they have for blood
sugar control. How will they know that Samantha has a normal blood sugar?
Which of the following represents your best response to these questions.
A. Your answers include:
1. Samantha is likely to remain on insulin for life. Research continues, but
there is currently no cure for diabetes
2. Activity is encouraged, but Samantha will have to monitor before and after
playing basketball and be prepared to correct low blood sugars.
3. Samantha should target a before-meal reading of 80-130 and an A1c goal
of < 7%
B. Your answers include:
1. Samantha is likely to remain on insulin for life. Research continues but
there is currently no cure for diabetes
2. Such rigorous activity is discouraged for type 1 diabetes as it is such a high
risk for hypoglycemia
3. Samantha should target a before-meal reading of 70-130 and and A1c goal
of <7.5%
C. Your answers include:
1. Samantha is likely to grow out of her diabetes and should not need insulin
later in life
2. Activity is encouraged, but Samantha will have to monitor before and after
playing basketball and be prepared to correct low blood sugars.
3. Samantha should target a before-meal reading of 90-130 and A1c goal of
<6.5%
D. Your answers include:
1. Samantha is likely to grow out of her diabetes and should not need insulin
later in life
2. Activity is encouraged, but Samantha will have to monitor before and after
playing basketball and be prepared to correct high blood sugars.
3. Samantha should target a before-meal reading of 80-130 and A1c goal of
<8%
E. Your answers include:
1. Samantha will remain on insulin for life. Research continues but there is
currently no cure for diabetes
Diabetes Day 1
2. Activity is encouraged, but Samantha will have to monitor before and after
playing basketball and be prepared to correct low blood sugars. Always
have a snack on hand.
3. Samantha should target a before-meal reading of 80-130 and A1c goal of
<7%
