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Patient with DM and obesity

A 44-year-old lady patient with Type 2 Diabetes on Metformin 850mg twice daily and HbA1c of 8.2% comes to see me for weight management. Her BMI is 28.7 and waist circumference is 97cm. She does not have hypertension. Her BP is 124/78mmHg. Which is the most appropriate advice I can give her?

A. Her HbA1C should be lowered to 7% and below with intensive diabetic pharmacotherapy before targeted weight loss treatment can be commenced

B. Increased physical activity or diet control alone is not sufficient to induce weight loss in her case

C. A high protein, moderate fat, low carbohydrate diet will yield the best result in terms of weight loss as compared to moderate fat, nutrient balanced, calorie induced diet or low fat and very low fat diet

D. She should be offered bariatric surgery as it is the most optimal way to allow her to achieve her target weight and glycemic control

E. She should be offered orlistat and phentermine

Ketogenic diet or very-low-carbohydrate diet gained widespread popularity in the 1990s due to their favorable effects on weight loss and diabetes among others with good short-term safety data. People on ketogenic diets exist in a state of “dietary ketosis” in which the body production of ketone is equal to consumption and no harmful effects of ketonemia occur. However, in face of stress, the harmless “dietary ketosis” can lead to profound acid-base disturbances due to massive overproduction of ketone bodies that overwhelms the acid buffer system of the body. A handful of case reports have been published on this topic calling the safety of ketogenic diet into question. In this article, we chronicle a unique case of ketogenic (Atkins) diet–associated ketoacidosis, and we present a comprehensive literature review on the etiology of ketoacidosis.

Case Discussion

Man, 52 years old, 86 kg, is treated for type 2 diabetes. He uses metformin 850 mg twice daily. At the pharmaceutical appointment the patient brought a paper with notes of the result of his blood test. With these notes, the patient asked me why he used metformin and the result of glycemia gave 92 mg/dl. Based on the data presented in the figure, I answered the following questions:

1. What is the importance of non-pharmacological measures for the treatment of diabetes?
2. Why the use of metformin twice a day, considering that the blood glucose is normal?
3. Why the achievement of glycated hemoglobin?

A 47 year old male

A 47 year old male patient sees me for the first time for NIDDM. He is currently on metformin 1g twice daily and glipizide 20mg twice daily dosage. His latest HbA1C result is 9.2%. He claims to be compliant to current medication. I have decided to start him on insulin therapy. Which of the following is the LEAST APPROPRIATE strategy?

A. Add basal insulin to current DM medications
B. Maintain current dosage of metformin, reduce glipizide dosage by half, and add on pre-meal bolus insulin
C. Discontinue metformin and glipizide, and replace with pre-meal bolus insulin
D. Discontinue metformin and glipizide, and add basal-bolus insulin
E. Maintain metformin, discontinue glipizide, and add on pre-mixed insulin

A 52-year-old man presented with a 20-minute history of chest pain radiating to the left shoulder and neck, associated with dyspnea and diaphoresis. He had a history of hypertension, long-term smoking, and a sedentary lifestyle. On physical examination, bibasilar crackles were noted on lung auscultation. An electrocardiogram (ECG) was performed in the primary care setting, and the patient was promptly referred to the emergency department.

A 28-year-old woman presented with a 3-day history of intense pruritus over the lower back. She reported no recent travel or exposure to new environments. She cares for a small kennel with approximately eight dogs rescued from the streets. Physical examination revealed multiple small vesicles, some clustered and others scattered, predominantly involving the lumbar region and the left gluteal area.

A 4-month-old male infant presented with skin lesions localized to the chin for the past 3 days. Physical examination revealed multiple small pustules with surrounding inflammatory signs on the chin, along with a few scattered papules on the chest.

Patient in late teens presenting after a collapse, no chest pain, no previous cardiac history, no history of sudden death in family, are there any features in this EKG that would warrant further work-up or is this just a pediatric EKG?