DETAILS

• Only answer the case assigned to your group

• Answer ALL case questions as a group in computerized format. Font style is times new roman
11, spacing single, default 1 inch margins.
• For questions that require rationale/justification, already type your justification in full detail on
your paper
• Make sure you indicate the group members, section, and submission date at the top portion of the
paper (group members and section at upper left, date at upper right)
• Submit first thing on Monday (4IPH) and Tuesday (4CPH)
• For class officers: arrange your seats by group during the day of the case discussion.
• I will be projecting the case and questions on the board, and each group will be answering their
assigned questions on their seats.
• I and Dar (for 4C) or Chesca (for 4I) would be facilitating the case discussion and asking any
necessary questions.
CASE #1
PATIENT PRESENTATION

Chief Complaint

Patient’s roommate reports the patient stating “I feel really sick, weak, and lightheaded. I think I have an infected
blister on my foot that is causing all of this” this morning just hours before she vomited and collapsed in the
bathroom of their dormitory.

HPI

Patient B is a 21-year-old woman with a history of Type 1 diabetes, diagnosed 5 years ago. She is a college senior at
the local university. She and her mom returned 2 days ago from a 5-day vacation in Key West, and she returned to
her college dormitory yesterday. It was a welcome break, as she is a 4.0 student and has been chronically tired from
studying diligently this past year. She states that she has been under a “lot of stress” in the last 2 months preparing
for her wedding and graduation. She wore flip-flops all week on the beach, and 5 days ago, she started to notice a
blister forming between her big toe and second toe (on her left foot). She dismissed it, putting a liquid bandage on it
and treating it with triple antibiotic ointment. Three days ago, it was larger and “oozing pus.” She called her primary
care physician, who called in a prescription that day for an oral antibiotic.

She began feeling nauseated with some stomach pains several hours after breakfast, and she began vomiting last
night immediately after dinner. Her roommate suggested she call her doctor, but she believed the antibiotic could be
the cause of her stomach upset leading to her hyperglycemia. Her blood glucose at that time (7 PM) was 350 mg/dL.
At bedtime, her blood glucose was 375 mg/dL. She tried sipping clear diet soda and eating a large popsicle, but was
unable to keep any fluids down. She vomited five more times that evening before falling asleep for several hours.
Since she fell asleep, she missed her evening dose of insulin glargine. Her roommate heard her fall in the bathroom
around 3:30 AM. She called 911 immediately.

When the paramedics arrived, she was alert but not oriented. The paramedics noted coffee ground emesis in the
toilet, Kussmaul respirations (and timed it to be 30 breaths/min), and “fruity breath.”

Her roommate told them that she was not intoxicated but that she has Type 1 diabetes. She was very warm to the
touch, and they noted the large lesion on her left foot. They immediately transported her to the ER. Her mother
arrived and provided background information to the admitting nursing staff. Patient B had a visit with her
ophthalmologist over a year ago and was told there was “nothing abnormal” upon receiving a dilated eye
examination. Her last screen for microalbuminuria 3 months ago was positive, although she has not had additional
screenings to confirm those results. She has no paresthesias of the feet or hands and has never previously had a foot
ulcer.

Her last lipid panel was obtained 3 months ago and was “not good.” Her mother suspects Patient B has not been
taking insulin regularly and is concerned about her recent weight loss. Her glucose control has been suboptimal, as
indicated by an HbA1C of 8.5% from 2 months ago. She infrequently sees a dietitian and admits that she has had
difficulty managing her diabetes due to the demands of college, her part-time job and planning the wedding.

PMH
Type 1 DM diagnosed 5 years ago; hospitalized 2 times for DKA in the past 5 years
PSH
Tonsillectomy 1997
FH
Father, age 45, has HTN and hyperlipidemia
Mother, age 43, has Type 2 diabetes and hypertension
One sister, age 15 and healthy

SH
College student; engaged to be married; no tobacco or illicit drug use; drinks two to three beers a month with friends
Meds
• Insulin glargine 13 units SC at bedtime
• Insulin lispro 5 units SC before breakfast, 5 units SC before lunch, and 6 units SC before dinner
• Ibuprofen 200 mg PRN menstrual cramps
• Glucagon injection kit

Allergies
NKDA

ROS
• HEENT—Complains of blurry vision and dizziness on postural change; denies vertigo, head trauma, ear
pain, tinnitus, dysphagia, odynophagia
• Resp—Complains of SOB; no complaints of cough or wheezing
• GI—Vomiting as noted above in HPI; complains of abdominal pain; denies constipation, diarrhea, or food
intolerance
• GU—Had polyuria (large volumes every hour) yesterday; incontinent when paramedics arrived
• OB-GYN—G0P0; denies current pregnancy and has ongoing menses; menses typically flows for 5 days
and is regular every 28 days; not sexually active and denies any vaginal discharge, pain,or itching
• Neuro—Has never had a seizure; complains of lethargy; no complaints of headache, paresthesias,
dysesthesias, or anesthesias
• Derm—No history of chronic rashes or sweating abnormalities; no history of injection site reactions or
problems
• Endo—Denies history of goiter and has no heat or cold intolerance; she has lost 10 lb in the last year
• Underweight white woman with a female body habitus appearing her stated age, with deep respirations,
ketones on her breath, and slurred speech; slightly confused, but responds appropriately to question
• VS: BP 110/69 supine, 105/65 sitting, P 130, RR 29, T 40.0°C; Wt 48 kg, Ht 5'6''

