Internal Medicine

P1: RLJ/OZN P2: KUF

0521779407-D-01 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:41

476 Diabetes Mellitus, Type 2

■Presentation: polyuria, polydipsia, nocturia, polyphagia, weight loss

or weight gain, fatigue, blurred vision, candidiasis, recurrent furun-

culosis

■Established disease:

➣Visual changes: blurred vision, floating specks, loss of vision

➣Paresthesias, numbness, lancinating, burning/aching pain, cold-

ness, usually affecting lower extremities, usually worse at night

➣Dysphagia, early satiety, bloating, nausea/vomiting, diarrhea,

constipation

➣Impotence, incontinence

➣Claudication

➣Foot ulcers

➣Microaneurysms, hemorrhages, exudates, cotton wool spots,

new vessels

➣Loss of sensation, proprioception, temperature discrimination,

absent ankle jerks

➣Hammerhead deformity of toes, calluses, ulcers

➣Miosis, diminished pupillary dilation

➣Resting tachycardia, postural hypotension

➣Necrobiosis lipoidicum diabeticorum

➣Diminished or absent pulses in lower extremities

tests

Laboratory

■Basic blood studies: elevated glucose, HgbA1c, creatinine, dyslipi-

demia; thyroid function tests

■Basic urine studies: glycosuria, albuminuria

■Specific Diagnostic Tests

➣Oral glucose tolerance test (glucose≥200 mg/dL at 2 h)

➣C-peptide, insulin

➣ECG

differential diagnosis

■Fasting glucose≥126 mg/dL on 2 occasions establishes diagnosis

management

What to Do First

■Assess whether symptomatic or glucose >300 mg/dL

■If asymptomatic, start with diet and exercise alone

■If symptomatic, start medication along with diet and exercise