Diabetes mellitus

Diabetes Mellitus
Case Presentation
 CC: fatigue and abdominal pain
 HPI: 7 y/o male reports above sx for past 3 months.
Mother says he has been less active, taking more
naps and wetting his bed, which he stopped doing 2
years prior.
 Pmhx, Pshx, Famhx: unremarkable
 ROS: Pertinent positives include weight drop from
the 75th percentile to the 50th percentile despite
report from mother that his food and drink intake
has increased.
 Labs to be ordered:
 WBC count, Urinalysis, Glucose level
 Labs return:
 WBC: 11,400/mm^3
 BUN: 14 mg/dL, Creatinine: 1.2 mg/dL, Sodium: 132 mEq/L,
Potassium: 5.0 mEq/L, Chloride: 100mEq/L
 Glucose: 350 mg/dL
 General: child appears lethargic but AOx3
 Skin: Appears dehydrated, no erythema or lesions
 HEENT, Heart, Lungs, Abdomen: negative findings
 Osteopathic Structural Exam: T7-9ERrSr with
hypertonic paraspinals, CRI slow, decreased
Assessment and Plan
 Diabetes Mellitus Type I
 Family and patient is trained in how to administer insulin,
check blood glucose levels, check for ketonuria, recognize
hypoglycemia and how to treat it.
 Family and patient is counseled on nutrition and timing of
carbohydrates and how to measure, rotate and adjust insulin
doses depending on the time of day, physical activity and
food/drink intake.
 F/U in two weeks.
Eventually F/U appointments need to be made every 6 mo. to
check weight, BP, eyes, extremities. Future concerns include
ETOH intake and depression/mental illness.
Type I
 Type IA diabetes is suggested by reduced insulin and the
presence of pancreatic (islet) autoantibodies.
Type IA vs. type IB
 Type I diabetes also is usually suggested by reduced
insulin and c-peptide levels.
 Uncertain etiology
 Peak onset bimodal:
4-6 and 10-14 years of age
 Prevalence in US:
2/1000 non-Hispanic whites
Slightly lower in other ethnic
Type I
 Classic new onset—most common presentation
 Diabetic ketoacidosis—very severe
 Deep, rapid breathing
 Dry skin and mouth
 Flushed face
 Fruity smelling breath
 Nausea and vomiting
 Stomach pain
 Incidental finding—take thorough hx of all patients,
no matter how young.
Case Presentation
 CC: new pt, physical exam
 HPI: 30 y/o African American female presents for
PE. Claims to be in good health but mentions she is
urinating more frequently and has had several UTIs
in the past year.
 Meds: Metoprolol
 Pmhx: HTN; Pshx: unremarkable
 Famhx: Father and Gmother + heart attacks,
Mother, Aunt, Sister + diabetes.
 Vitals:
 BP: 125/90 right arm; RR: 14 breaths/min; HR: 85 beats/min
 PE:
 General: Morbid obesity at BMI of ~48 kg/m2
 Heart, Lungs, Abdomen: negative findings
 Urine dipstick: 2+ glucosuria
 Random plasma glucose: 240 mg/dL
 Osteopathic Structural Exam:
 Hypertonic pelvic and abdominal diaphragm, hypertonic
paraspinals T7-9, and diminished CRI
Assessment and Plan
 Diabetes Mellitus type II
 Diet, exercise weight reduction
 Oral hypoglycemic agent
 Avoidance of macro/microvascular
 F/U in 2 weeks and
eventually every 6
months to check
weight, BP, eyes
extremities and
renal function.
Type II
 Prevalence in the US:
 0.18 per 1000 non-Hispanic white youth 10-19 years old
 1.06 and 1.45 per 1000 African-American and Navajo youth,
 All ages: 25.8 million people, or 8.3% of the U.S
 Risk factors:
 Positive family history
 Obesity
 Female gender
 Pregnancy
Type II
 Sx:
 Commonly asymptomatic
 Increased thirst, increased frequency of urination, blurred
 Glucose testing
 Random blood glucose test
 Fasting blood glucose test
 Hemoglobin A1C level
 Oral glucose tolerance test
Type II
 Diagnostic Criteria:
 Sx of diabetes and a random blood sugar of 200 mg/dL (11.1
mmol/L) or higher
 A fasting blood sugar level of 126 mg/dL (7.0 mmol/L) or
 A blood sugar of 200 mg/dL (11.1 mmol/L) or higher two
hours after an oral glucose tolerance test.
 An A1C of 6.5 percent or higher
 The blood tests must be repeated on another day to confirm
the diagnosis of diabetes.
Type II
 Complications:
 Macrovascular
Heart disease
 Stroke
 Peripheral vascular disease
 Nephropathy
 Neuropathy
Staph infection at injection site
 Fungal infections involving oral mucosa, genitals, skin and nails
 Medical:
 Type I:
Short acting insulin= lispro or insulin
 Intermediate acting= NPH
 Long acting: Lente or Ultralente
Type II:
Biguanides: Metformin, mc first line
 Sulfonylureas: Tolbutamide, Chlorpropamide, Glipizide
 Glitazones: Pioglitazone, Rosiglitazone
 Alpha-glucosidase Inhibitors: Acarbose, Miglitol
 Osteopathic:
We can directly improve circulation which indirectly enhances
hormone release, cellular uptake and cellular response and helps the
patient avoid infection.
Pancreas T7-9:
Abdominal and pelvic diaphragm release and rib raising
Remove restrictions and SD, improve and maintain ROM thereby
helping the pt stay active and proactive in their own health
To improve circulation and lymphatic flow
Treat legs and feet
Treat paraspinals, somatic dysfunctions
Improve CRI=improve flow of blood, nutrients from the CSF and
Compile exercise and nutrition/diet program or refer to specialists
 First Aid, Case Reports for the USMLE Step 1
 Pub Med, Ketoacidosis
CDC, Prevalence of Diabetes Mellitus in US
Up To Date, Diabetes Mellitus I and II
American Diabetes Association Home Page
Rediscovering the classic osteopathic literature to advance contemporary
patient-oriented research: A new look at diabetes mellitus. John C
Licciardone. http://www.om-pc.com/content/2/1/9
An osteopathic approach to type 2 diabetes mellitus. Shubrook JH Jr,
Johnson AW.
Common crossroads in diabetes management. Michael Valitutto

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