ABG
On room air: pH 7.2; pCO2 7.6; pO2 139; HCO3 2.0, O2 sat 97%

LABS

UA
SG 1.0005, pH 6, glu (–), protein (–), ketones (3+), blood (–); nitrite (–); leukocyte esterase (–); 1 WBC/hpf; 0
RBC/hpf, no bacteria, 1–5 epithelial cells

Chest X-Ray
Normal

ECG
Sinus tachycardia
Patient details
1. In the case of diabetes mellitus type 1, state the risk factors for DM1 that is associated with the patient.
2. What is happening to the patient showing when she was showing unusual signs when paramedics arrived? State
the specific mechanism for her unusual breathing pattern and breath odor.

3. What are the diagnostic criteria for your answer to question 2?

4. Based on the case details, what lapses could cause the patient to have a tendency to experience what she is
experiencing when the paramedics arrived?

Treatment details
1. What are the goals of therapy for this patient?
2. Explain why the patient uses both insulin glargine and lispro, and why she has a glucagon kit with her.
3. Are there any other medications that should be added to her regimen based on her presenting laboratory values
and/or history of present illness?

4. What lifestyle recommendations, if any, would you make?

5. Describe the nonpharmacologic approaches that should be taken to prevent further complications associated with
diabetes, including the prevention of future foot ulcerations.
6. What additional counseling or interventions should occur with this patient regarding prevention of future DKA?
CASE #2
Chief Complaint
“My gynecologist said I should have a check-up since I am tired all the time.”

HPI
Patient LJ is a 49-year-old woman who presents to her primary care physician after her gynecologist recently
diagnosed her with polycystic ovarian syndrome (PCOS) during an evaluation for amenorrhea. She complains of
increasing fatigue, which she attributes to being overweight. She states her last appointment with her PCP was over
2 years ago.

PMH
PCOS × 2 months
Hyperlipidemia × 2 years (diet controlled)
HTN × 4 years

FH
Diabetes present in both mother and maternal grandmother. Father died suddenly of colon cancer at age 59, mother
alive age 76 with history positive for DM Type 2, HTN, and hyperlipidemia; one younger sister with PCOS and
HTN.
SH
Married × 23 years with two children. Works full-time as insurance consultant which is telephone based from home.
No alcohol or tobacco use. Rarely exercises and admits to trying fad diets for weight loss with little success. She
reports adherence to her medications.

Meds
Ortho-Novum (norethindrone/ ethinylestradiol) 1/35 as directed
Hydrochlorothiazide 50 mg po daily
ROS
Frequent fatigue. Occasional polydipsia, polyphagia, weakness, and lightheadedness upon standing. Denies blurred
vision, chest pain, dyspnea, tachycardia, dizziness, or tingling or numbness in extremities, leg cramps, peripheral
edema, changes in bowel movements, GI bloating or pain, nausea or vomiting, urinary incontinence, or presence of
skin lesions.

Physical Examination
Gen
Patient is an African-American woman with central obesity in no apparent distress

Vital signs
BP 152/88 sitting R arm
BP 130/70 standing R arm
HR 82
RR 18
T 37.2°C
Wt 95.5 kg
Ht 5'6''
Labs

Na 141 mEq/L Ca 9.9 mg/dL

K 4.0 mEq/L Phos 3.2 mg/dL
Cl 96 mEq/L AST 21 IU/L
CO2 22 mEq/L ALT 15 IU/L
BUN 16 mg/dL Alk phos 45 IU/L
SCr 1.2 mg/dL T. bili 0.9 mg/dL
Random Glu 280 mg/dL
T. chol 260 mg/dL

UA
(–) ketones, (–) protein, (–) microalbuminuria
Clinical Course
The patient returned to clinic 3 days later for lab work, which revealed:
FBG 189 mg/dL;
HBA1C 9.4%;
FLP: T. chol 263 mg/dL
HDL 31 mg/dL
LDL 152 mg/dL
Trig 260 mg/dL.

QUESTIONS

Patient Details
1. Is the patients DM more likely to be type 1 or 2? Support your statement by noting relevant details of the case.
2. What risk factors for DM are present in this patient?

3. What information signs and symptoms of the patient are characteristic of DM?
4. What lab data support the diagnosis of DM? Explain why they are related to DM diagnosis. Also make sure that
you state the normal range for each lab data for comparison purposes.

