NMS Q&A Family Medicine

Diabetes Mellitus 20116. The answer is B. An arterial pH level of 7.25 to 7.30 isonly mildly depressed and is compatible with an alert personin early DKA. At this level of acidosis, the patient maybe managed as an outpatient. A moderately acidotic pHlevel is defined as 7 to 7.224 and severe is defined as 7.Urine ketones would be positive in all three degrees ofseverity. Similarly, hydroxybutyrate might be elevated tohigh levels in all three categories of severity, and bloodsugar levels above 120 mg/dL are to be found in all threecategories. Bicarbonate levels of 10 to 15 mEq/L are in themoderately acidotic category and 10 is consideredsevere. Mild DKA is reflected by a bicarbonate level of 15to 28 mEq/L.17. The answer is A. Retinal surface proliferative changesare directly related to visual loss (and distinctly so comparedto the other factors mentioned). The fact that thevisual loss is unilateral (OS left eye) and that randomblood sugar determination is nearly normal rules out achange in refraction brought about temporarily by hyperglycemia.The elevated glycolated hemoglobin allows theinference that long-term control, however, has been lessthan optimal. Thus, the patient likely suffers from retinopathy.Such retinopathy occurs in approximately onehalfof all diabetics after 10 years of living with type1 disease and after a variable duration in type 2. This retinallesion is the reason that diabetes is the leading cause ofblindness in the United States. For this reason, the standardof care is for routine ophthalmologic examinationscheduled annually after 5 years of disease or after a proliferativelesion has been seen. The other changes, microaneurysms,dot hemorrhages, and cotton-wool exudates aswell as hard exudates, are commonly seen in diabetes,microaneurysms being virtually pathognomonic of thedisease, but no authors have stated that they are causes ofblindness .18. The answer is D. This man’s creatinine clearance issignificantly less than would be expected for a man of hisage and size. If this problem is not acted upon, he is likelyto be headed ultimately for end-stage renal disease. Onethirdis the approximate proportion of cases of end-stagerenal disease that are caused by diabetes. The followingtable puts diabetes, hypertension, and renal disease into aperspective of their clinical interaction.DiseasesPercentageDiabetes mellitus 31Hypertension 27Glomerulonephritis 14Obstructive uropathy 5.7Polycystic renal disease 3.6Others 5.7Unknown 13Used with permission from Rudy and Kurowski (1997). The diseaseslisted in the left column are responsible for the correspondingpercentages of end-stage renal disease.ReferencesFamily Medicine Board Review 2009 M 3–10, 2009 . Kansas City,Missouri Kimmel B and Inzucchi SE: Oral Agents for Type 2Diabetes . Clinical Diabetes 2005 ; 23 ( 2 ): 65 – 75 .Masharani U . Diabetes mellitus and hypoglycemia . In: TierneyLM , McPhee SJ , Papadakis MA , eds. Current MedicalDiagnosis and Treatment . 45th ed . New York/Chicago: Lange ;2006 .McPhee SJ , Papadakis MA . Current Medical Diagnosis and Treatment2010 , 49th ed . New York/Chicago : McGraw-Hill/Lange ;2010 .Rudy DR . Hypertension . In: Rudy DR, Kurowski K, eds. FamilyMedicine: House Officer Series . Baltimore : Williams &Wilkins ; 1997 .Stoner GD . Hyperosmolar hyperglycemic state . Am FamPhysician . 2005 ; 71 : 1723 – 1730 .Turok DK , Ratcliffe SD , Baxley EG . Management of gestationaldiabetes . Am Fam Physician . 2003 ; 68 : 1967 – 1972 , 1075–1076 .Tzagournis M , Rudy DR . Diabetes mellitus . In: Rudy DR ,Kurowski K , eds. Family Medicine: House Officer Series .Baltimore : Williams & Wilkins ; 1997 : 513 – 542 .