Diabetes Mellitus
A PRESENTATION BY
MEIGHAN O’CONNOR, POPPF
DIDACTICSONLINE.COM
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.
Objective
 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
groups
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.
Objective
 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
complications
 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,
respectively.
 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
vision
 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
higher
 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


Microvascular
Retinopathy
 Nephropathy
 Neuropathy


Infections
Staph infection at injection site
 Fungal infections involving oral mucosa, genitals, skin and nails

Treatment
 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

Treatment
 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
Cranial


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
lymphatics
Compile exercise and nutrition/diet program or refer to specialists
References
 First Aid, Case Reports for the USMLE Step 1
 Pub Med, Ketoacidosis






http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001363/
CDC, Prevalence of Diabetes Mellitus in US
http://www.cdc.gov/diabetes/projects/cda2.htm
Up To Date, Diabetes Mellitus I and II
http://www.uptodate.com.ezproxylocal.library.nova.edu
American Diabetes Association Home Page
www.diabetes.org
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