Eduovisual
CCS Integrated Cases
CCS case: outpatient management of new-onset diabetes
— Type 2 diabetes (T2DM) affects ~11% of US adults; ~1 in 5 are undiagnosed
— USPSTF (2021): screen asymptomatic adults age 35–70 with overweight/obesity (BMI ≥25, or ≥23 in Asian Americans)
— ADA broadens: screen any adult with BMI ≥25 + one risk factor (family hx, HTN, dyslipidemia, PCOS, prior GDM, sedentary, high-risk ethnicity, CVD, HIV on ART)
— Rescreen every 3 years if normal; annually if prediabetes
— Symptomatic: polyuria, polydipsia, polyphagia, weight loss, blurry vision, recurrent candidiasis, slow-healing wounds
— Subclinical: incidental hyperglycemia on routine labs, A1c on preventive visit, gestational glucose tolerance follow-up
— Atypical presentations: acanthosis nigricans in a teen, recurrent UTIs in an older adult, neuropathic foot ulcer as index finding
— T1DM clues: lean body habitus, rapid weight loss, ketosis at presentation, age <30 (but LADA can present in 40s–50s)
— T2DM clues: obesity, metabolic syndrome features, gradual onset, family hx, dyslipidemia
— Key distinction: Any adult presenting with DKA, unintentional weight loss, or A1c >10% in a lean patient → obtain GAD-65, IA-2, ZnT8 antibodies and C-peptide before assuming T2DM. Misclassification leads to inappropriate oral therapy and DKA
— Most new-onset diabetes is diagnosed and managed in the outpatient/ambulatory setting
— Your CCS clock starts at the office visit — labs, education, lifestyle Rx, and pharmacotherapy initiation all happen across weeks, not minutes
— Coordinate with diabetes educator, ophthalmology, podiatry, nutrition, and behavioral health early
Board pearl: A1c reflects ~3-month average glycemia but is unreliable in hemoglobinopathies, recent transfusion, hemolysis, iron deficiency, pregnancy, and CKD/ESRD with EPO use — use fructosamine or fasting glucose/OGTT in those settings.
— Polyuria: osmotic diuresis when serum glucose exceeds renal threshold (~180 mg/dL)
— Polydipsia: secondary to volume depletion
— Polyphagia with paradoxical weight loss: cellular glucose starvation despite hyperglycemia
— Blurred vision: osmotic lens swelling — reversible with glycemic control (counsel: defer new glasses prescription for 6–8 weeks after starting therapy)
— Duration: time from symptom onset informs urgency and likelihood of complications already present
— Weight trajectory: gain (insulin resistance) vs loss (insulin deficiency, possible T1DM/LADA, or malignancy)
— Family history: first-degree relative with T2DM doubles risk; MODY suggested by ≥3 generations affected, dx <25, non-obese, no antibodies
— Obstetric: GDM, macrosomic infant (>9 lb), PCOS
— Medications: glucocorticoids, atypical antipsychotics (olanzapine, clozapine), thiazides at high dose, tacrolimus, protease inhibitors, statins (mild), checkpoint inhibitors (can cause autoimmune T1DM)
— Social: diet pattern, food security, physical activity, sleep (OSA), tobacco, alcohol, occupation (shift work, CDL driver — hypoglycemia implications)
— Neuropathic: burning/numb feet, erectile dysfunction, early satiety (gastroparesis), orthostasis
— Retinopathic: floaters, vision loss
— Cardiovascular: exertional chest pain, claudication, prior MI/stroke
— Renal: foamy urine, edema
— ~20% of T2DM patients have microvascular complications at diagnosis because hyperglycemia precedes diagnosis by years
— Ketonuria + hyperglycemia + acidosis → DKA workup, not outpatient titration
— Glucose >600 mg/dL with altered mentation → HHS
— Severe weight loss in lean adult → rule out T1DM/LADA, pancreatic cancer (especially new diabetes in adult >50 with weight loss — get cross-sectional imaging of pancreas)
Step 3 management: Always ask about CDL/commercial driving and aviation jobs — hypoglycemia from sulfonylureas or insulin has occupational and legal reporting implications.
