QUESTION: 97

A 32-year-old woman complains of episodic confusion in the morning for the past 6 months. During one of these episodes, she was brought to the ER and her serum glucose was found to be 40 mg/dL. She was given intravenous dextrose and her symptoms resolved within 15 minutes. She has gained approximately 25 lbs during the past year. Which of the following would be the most appropriate next step?

measure serum insulin and proinsulin 2 hours after a mixed meal
MRI of the pancreas
measure insulin, C-peptide, and sulfonylurea level on the initial blood sample in ER
octreotide scan
advise a high protein diet with frequent feedings

Answer(s): C

Explanation:

The patient appears to have significant hypoglycemia and neuroglycopenia. The differential diagnosis includes medications such as sulfonylureas; alcohol; endocrine deficiency syndromes such as adrenal insufficiency, hypopituitarism, and hypothyroidism; surreptitious insulin administration; and insulinoma. The best way to establish the diagnosis is to measure the levels of each of these levels on the critical sample demonstrating hypoglycemia.

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QUESTION: 98

A 74-year-old male with a history of hypertension, type II diabetes, myopia, and cataract surgery 2 weeks ago presents with the sudden onset of severe flashes of light and multiple new floaters in his right eye. He denies photophobia, ocular trauma, or diplopia. He also states that he feels as if there is a curtain lowering over his right eye.
What is the most likely cause of his symptoms?

central retinal artery occlusion
acute lens displacement
iritis
retinal detachment
staphylococcal endophthalmitis

Answer(s): D

Explanation:

Retinal detachment is fairly uncommon but should be considered for any patient with visual loss. Risk factors for retinal detachment include advanced age, myopia, cataract surgery, focal retinal atrophy, congenital eye diseases, fibromuscular hyperplasia (FMH) retinal detachment, prematurity, uveitis, diabetic retinopathy, and hereditary vitreoretinopathy. Patients may be asymptomatic but usually present with sudden onset of flashes of light, new floaters, visual field defects, and a sensation of a "curtain" coming down over their visual field. Prompt ophthalmology evaluation, preferably by a retinal specialist, is warranted. Immediate care is paramount as often retinal tears can be managed so as to prevent retinal detachment. Symptomatic retinal tears can be managed with laser or cryo burns to create a chorioretinal scar that prevents fluid access to the subretinal space. This is effective 95% of the time to prevent progression to a retinal detachment. Retinal detachment can be surgically corrected with scleral buckling techniques (90% success rate) or posterior vitrectomy (7590% success rate).

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QUESTION: 99

A 74-year-old male with a history of hypertension, type II diabetes, myopia, and cataract surgery 2 weeks ago presents with the sudden onset of severe flashes of light and multiple new floaters in his right eye. He denies photophobia, ocular trauma, or diplopia. He also states that he feels as if there is a curtain lowering over his right eye. Your examination and a stat ophthalmology consultation confirm your clinical diagnosis. Of the choices listed below, what would be the most appropriate next step to provide definite treatment for this patient?

lens removal and surgical replacement
corneal transplant
removal of vitreous humor (posterior vitrectomy)
intraocular antibiotics
stat angiogram and thrombolytics if needed

Answer(s): C

Explanation:

Retinal detachment is fairly uncommon but should be considered for any patient with visual loss. Risk factors for retinal detachment include advanced age, myopia, cataract surgery, focal retinal atrophy, congenital eye diseases, fibromuscular hyperplasia (FMH) retinal detachment, prematurity, uveitis, diabetic retinopathy, and hereditary vitreoretinopathy. Patients may be asymptomatic but usually present with sudden onset of flashes of light, new floaters, visual field defects, and a sensation of a "curtain" coming down over their visual field. Prompt ophthalmology evaluation, preferably by a retinal specialist, is warranted. Immediate care is paramount as often retinal tears can be managed so as to prevent retinal detachment. Symptomatic retinal tears can be managed with laser or cryo burns to create a chorioretinal scar that prevents fluid access to the subretinal space. This is effective 95% of the time to prevent progression to a retinal detachment. Retinal detachment can be surgically corrected with scleral buckling techniques (90% success rate) or posterior vitrectomy (7590% success rate).

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QUESTION: 100

A 23-year-old pregnant woman with type 1 diabetes was admitted to the Obstetrics service for DKA. The DKA was appropriately treated and has resolved. You were consulted for medical management of the diabetes, as her sugars have been labile throughout the hospital stay. Your history and review of records reveals that the patient has a long-standing history of noncompliance with diet and medication regimens. She currently uses any insulin she can get and does not eat regular meals. She has fluctuating blood sugars with episodes of hypoglycemia.
You counsel the patient extensively, order nutrition and diabetic teaching consults, and discuss keeping home glucose logs. Assuming the patient will follow your advice, which regimen would you recommend to minimize fluctuating glucose readings?

NPH insulin twice daily
insulin glargine once daily and insulin lispro before meals
Humulin 70/30 twice daily
NPH twice daily and regular insulin three times daily with meals E. insulin glargine twice daily

Answer(s): B

Explanation:

See Table below for onset, peak, and duration of the various types of insulin.

Multiple randomized-controlled trials have shown that tight blood sugar control type I diabetics will reduce the risk of micro- and macrovascular complications, such as retinopathy, neuropathy, and cardiovascular disease.
The Diabetes Control and Complications Trial (DCCT) showed that, compared with conventional therapy, intensive therapy significantly reduced the risk of retinopathy progression and clinical neuropathy. Other studies have shown that intensive therapy prevented one cardiovascular event for every 25 patients treated over a 10-year period in a relatively young group of patients. Intensive therapy is not without risk, however. The risk of severe hypoglycemia and subsequent coma or seizure was significantly higher in the intensive therapy group. Control of type I diabetes is dependent on controlling diet with regular low fat meals, keeping blood sugar logs (fasting/ preprandial and postprandial) and adherence to insulin. In type I diabetes, oral hypoglycemics are not useful, as patients have a lack of endogenous insulin production. Most oral hypoglycemic agents work either as insulin sensitizers, secretagogues, or a combination. Type I diabetics need insulin for glycemic control and for prevention of ketoacidosis. Patient acceptance and compliance is critical, for which education is key. Patients must be taught the implications of poor control, and the means to optimize control. Blood sugar testing techniques and nutrition counseling are essential features of success. Regular cardiovascular exercise is also of paramount importance. For patients with poor diet regimens, medication compliance, and blood sugar testing, a longacting agent without peaks and valleys of insulin levels would be an ideal agent for basal insulin. For patients who have no regular mealtimes and history of hypoglycemia, rapidacting insulin is taken at the time of meals is recommended. Patients should also be taught to count carbohydrates and adjust the insulin accordingly (1 g carbohydrate = 1 unit of lispro).
Another option is to use a sliding scale for the lispro based on the premeal sugar levels (using 1 unit for every 3050 mg/dL that the blood sugar is above target). Thus, based on these recommendations, the best option for this patient would be to use insulin glargine as the basal insulin and insulin lispro at the time of meals. However, regular follow-up and compliance with lifestyle measures are key to achieve optimal short- and long-term control and reduction of complications.

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QUESTION: 97

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