Rural and Medically Underserved Population Primary Care

OMS III CLINICAL ROTATION

MODULE 1

It is anticipated that completing this Case (along with what you are learning clinically we expect that
completing this module will take at least three days).

Cases:
1) Diabetes
2) Nutrition
3) Interpreting Lab Results

Reading Assignment:

 Rakel Textbook of Family Medicine, Chapter 34, pages 782-816

Learning Objectives:

Diabetes
a. Identify and state the groups of diabetes and how diabetes is diagnosed

b. Recall the changing epidemiology of diabetes in the United States

c. Recall the morbidity and mortality (complications) associated with
diabetes mellitus (DM) and preventive measures that lower morbidity
d. Recognize the two common pathogenic mechanisms associated with the
development of DM and the characteristics of type 1 and type 2 DM
e. Identify the dietary recommendations of the ADA and the effects of
exercise on DM
f. Recognize the classes of diabetic agents, mode of action and side effects;
identify agents that may promote weight loss
g. Recall the classes of insulin preparations
h. Recognize how to initiate insulin in the type 2 DM patient and when to
consider the discontinuation of insulin
i. Calculate basal-bolus insulin dosing
j. Apply evidence-based standards of care in the management of a patient
with type 2 diabetes mellitus
k. Formulate patient education regarding type 2 diabetes with attention to
and respect for the patient’s own disease model

Rakel Textbook of Family Medicine, Chapter 37, pages 891-911

Learning Objectives:

Nutrition
a. Recall current dietary guidelines when using websites (and be
familiar with websites) such as www.MyPlate.gov and
www.dietaryguidelines.gov for resources
 b. Develop patient education on dietary sources of minerals
c. Recall sites of absorption of key vitamins and minerals
d. Recognize health conditions that may impair metabolism or
absorption of vitamins and minerals
e. Recognize health conditions that may result in increased excretion
or increased requirements of vitamins and minerals
f. Identify important aspects of the patient history and physical
examination in a nutrition assessment and the components of
metabolic syndrome
g. Develop patient education on body mass index (BMI) and its role in
their health and recognize how to classify obesity
h. Recognize appropriate lab work for malnutrition assessment
i. Recognize and educate patients about changing nutritional needs
in pregnancy and lactation, childhood, adolescence and old age
j. Appraise various diets for pros, cons and contraindications

 Rakel Textbook of Family Medicine, Chapter 14, pages 157-180

Learning Objectives:

Interpreting Lab Result

a. Recognize biologic variables that can affect test results
b. Recall how to calculate a test’s sensitivity, specificity and determine true vs false
positives and negatives
c. Categorize causes of decreased albumin levels
d. Differentiate bone vs liver vs other causes of increased alkaline phosphatase
levels
e. Differentiate pancreatic vs non-pancreatic causes of elevated amylase and lipase
levels
f. Recall causes of hypercalcemia and hypocalcemia
g. Categorize causes of vitamin B12 and folate deficiency
h. Stratify causes of leukocytosis and leukopenia by white blood cell type
i. Recall causes of thrombocytopenia and categorize them into decreased
production and increased destruction
j. Assess factors affecting erythrocyte sedimentation rate

Case 1: Diabetes: Diagnosis and Management in the Ambulatory Setting

A 48-year-old male presents to the outpatient clinic for chronic disease follow-up. He is a recently-
diagnosed type 2 diabetic. He has not been seen by a physician in five years prior to last month, when he
presented with excessive thirst, hunger and a 20 lb unintentional weight loss. Urinalysis at that time
showed glucosuria. His bloodwork showed an elevated non-fasting glucose of 300mg/dL and
hemoglobin A1c of 12.1%.
 Diagnosis:

1. In what ways can you diagnose diabetes and what are the appropriate values that
support a diagnosis of diabetes?

Hb A1c >/= than 6.5, fast blood glucose >/= 126, oral glucose tolerance test >/= 200

2. Does the patient meet criteria for diabetes based on his initial presentation?

Yes

3. What range is considered impaired fasting glucose?

</=99

Management:

1. What role does exercise have in management of diabetes?

Exercise influences the body by upregulating Glut4 receptors to uptake the glucose
in the blood and helps lower blood glucose levels and faciliates the release of insulin
and glucagon depending on the blood sugar level.