— BMI, waist circumference (≥40 in men, ≥35 in women = central adiposity)
— BP at every visit, both arms initially; orthostatics if symptomatic (autonomic neuropathy)
— Resting tachycardia → consider autonomic dysfunction or volume depletion from osmotic diuresis
— Fingerstick glucose at the office visit
— Acanthosis nigricans: velvety hyperpigmentation at neck, axillae — marker of insulin resistance
— Skin tags (acrochordons): same association
— Necrobiosis lipoidica diabeticorum: yellow-brown atrophic shin plaques
— Diabetic dermopathy: hyperpigmented shin patches ("shin spots")
— Eruptive xanthomas: suggest severe hypertriglyceridemia from uncontrolled DM
— Candidal intertrigo, balanitis, vulvovaginitis — often the presenting complaint
— Funduscopy: dot/blot hemorrhages, microaneurysms, exudates, neovascularization
— Dental exam: periodontal disease is bidirectionally linked to glycemic control
— Thyroid palpation (autoimmune overlap in T1DM)
— Carotid bruits, diminished pedal pulses, femoral bruits
— Ankle-brachial index if claudication symptoms or pulse abnormality
— Key distinction: Pulse exam alone is insensitive for PAD in diabetes (calcified vessels) — get ABI or toe-brachial index if any suspicion
— 10-g Semmes-Weinstein monofilament at plantar surfaces (1st, 3rd, 5th MTHs and hallux)
— 128-Hz tuning fork at hallux dorsum for vibration
— Ankle reflexes, pinprick, proprioception
— Inspect for ulcers, calluses, fissures, Charcot deformity, ingrown nails, fungal infection
— Footwear inspection
— Tanner staging if pediatric; check for genital candidiasis (especially before starting SGLT2i)
CCS pearl: At the initial outpatient diabetes visit, your CCS order set always includes: vitals with BMI, comprehensive foot exam, dilated fundus exam referral, fingerstick glucose, urine dip for ketones/protein. Skipping the foot exam at diagnosis is a Step 3 deduction.
— Fasting plasma glucose ≥126 mg/dL (≥8 hr fast)
— 2-hr OGTT ≥200 mg/dL (75 g load)
— HbA1c ≥6.5% (NGSP-certified, DCCT-aligned)
— Random glucose ≥200 mg/dL WITH classic symptoms — no confirmation needed
— Prediabetes: FPG 100–125, A1c 5.7–6.4%, 2-hr OGTT 140–199
— HbA1c, fasting lipid panel, CMP (creatinine for eGFR, LFTs, electrolytes), TSH
— Urine albumin-to-creatinine ratio (UACR) — first-morning sample preferred
— Urinalysis (glucose, ketones, protein, infection)
— CBC (anemia affects A1c interpretation)
— Hepatitis B serologies (vaccinate if susceptible — ACIP for diabetics <60)
— EKG if age >40, hypertension, or any cardiac symptoms (baseline before stress testing decisions later)
— GAD-65, IA-2, ZnT8 antibodies + C-peptide with simultaneous glucose: lean adult, age <35 with new "T2DM," DKA presentation, rapid progression to insulin requirement, family hx autoimmune disease
— Fasting C-peptide <0.6 ng/mL with glucose >70 mg/dL suggests insulinopenia (T1DM/LADA)
— MODY genetic panel if young, lean, non-ketotic, antibody-negative, strong autosomal dominant family history
— Cushing screen (24-hr urine free cortisol or 1 mg dexamethasone suppression) if cushingoid features
— Iron studies/ferritin if liver enzymes elevated or family hx — hemochromatosis ("bronze diabetes")
— Lipase, abdominal CT if epigastric pain, weight loss, age >50 — pancreatic adenocarcinoma
— Acromegaly screen (IGF-1) if features present
Board pearl: A discrepancy between A1c and glucose values (e.g., A1c 5.8% but FPG 160) should prompt thought about shortened RBC lifespan (hemolysis, recent blood loss, EPO) lowering A1c falsely. Use fructosamine or repeated FPG/OGTT.
— Single abnormal test → repeat the same test on a different day (preferred) or confirm with a second criterion
— If two different tests are discordant, repeat the abnormal one
— Symptomatic + random glucose ≥200 = diagnosis, no repeat needed
— OGTT is the most sensitive test — use when high suspicion despite normal FPG/A1c, in GDM follow-up, and in cystic fibrosis screening
— Dilated retinal exam by ophthalmology or optometry within 1 month of diagnosis; annually thereafter (q2y acceptable if no retinopathy and well-controlled per ADA)
— UACR + eGFR for diabetic kidney disease staging — confirm albuminuria with 2 of 3 samples over 3–6 months
— Monofilament + vibratory + reflex foot exam
— Lipid panel for ASCVD risk
— 10-year ASCVD risk calculation (Pooled Cohort Equation) for statin decisions
— Routine stress testing in asymptomatic diabetics is not recommended (BARI-2D, DIAD trials)
— Test if: typical/atypical angina, dyspnea on exertion, resting EKG abnormalities, PAD, carotid disease, or planned vigorous exercise program in previously sedentary patient
— Coronary artery calcium (CAC) score can refine risk in borderline cases
— MASLD (metabolic-associated steatotic liver disease) prevalence in T2DM is ~70%
— If ALT elevated or imaging shows steatosis, calculate FIB-4 index — if ≥1.3 (age <65) or ≥2.0 (≥65), refer for elastography or hepatology
— ADA now recommends FIB-4 screening in all T2DM patients
— STOP-BANG questionnaire; polysomnography if positive — untreated OSA worsens insulin resistance and BP
Key distinction: T1DM complication screening starts 5 years after diagnosis (puberty for children); T2DM screening starts at diagnosis because hyperglycemia has likely been present subclinically for years before detection.
