EMQs in Clinical Medicine.pdf - Peshawar Medical College

Treatment of diabetes – answers 209
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A 45-year-old woman with diabetes presents with shiny areas on her
skin with a yellowish colour and overlying telangiectasia.
Necrobiosis lipoidica most commonly appears over the shins.
Pyoderma gangrenosum is not a diabetic complication and involves the
presence of nodulopustular ulcers. It is associated with inflammatory
bowel disease.
A 50-year-old person with diabetes presents with a swollen joint with
abnormal but painless movement.
‘Charcot’s joints’ is the term used to describe severe neuropathic
arthropathy. Loss of pain sensation leaves swollen and deformed, yet
painless, joints. Charcot’s joints are also seen in syringomyelia and tabes
dorsalis.
An 85-year-old man presents with painful wasting of the quadriceps
muscle of the right leg with absent knee reflex. The area is very tender.
Diabetic amyotrophy is more common in the scenario of untreated
diabetes in elderly people. It presents with a painful proximal motor
neuropathy affecting the lower limbs. This is followed by weakness and
wasting of the thigh muscles. The symptoms usually improve with good
glycaemic control. This condition is distinct from the more common
classic diabetic neuropathy.
84 Treatment of diabetes
Answers: E C K M H
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A 45-year-old man with type 2 diabetes presents with hyperglycaemic,
hyperosmolar, non-ketotic coma. Blood glucose 40 mmol/l.
Initial management of hyperosmolar, non-ketotic coma (HONK) involves
treating the severe hyperglycaemia and dehydration that has occurred as
a consequence of osmotic diuresis (occurs only in type 2 diabetes). It is
associated with a high risk of thrombosis and hence heparin is indicated.
First-line treatment for a 19-year-old with diabetes and metabolic
ketoacidosis.
C Diabetic ketoacidosis is a medical emergency. Fluid replacement (with 0.9
per cent saline) is the most important initial measure. Hyperglycaemia
should be treated with an intravenous infusion of insulin. This should be
continued until ketones are absent from the urine. If the blood glucose
falls to below 12 mmol/l during insulin infusion, 10 per cent glucose
solution can be used for fluid replacement to buffer blood glucose until
the insulin infusion can be discontinued. Patients usually present with
hyperkalaemia caused by the metabolic acidosis. However, as a consequence
of the prolonged osmotic diuresis preceding the acute presentation,