1/9
A 33 y/o F with carpal tunnel syndrome presents with polyuria and polydipsia. She has a fasting serum glucose of 212 mg/dL and a hemoglobin a1c of 9.7%.
Do you have an approach to hyperglycemia? x.com
A 33 y/o F with carpal tunnel syndrome presents with polyuria and polydipsia. She has a fasting serum glucose of 212 mg/dL and a hemoglobin a1c of 9.7%.
Do you have an approach to hyperglycemia? x.com
2/9
The first step is to determine whether we are dealing with insulin-dependent hyperglycemia or insulin-independent hyperglycemia. x.com
The first step is to determine whether we are dealing with insulin-dependent hyperglycemia or insulin-independent hyperglycemia. x.com
3/9
Insulin-dependent hyperglycemia occurs as a result of insulin deficiency; insulin-independent hyperglycemia occurs despite the presence of insulin and is primarily the result of insulin resistance. x.com
Insulin-dependent hyperglycemia occurs as a result of insulin deficiency; insulin-independent hyperglycemia occurs despite the presence of insulin and is primarily the result of insulin resistance. x.com
4/9
This can usually be determined clinically. When in doubt, fasting glucose, insulin, and C-peptide levels can help. In setting of hyperglycemia, insulin and C-pep levels should be up; low values = insulin-dependent hyperglycemia.
In this case, insulin/C-pep levels are up. x.com
This can usually be determined clinically. When in doubt, fasting glucose, insulin, and C-peptide levels can help. In setting of hyperglycemia, insulin and C-pep levels should be up; low values = insulin-dependent hyperglycemia.
In this case, insulin/C-pep levels are up. x.com
5/9
Would be easy to call this type 2 DM and stop. The advanced clinician must consider secondary causes. That’s why frameworks are so useful, even for “every day” problems like hyperglycemia. The framework compels us to consider other possibilities.
Back to our patient. x.com
Would be easy to call this type 2 DM and stop. The advanced clinician must consider secondary causes. That’s why frameworks are so useful, even for “every day” problems like hyperglycemia. The framework compels us to consider other possibilities.
Back to our patient. x.com
6/9
Prominent facial features, most pronounced in forehead (frontal bossing), nose, and lips, should generate a hypothesis.
With this in mind you shake our patient’s hand. It feels moist and doughy. Hands of a different patient with the same condition (thx @PeteSullivanPDx): x.com
Prominent facial features, most pronounced in forehead (frontal bossing), nose, and lips, should generate a hypothesis.
With this in mind you shake our patient’s hand. It feels moist and doughy. Hands of a different patient with the same condition (thx @PeteSullivanPDx): x.com
7/9
Our hypothesis leads to retrospective history. The pt's shoe size has increased to the point she only fits into men’s shoes. Ring size has doubled. Her tongue has gotten larger.
We have all but made our diagnosis. Elevated serum levels of IGF-1 would be confirmatory. x.com
Our hypothesis leads to retrospective history. The pt's shoe size has increased to the point she only fits into men’s shoes. Ring size has doubled. Her tongue has gotten larger.
We have all but made our diagnosis. Elevated serum levels of IGF-1 would be confirmatory. x.com
8/9
Acromegaly is caused by hypersecretion of GH and IGF-1, usually from a pituitary adenoma. Manifestations develop slowly. Common features: headache, visual field deficits, acral and soft tissue overgrowth, macroglossia, macrognathia, HTN, DM, OSA, and carpal tunnel syndrome.
Acromegaly is caused by hypersecretion of GH and IGF-1, usually from a pituitary adenoma. Manifestations develop slowly. Common features: headache, visual field deficits, acral and soft tissue overgrowth, macroglossia, macrognathia, HTN, DM, OSA, and carpal tunnel syndrome.
9/9
Viewing old photos (eg, from a driver license) can help in recognizing altered physical features caused by an underlying insidious disorder like acromegaly.
They will tell you physical exam doesn’t matter. They will also diagnose this patient with DM2.
Don’t be like them.
Viewing old photos (eg, from a driver license) can help in recognizing altered physical features caused by an underlying insidious disorder like acromegaly.
They will tell you physical exam doesn’t matter. They will also diagnose this patient with DM2.
Don’t be like them.
Hyperglycemia is one of 8 new chapters in the 2nd edition of Frameworks for Internal Medicine.
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