<\/p>\n
Ambulatory Top Ten<\/p>\n
Diabetes Clinical
\nQuestions<\/p>\n
\u00a0<\/p>\n
Here are a few common clinical scenarios that you probably encounter \u00a0<\/p>\n 1.\u00a0 <\/span>You have a \u00a0<\/p>\n \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>-Can \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>-When \u00a0<\/p>\n 2. The patient is a 52 year-old Guyanese woman who had onset \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span><\/p>\n -What evidence is there to support \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>-Is \u00a0<\/em><\/p>\n 3.\u00a0 <\/span>The patient is a \u00a0<\/em><\/p>\n – – – – –\u00a0\u00a0\u00a0\u00a0 <\/span>Should the patient be referred to a diabetes specialist?<\/em><\/p>\n<\/div>\n \u00a0<\/p>\n 4. The patient is a 56 year-old woman with type 2 diabetes \u00a0<\/p>\n \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>– What \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>–\u00a0 <\/span>What is the role of regular insulin in a \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>–\u00a0 <\/span>When should a type 2 diabetic be switched to \u00a0<\/p>\n \u00a0<\/p>\n 5.\u00a0 <\/span>You have an 82 <\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":" Ambulatory Top Ten Diabetes Clinical Questions \u00a0 Here are a few common clinical scenarios that you probably encounter several times a week.\u00a0 Your job now is to say what you would do in these situations and why.\u00a0 In extreme detail.\u00a0 Detail the parts of your recommendation which stand on a firm evidence base and….<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":901,"menu_order":0,"comment_status":"open","ping_status":"open","template":"","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"class_list":["post-905","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/905","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/comments?post=905"}],"version-history":[{"count":1,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/905\/revisions"}],"predecessor-version":[{"id":909,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/905\/revisions\/909"}],"up":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/901"}],"wp:attachment":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/media?parent=905"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
\nseveral times a week.\u00a0 <\/span>Your job now is
\nto say what you would do in these situations and why<\/strong>.\u00a0 <\/span>In extreme detail.\u00a0 <\/span>Detail the parts of your recommendation which stand on a firm
\nevidence base and the parts which stand on shaky or non-existent evidence.\u00a0\u00a0 <\/span><\/p>\n
\npatient, a 39 year-old Puerto Rican woman who weighs 200 pounds (BMI of 31) and
\nhas a family history of diabetes.\u00a0 <\/span>She
\nhas tried various diets and exercise regiments but has failed to lose
\nweight.\u00a0 <\/span>She wants to know whether she
\nhas diabetes or not.\u00a0 <\/span>Random afternoon
\nglucose (2 hours after lunch) is 170.
\n<\/span>Hemoglobin A1c is 6.9%\u00a0 <\/span>What
\nwould you recommend?<\/p>\n
\nhemoglobin A1c be used to \u201cdefine\u201d diabetes?<\/em><\/p>\n
\nshould drug therapy for prevention be initiated?<\/em><\/p>\n
\nof polyuria and polydypsia\u00a0 <\/span>several
\nmonths ago.\u00a0 <\/span>Fasting glucose three days
\nago at urgent care was 178 mg\/dl, Hemoglobin A1c is 8.5%.\u00a0 <\/span>Her BMI is 25, she has gained 4 lbs. in the
\nlast year.\u00a0 <\/span>Her husband also has diabetes;
\nshe has been following his diabetic diet with him.\u00a0 <\/span>His doctor has him on Actos \u2013 the patient tried her husband\u2019s
\nmedication twice and says it was \u201ca good pill.\u201d\u00a0 <\/span>What would you recommend?<\/p>\n
\nrecommendations for a particular diabetic diet?<\/em><\/p>\n
\nthere evidence to support one oral therapy over another?<\/em><\/p>\n
\n55 year-old mixed race Hispanic man who has had diabetes for eight years.\u00a0 <\/span>Initially he responded to recommendations
\nfor diet and exercise \u2013 he lost five pounds and his glucose normalized.\u00a0 <\/span>Then two years later, despite continued
\nefforts, his glucose rose and he began taking metformin.\u00a0 <\/span>After increasing the dose to 1000 mg bid,
\nthe glucose normalized again.\u00a0 <\/span>Then
\nafter two years, the glucose began to climb again.\u00a0 <\/span>Glyburide 5 mg bid has been added and compliance with diet and
\nexercise continues, but the patient\u2019s last two Hemoglobin A1c\u2019s have been 8.3%.\u00a0 <\/span>He has gained four pounds over the last
\nthree years.\u00a0 <\/span>What changes if any would
\nyou recommend in his medical regimen?<\/p>\n
\n<\/span><\/span>At what rate do oral therapies fail?\u00a0 <\/span>Why do they fail?<\/em><\/p>\n
\n<\/span><\/span>What evidence is there for combination oral therapy?<\/em><\/p>\n
\n<\/span><\/span>When should insulin treatment be initiated?<\/em><\/p>\n
\n<\/span><\/span>When insulin is started, should the oral therapies
\nbe continued?<\/em><\/p>\n
\n<\/span><\/p>\n
\nfor five years.\u00a0 <\/span>She is on metformin
\n1000 bid and NPH 50 U in the am, 30 U at bedtime.\u00a0 <\/span>Morning fasting fingersticks are 55 to 150, bedtime fingersticks
\nare 110 to 200.\u00a0 <\/span>Hemoglobin A1c is
\n8%.\u00a0 <\/span>Attempts to increase her am NPH
\nhave caused sporadic hypoglycemic episodes, one of which resulted in
\nsyncope.\u00a0 <\/span>What changes would you
\nrecommend?<\/p>\n
\ntimes of day should fingersticks be performed?<\/em><\/p>\n
\ntype 2 diabetic?<\/em><\/p>\n
\nthe newer insulins, glargine and lispro?
\n<\/span>Is there evidence of improved control with these<\/em>?<\/p>\n
\nyear-old man as your patient.\u00a0 <\/span>He has
\ntype 2 diabetes, hypertension, arthritis, and very mild dementia.\u00a0 <\/span>He has been injecting insulin twice a day
\nfor twenty years.\u00a0 <\/span>He has never had an
\nMI, a stroke, PVD, or more than background retinopathy.\u00a0 <\/span>Creatinine is 1.5.\u00a0 <\/span>BP is 130\/70, P 68. He has loss of protective sensation in his
\nfeet in all areas tested.\u00a0 <\/span>He does not
\nperform glucometer checks.\u00a0 <\/span>His random
\nglucoses are always between 130 and 200 and his Hemoglobin A1c is always
\nbetween 9% and 10%.\u00a0\u00a0 <\/span>His insurance is
\nmedicare alone.\u00a0 <\/span>Medications are insulin
\n25 U in the am, 15 U in the pm, monopril 40, atenolol 50, ASA 81 mg, Zocor 20
\nmg and acetimenophen prn.\u00a0 <\/span>He lives at
\nhome with his wife who reminds him to take his medication.\u00a0 <\/span>He performs all his own ADLs.\u00a0 <\/span>Would you recommend any changes in his
\nregimen?<\/p>\n