Case Study:

1. Case Study: Carla Get Started!

2. Case Study: Carla In this four-part case study, you’lltry to determine whether a patient should be screened for diabetes. You’ll then determine whether to pursue additional tests or treatments based on your initial decision. Next

3. Question One You are seeing a 16-year-old Hispanic girl named Carla, who has a rash. You determine that she has contact dermatitis and provide the appropriate treatment. Per your routine, your staff has determined that her BMI is more than the 85th percentile for her age. Her mother has diabetes. What should you do? • Screen for diabetes. • She does not meet screening criteria for diabetes. Check her blood pressure and examine the neck. • Screen for diabetes, check her blood pressure, and examine the neck.

4. FEEDBACK Answer A is incorrect. She should be screened for diabetes, but her blood pressure also should be checked and her neck should be examined for AN while she is in your office. Next

5. FEEDBACK Answer B is incorrect. She already meets the screening guidelines for diabetes because she is older than 9 years, has a BMI of more than 85th percentile, and is of non-European ancestry. In addition to the examination, laboratory screening for diabetes also should be conducted. Next

6. FEEDBACK Answer C is correct. She meets the screening criteria for diabetes. Her blood pressure also should be obtained to see if it is high and her neck should be examined for AN. Next

7. Question Two Carla and her mother are very busy. You are not sure they would come back for Carla’s fasting blood tests. What laboratory test should you obtain? Finger-stick glucose concentration using the office glucose meter Hemoglobin A1c Insulin concentration Random serum glucose concentration

8. FEEDBACK Answer A is incorrect. A finger-stick glucose concentration using an office glucose meter is not accurate enough to be used for such a serious diagnosis. Next

9. FEEDBACK Answer B is correct. The best test to perform in this situation is hemoglobin A1c because it is not affected by food. It is the only diagnostic test that does not require fasting. Next

10. FEEDBACK Answer C is incorrect. A high insulin value may tell you that the patient is insulin resistant. However, the insulin concentration is not used to make a diagnosis of diabetes. Next

11. FEEDBACK Answer D is incorrect. The random serum glucose concentration must be more than 199 mg/dL to make a diagnosis of diabetes. Without symptoms, the patient is unlikely to have a glucose value this high. However, if the patient’s glucose is more than 100 mg/dL, you have not ruled out prediabetes or diabetes. Next

12. Question Three It is late afternoon. A hemoglobin A1c,creatinine, and CBC, are obtained for Carla. You might also want to obtain AST and ALT concentrations because they are not affected by fasting. You find the A1c is 9.5%. The ALT is 78 U/L with an AST of 30 U/L. The creatinine and CBC count results are normal. What should you do next? Start metformin, 500 mg per day, and escalate the dose to 1,000 mg twice a day during the next 2 to 4 weeks. Start metformin, 1,000 mg bid, or metformin XR, 2,000 mg/d. Refer to endocrinology to start insulin or oral second-line hypoglycemic. Give the patient 3 months to try to lose weight.

13. FEEDBACK Answer A is correct. Starting at a low dose of 500 mg and increasing by 500 mg every 3 to 7 days would reduce the chances of diarrhea and nausea. Patients should also take metformin with food. Starting at the maximum dose would increase the chance that the patient might have gastrointestinal symptoms. Although insulin can be used for type 2 diabetes mellitus, metformin would be a better option because it reduces hepatic glucose release. In patients without a contraindication to metformin, insulin should be used only as initial therapy if the fasting glucose level is more than 200 mg/dL or the hemoglobin A1c value is more than 10%. Next

14. FEEDBACK Answer B is incorrect. This is not the best choice. This patient will probably require a dose of 2,000 mg/d. However, starting at such a high dose increases the risk of gastrointestinal side effects. If patients have gastrointestinal side effects, they might stop taking the medicine. Starting at a low dose of 500 mg and increasing by 500 mg every 3 to 7 days would reduce the chances of diarrhea and nausea. Next

15. FEEDBACK Answer C is incorrect. Although insulin can be used initially for type 2 diabetes mellitus, metformin would be a better option because it reduces hepatic glucose release and does not cause weight gain. Next

16. FEEDBACK Answer D is incorrect. Although weight loss should always be encouraged, it will not occur quickly enough to control the glucose level acutely. Acute control is important because the glucose level is high. If the A1c value were less than 8%, one could perhaps consider a trial of lifestyle changes for 2 to 3 months. Metformin would be a better option. When prescribing metformin, starting at a low dose of 500 mg and increasing by 500 mg every 3 to 7 days would reduce the chances of diarrhea and nausea. Next

17. Question Four After 4 months of taking metformin, 1,000 mg twice a day, Carla’s hemoglobin A1c is 5.8%. She also has lost 7 pounds and is running 2 miles each day. During the next year, Carla’s hemoglobin A1c value gradually increases to 9% and she has a 10-lb increase in weight. You see her again in 2 months and her hemoglobin A1c value is again 9%. What should you do next? Refer her to an endocrinologist. Repeat the test in 2 to 3 months. • Ask the patient and family about medication adherence. • Add another medication.

18. FEEDBACK Answer A is incorrect. This is a valid option, but as this family’s primary care provider, you have the best rapport with this patient and family. You should first determine if the patient has been taking metformin as prescribed. Poor adherence is a common cause of hemoglobin A1c elevation. Next

19. FEEDBACK Answer B is incorrect. This is not the best answer. Several instances of elevated hemoglobin A1c concentrations have been found. Obtaining another hemoglobin A1c value in 2 months would not be helpful. You need to determine the cause of the increases in the hemoglobin A1c value. Next

20. FEEDBACK Answer C is correct. The  first thing to explore would be medication adherence. Acknowledge that it is difficult to take medicine daily and inquire about barriers to medication adherence. Consider enlisting the parents’ help in removing some of these barriers to adherence. If nonadherence to medication is identified, a plan to overcome the adherence barrier should be made with the patient and family. The teen should then come back for another hemoglobin A1c measurement in 2 months.   Next

21. FEEDBACK Answer D is incorrect. You would only add another medicine if you have first ruled out medication nonadherence. Next

22. Case Study Summary • Here are the steps you took to identify and manage Carla’s Type 2 diabetes: • Screened for diabetes, checked her blood pressure, and examined her neck for AN after your staff found her BMI was more than the 85th percentile for her age. (Her mother also has diabetes.) • Ordered a hemoglobin A1c, creatinine, and CBC because you thought Carla might not return for a fasting test. • Based on test results, prescribed metformin, starting at 500 mg per day and increasing to 1,000 mg twice a day during the next 2 to 4 weeks. • Based on increases in weight andhemoglobin A1c during the nextyear, asked about adherence tothe medication and helped Carlaand her family devise a plan to helpremove any barriers to adherence;scheduled a follow-up hemoglobinA1cmeasurement in 2 months.   Exit Course