— A1c <7.5%: lifestyle + metformin monotherapy
— A1c 7.5–9%: lifestyle + metformin + consider early dual therapy based on comorbidities
— A1c 9–10% without symptoms: dual oral/injectable therapy at start
— A1c >10%, glucose >300 mg/dL, or symptomatic (weight loss, ketosis, polyuria): initiate insulin at diagnosis; can taper later as glucotoxicity resolves
— DKA/HHS or ketonuria → admit, not outpatient
— <7.0% for most non-pregnant adults
— <6.5% if achievable safely (young, short duration, no CVD, low hypoglycemia risk)
— <8.0% if elderly, limited life expectancy, severe hypoglycemia history, advanced micro/macrovascular complications, extensive comorbidities
— Pregnancy: <6.0–6.5% pre-pregnancy/early; flexible later to avoid hypos
— ASCVD or high CV risk → GLP-1 RA (semaglutide, liraglutide, dulaglutide) or SGLT2i with proven CV benefit (empagliflozin, canagliflozin)
— Heart failure (HFrEF or HFpEF) → SGLT2i (empagliflozin, dapagliflozin) regardless of A1c
— CKD (eGFR ≥20 with albuminuria) → SGLT2i preferred; add finerenone if albuminuria persists; GLP-1 RA if SGLT2i not tolerated
— Obesity/weight loss priority → GLP-1 RA (semaglutide, tirzepatide [GIP/GLP-1])
— Cost-limited → metformin + sulfonylurea or basal insulin
— 5–10% weight loss target in overweight/obese — can normalize glucose in early disease
— 150 min/week moderate aerobic + 2–3 resistance sessions
— Mediterranean or DASH-style diet; carbohydrate consistency; reduce sugar-sweetened beverages
— Tobacco cessation, alcohol moderation, sleep hygiene
CCS pearl: On the CCS, order "diabetes self-management education and support" (DSMES) and "medical nutrition therapy" referral at the diagnosis visit — Medicare covers both. Forgetting these is a high-yield omission.
— Start 500 mg PO daily or BID with meals; titrate by 500 mg weekly to 1000 mg BID (max 2550 mg/day)
— Mechanism: ↓ hepatic gluconeogenesis, ↑ peripheral insulin sensitivity
— A1c reduction: ~1.0–1.5%
— Weight neutral or modest loss; no hypoglycemia as monotherapy
— Hold for eGFR <30; do not initiate if eGFR <45; continue cautiously 30–45
— Hold 48 hr before iodinated contrast if eGFR <60, AKI, or contrast volume large
— GI side effects: 20–30% — mitigate with slow titration, ER formulation, take with food
— B12 deficiency: check level annually after 4–5 years of use
— Rare lactic acidosis: contraindicated in decompensated HF, severe hepatic disease, EtOH abuse
— Dosing: empagliflozin 10 mg → 25 mg daily; dapagliflozin 5 → 10 mg daily
— A1c reduction: ~0.5–1.0%; weight loss 2–4 kg; BP reduction 3–5 mmHg
— CV mortality benefit (EMPA-REG, CANVAS), HF hospitalization reduction (across EF), renal protection (DAPA-CKD, EMPA-KIDNEY)
— Side effects: genitourinary mycotic infections, volume depletion, euglycemic DKA (especially periop, illness, low-carb), Fournier gangrene (rare), canagliflozin amputation signal
— Hold 3 days before surgery (ertugliflozin/empagliflozin/dapagliflozin); 4 days for ertugliflozin
— Semaglutide SC 0.25 → 0.5 → 1.0 → 2.0 mg weekly; oral semaglutide 3 → 7 → 14 mg daily
— Tirzepatide (dual GIP/GLP-1): 2.5 → 5 → up to 15 mg weekly
— A1c reduction: 1.0–2.0%; weight loss 5–15%
— CV benefit: liraglutide, semaglutide, dulaglutide
— Side effects: nausea, vomiting, delayed gastric emptying, pancreatitis (rare), gallstones; contraindicated in personal/family hx MTC or MEN2
Board pearl: A patient on SGLT2i presenting with abdominal pain, nausea, malaise and glucose only 180 mg/dL — check anion gap and ketones. Euglycemic DKA is a classic Step 3 trap.
