A 63-year-old woman presents to the ED with palpitations, with a pounding feeling in her chest and shortness of breath. An EKG done shows the following:
This patient has:
Correct Answer B:
An EKG of Atrial flutter will show the following: Atrial rate: Usually 300 beats/min, ranging between 220 and 350 beats/min Rhythm: The atrial rhythm is regular P waves: Flutter waves resemble a sawtooth or picket fence and are best seen in leads II, III or aVF PR interval: Usually the PR interval is regular, but it may vary QRS interval: This pattern is usually normal Treatment involves rate control with calcium channel blockers or beta blockers. Conversion of rate with a type I antiarrhythmic agent, such as quinidine or procainamide follows.
Which of the following diabetes drugs is contraindicated in liver and kidney failure?
Insulin works by directly pushing glucose from the bloodstream into the cells. Metformin works by inhibiting hepatic gluconeogenesis. Glyburide is an oral sulfonylurea hypoglycemic drug that increases pancreatic insulin secretion.
Acarbose inhibits enzymes needed to digest carbohydrates. Because the carbohydrates are not broken down into glucose molecules, less glucose is absorbed into the bloodstream.
Metformin is contraindicated in people with any condition that could increase the risk of lactic acidosis, including liver and kidney disorders (creatinine levels over 132 µmol/l).
The drug of choice for an obese diabetic type 2 patient is:
Metformin has been clearly established as the drug of choice in obese patients with diabetes mellitus. Metformin is as effective as sulphonylureas at reducing HbA1c, and most importantly has a beneficial effect on overall mortality in obese patients.
Metformin monotherapy is unlikely to be effective in patients who fail to respond to sulphonylureas, but in patients who are secondary failures to sulphonylureas, the addition of metformin causes substantial blood glucose lowering. Metformin should be avoided in patients with renal dysfunction. Otherwise its effects on body weight, serum lipids and its lack of hypoglycemia effect make it an excellent first line agent.
Which of the following is the best test in the long term follow up of a diabetic patient?
Correct Answer A:
There are two common ways to assess how well diabetes is controlled:
Each method has its good and bad points, but combined they give a fairly accurate picture of the state of glucose control in a diabetic. Most physicians will use both methods.
Hemoglobin is an iron containing molecule present in red blood cells that is responsible for transporting oxygen around the body. Glucose can bind irreversibly to hemoglobin via a process known as glycation. Hemoglobin that has glucose attached is known as glycated hemoglobin, often abbreviated to HbA1c or simply A1c.
Because red blood cells have life span of 120 days (3 months) measuring the level of glycated hemoglobin in blood effectively shows the average blood glucose level for the previous 6-8 weeks. In conjunction with regular blood glucose monitoring diaries, A1c tests can help in determining if a patient's treatment plan needs altering in any way to better control blood glucose levels. Studies have shown that glycohemoglobin values in the "better ranges" correlate with less incidence of diabetic complications later in life.
Which one of the following is the best indicator of adequate control in a patient with diabetes mellitus?
Correct Answer D:
In the normal 120-day life span of the red blood cell, glucose molecules join hemoglobin, forming glycated hemoglobin. In individuals with poorly controlled diabetes, increases in the quantities of these glycated hemoglobins are noted.
Once a hemoglobin molecule is glycated, it remains that way. A buildup of glycated hemoglobin within the red cell reflects the average level of glucose to which the cell has been exposed during its life cycle. Measuring glycated hemoglobin assesses the effectiveness of therapy by monitoring long-term serum glucose regulation.
The International Diabetes Federation recommend HbA1c values below 6.5%, while the American Diabetes Association recommends that the HbA1c be below 7.0% for most patients. A high HbA1c represents poor glucose control.
Persistent elevations in blood sugar (and therefore HbA1c) increase the risk for the long-term vascular complications of diabetes such as coronary disease, heart attack, stroke, heart failure, kidney failure, blindness, erectile dysfunction, neuropathy (loss of sensation, especially in the feet), gangrene, and gastroparesis (slowed emptying of the stomach).
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