Exercise also increase the sensitivity to insulin

2. What are the effects of exercise on blood glucose levels-immediately, within 1-2
days and chronically?

Initiately exercise can trigger an dramatic drop in blood glucose level, but over time
the blood glucose levels will be normalize due to the balance from glucagon and
insulin

3. What role does developing and maintaing a lower body mass index (BMI) have in
diabetes management?

Less fat prevents the tolerance to insulin

4. Consider medication options for management of diabetes. What are the different
options?

First line for DM2 is diet modifications, excerise and metformin

DM1 insulin is the main stay of treatment

5. What are the pros and cons of the different types of diabetic control?

a. Biguianides are good since it’s a oral medication for DM2, but cannot be used in renal
disease
 b. Sulfonyureas and megkitinides are good since it increases the release of insulin but there is a
risk of hypogylcemia and weight gain
c. Insulin preparation are good at controling blood glucose but there is a risk of hypoglycemia and
weigth gain
d. Amylin analogs can reduce the amount of food intake but hypoglcemia can precipitate if the
timing with insulin doses are off
e. Glitazones/thiazolidinediones are good at increasing sensitivity to insulin but it takes time to
work and cannot be given to heart failure paitents due to the fluid accumulation as a side effect

6. How is self blood glucose monitoring, whether through fingersticks or a continuous

monitoring device, important for management of diabetes?

It is important, patients can prevent possible hypoglycemia or hyperglycemia

episodes along with the prevention of long term complications if blood glucose is
under control

Case 2: Nutrition and Family Medicine, Obesity diagnosis and management, and Metabolic Syndrome

On physical examination, your patient is noted to have a body mass index (BMI) of 40, putting her in the
morbidly obese category. Her blood pressure is 150/92 mmHg. Her waist circumference is 50”. Her body
habitus is significant for centripetal obesity-i.e. relatively thin arms and legs with fat distribution around
her midsection. She was also noted to have a triglyceride level of 400 on her recent labwork.

1. She is curious about dietary options that you could recommend for her. What would be
a couple of options that she could use help eating more healthy?

2. She drinks four sodas per day and asks if diet sodas are a good idea to help her lose
weight. What do you recommend?

Diet sodas contaim artificial sweetners and show be avoid all together if possible because water is
needed for the body’s normal metabolic activities.

3. When asked about her diet on a daily basis, she describes it as a “scavenger diet,” saying
she just grabs whatever is nearby when she’s hungry and doesn’t really think about it.
How can you help her be more mindful about what she’s consuming?

a. To store unhealthy snacks or refrain from buying un heathly snacks. She could ask each
small meals more often to prevent overeating
 4. You have her keep a food journal for a week. When she returns, you review it and find
that she’s only averaging 5g of fiber per day. How much should she be getting?
25-30g of fiber per day

5. She doesn’t like to eat a lot of meat. While most nutrients can be adequately obtained
from plant sources, what nutrient is she most at risk of being deficient in without
occasional meat or fortified foods?
Vitamin B12 and Iron

6. She asks about trying a low-fat diet. Taken to an extreme, what vitamins could she end
up being deficient in with insufficient fat in her diet?
Vitamins A,D,E,K

7. Someone told her the Keto Diet is the way to go, but in addition to not liking meat
much, she’s worried about nutritional deficiencies with this diet. What nutrients may
need to be supplemented with this diet?

Multivitamin, proteins and fish oil

Case 3: Interpreting laboratory tests and results

Your patient had labwork done in advance of her visit. A lot of the results are in the red (abnormal).
She’s a bit alarmed and has some questions about them. Her hemoglobin A1c was 12.1%. Urine
micralbumin:creatinine ratio was elevated. Non-fasting glucose was 300mg/dL. Her vitamin B12 level
was 150 pg/mL. Her total cholesterol was 260 mg/dL, high density lipoprotein was 30 and her low-
density lipoprotein was 165. Her triglycerides were 400 mg/dL. Her vitamin D level was 20 ng/mL
(normal 30-89).

1. Approximately what was her average 3 month blood glucose to give her an A1c of
12.1%?
12.2
2. What is a normal fasting glucose value?
Less than 99
3. At what range is a fasting glucose value considered impaired fasting glucose?
100-126
4. She reports taking tums and omeprazole frequently for heartburn. What role might this
have in her low vitamin B12 level?

Decrease the acidity needed for absorption of vitamin B12

5. What role does low meat intake have?

 Decrease amount of consumer proteins and cholesterol

6. How can she improve her vitamin B12 level? Does she have options that don’t include
meat?

Supplement with vitamin B12 tablets or injections of B12

7. How would initiation of a statin medication be expected to change her lipid profile?

Decreases LDL, slightly decrease triglycerides,slightly increase HDL decrease total

cholesterol levels

8. How does her continually high blood glucose affect her triglycerides?

When the body becomes resistant to insulin and cannot uptake glucose this causes the
body to break down fat as the source of fuel

9. Could her obesity play a role in her vitamin D level being low?
possibly

10. How can she increase her HDL (good) cholesterol?

Take niacin, fish oil