Treatment details
5. What are the best medications to give patient LJ? Justify each medication you mention (You must based your
answers of 2015 AACE algorithm https://www.aace.com/files/aace_algorithm.pdf)

6. List all potential adverse effects with all oral hypoglycemic agents. What adverse effects of the OHAs are
particularly an issue to the patient? Would they influence your decisions on what OHA the patient should take?
7. What nonpharmacologic therapies might be useful in the management of this patient?
GROUPINGS
4CPH
CASE 1
GRP 1
Florida, Aedel Cordero
Laylo, Romina Pelayo
Magno, Maeko Rabi
Guevarra, Bianca Marie Sacdalan
Alonzo, Angela Wilma Gines
GRP 2
Collantes, Bryan Dollaga
Chuatiamsing, Madelaine Louise Soon
Barandon, Eloisa Lorraine Vela
Lu, Rizelle Jane Tanya
Vizcarra, Christian Chavez
GRP 3
Dychinco, Beatrice Ysabel Salvador
Jones, Joan Kae Gatchalian
Limjoco, Bianca Mae Gonzales
Vega, Ma. Beatrice Montes
Chua, Kharl Edriane Diocson
GRP 4
Dimayacyac, Catrina Reyes
Albances, Loren Joy Rodriguez
Artillera, Erika Krisha Ong
Custodio, Aileen Pena
Langit, Prince Karlomagne Martinez
Uy, Dana Belle Segundo
CASE 2
GRP 5
Agbayani, Avegail Dizon
Balonzo, Mikaela Angela Torres
Labay, Mitzi Coleen Heredia
Paras, Jezreel Nikholai Maulion
Mercado, Nica Jane Delfin
Lim, Eris Fernandez
GRP 6
Chavez, Noreen Mae Espeleta
Sigua, John Isaiah Romero
Celzo, Chelzea Ma. Jelica Dumpit
Tomaclas, Rosie Ann Romano
Cantes, Leo Camillus Crvel
Diu, Gillian Chelsea Cu
GRP 7
Aviles, Jenella Andrea Abano
Pagulayan, Mark Lingan
Opelario, Melchi Esrom Layugan
Tunod, Edmin Christian Rubio
Ortega, Jericho Camenforte
GRP 8
Varon, Shaira Isabela Badilles
Leobrera, Krystel Danica Ricaforte
Gatbonton, Anaterrica Faith Vinuya
Boongaling, Jinger Florence Castillo
Llamas, Maria Isabela Virginia Castillo
4IPH
CASE 1
GRP 1
BELILA, GENIE Z.
BAAY, GUERLLEIN JOYCE G.
PRIELLA, MARIA BEATRICE R.
ANTONIL, JUDIEL FAITH D.
SALAZAR, CHRISSIA MARIE T.
TAN, MILAN PAOLO P.
GRP 2
GRANADA, ARIALE G.
MENGOTE, AILEEN ROCHELLE B.
MERCADO, CANDICE JULYETTE
MANIEGO, KIM CIENA M.
BALLESTAMON, HANNAH SOFIA I.
FIGEROA, MYLES CARLO B.
GRP 3
NESNIA, GRACIELA CAMILLE C.
NATIVIDAD, ALEXANDRA LOUISE D.C.
ORTIZ, PATRICIA DIANE M.
HONRALES, KIARA KATE I.
DATU, SAMANTHA GUINEVERE C.
TABERNILLA, ANGELO JOSE A.
GRP 4
TULOD, IVANA LINDA M.
YU, JAMIE J.
PRADES, JUSTINE MAE V.
BRUCAL, NEIL JOHN G.
JACINTO, HAZEL M.
ASIGNACION, ANDREA V.
LENON, JANE RAEL P.
CASE 2
GRP 5
HERNANDEZ, LESLIE ANNE C.
RESULTAY, MA. ALLYSA KLAIRE D.
GUEVARRA, CLARIELLE M.
BITOIN, CARMELI RUTH T.
ANDAL, CHESLIE CAMYLLE A.
CUETO, CHARLENE MAE E.
ESPINA, ERA MAE P.
GRP 6
REBANCOS, CZARINA VENELL D.
CARDENAS, ELLAINE H.
PALAD, JAMES KARLENE H.
TORRES, MELTRICK R.
CASTILLO, AUDREY LARRAINE A.
BALMACEDA, MA. CHRISTINE L.
BIAG. VINCE CHRISTIAN L.
GRP 7
APALISOC, JOHN ADRIAN T.
LAPIRA, ALEXANDRA MARIE A.
EBORA, KRISHABELLE GRACE A.
SORIANO, CARLA MARIA C.
GUNO, NICOLE JOYCE R.
PARINAS, DARIANNE C.
PERONA, KYLE FRANCIS B.
GRP 8
CAMARAO, MARIUS JEFFERON M.
MAÑAGO, AYANNA MARIE M.
EBUENGA, JHEF JOSEPH H.
RODELAS, ANN SAMANTHA V.
MIQUIABAS, KATRINA T.
CALDERON, MAYLENE M.