— Choose based on compelling indications (see chunk 6), cost, and patient preference
— No mandatory waiting period if A1c far from target — combine at start
— Cheap, oral, A1c drop 1–1.5%; risk: hypoglycemia and weight gain
— Prefer glipizide in CKD/elderly (shorter half-life, no active renal metabolites)
— Avoid glyburide in elderly (Beers list) — prolonged hypoglycemia
— Weight neutral, no hypoglycemia, A1c drop 0.5–0.8%
— Linagliptin no renal dose adjustment
— Caution: saxagliptin/alogliptin — HF hospitalization signal
— Do not combine with GLP-1 RA (redundant mechanism)
— Improves insulin sensitivity, useful in MASLD
— Side effects: weight gain, fluid retention, HF exacerbation (contraindicated NYHA III/IV), fractures, bladder cancer signal
— Basal insulin (glargine, detemir, degludec): start 10 units or 0.1–0.2 U/kg at bedtime
— Titrate by 2 units every 3 days until fasting glucose 80–130 mg/dL
— If A1c remains elevated despite basal at goal → add prandial insulin to largest meal first (basal-plus), or transition to basal-bolus or premixed
— Alternative: add GLP-1 RA to basal (less weight gain, less hypoglycemia than full basal-bolus)
— Total daily dose (TDD) ≈ 0.5 U/kg/day at presentation (less in honeymoon)
— Split: 50% basal, 50% bolus divided across meals
— Carb counting; insulin-to-carb ratio (~1 U per 10–15 g); correction factor (~1800/TDD rule)
— Consider pump + CGM referral early; hybrid closed-loop systems standard of care
— BMI ≥35 with T2DM, or BMI ≥30 with poorly controlled DM despite optimal therapy
— Sleeve gastrectomy and RYGB → 60–80% remission rates
Step 3 management: When starting insulin outpatient, always co-prescribe glucagon (nasal or auto-injector) and provide written hypoglycemia action plan. Document driving safety counseling in the chart.
— Relax A1c targets: 7.0–7.5% if healthy; 7.5–8.0% with multiple comorbidities; <8.5% in poor health, dementia, end-stage disease
— Prioritize hypoglycemia avoidance over tight control — falls, fractures, cardiovascular events
— Avoid glyburide, chlorpropamide (Beers)
— Preferred agents: metformin (if eGFR allows), DPP-4i, GLP-1 RA, SGLT2i with monitoring
— Insulin: simplify regimens — avoid sliding scale alone; use long-acting basal once daily
— Deintensify if A1c <6.5% on hypoglycemia-prone agents
— Screen for cognition (Mini-Cog), depression (PHQ-9), polypharmacy, frailty, falls annually
— Metformin: full dose eGFR ≥45; half dose 30–44; stop <30
— SGLT2i: initiate down to eGFR ≥20 (dapagliflozin/empagliflozin) for kidney/CV protection; continue until dialysis
— GLP-1 RA: no renal adjustment for liraglutide, semaglutide, dulaglutide; exenatide avoid if eGFR <30
— Sulfonylureas: glipizide preferred; reduce dose
— Insulin: requirements often decrease as eGFR falls (reduced renal insulin clearance) — anticipate dose reductions
— DPP-4: dose-adjust sita/saxa/aloglipitin; linagliptin no adjustment
— Metformin contraindicated in decompensated cirrhosis (lactic acidosis risk)
— Pioglitazone avoided in active liver disease
— GLP-1 RA generally safe; useful in MASLD
— Insulin always safe but watch for hypoglycemia in advanced cirrhosis (impaired gluconeogenesis)
— SGLT2i preferred across EF
— Avoid pioglitazone and saxagliptin
— Metformin safe in stable HF
Key distinction: As CKD progresses, insulin clearance decreases — patients often need less insulin, not more. Failing to anticipate this causes hypoglycemia. Conversely, metformin requirements don't change with renal function — but accumulation does, hence dose reduction.
— Preconception A1c target <6.5% to minimize congenital malformation risk (proportional to A1c)
— Switch to insulin before conception or at confirmation — discontinue oral agents except metformin per shared decision
— First-trimester: dilated eye exam, baseline UACR, TSH, A1c
— Folic acid 5 mg daily (higher than usual 400 mcg) preconception through first trimester
— Stop ACEi/ARB, statins before conception
— BP target <135/85; methyldopa, labetalol, nifedipine safe
— Screen 24–28 weeks with 50-g 1-hr glucose challenge; if ≥130–140 → 100-g 3-hr OGTT
— Early screen at first prenatal visit if BMI ≥25 + risk factors
— First-line: lifestyle + glucose monitoring (fasting <95, 1-hr postprandial <140, 2-hr <120)
— Pharmacotherapy: insulin is preferred; metformin and glyburide are alternatives but cross placenta
— Postpartum: 75-g OGTT at 4–12 weeks; if normal, screen every 1–3 years (50% lifetime T2DM risk)
— Screen overweight youth ≥10 yr with risk factors q3y
— First-line: metformin + lifestyle; liraglutide approved ≥10 yr; insulin if A1c >8.5% or symptomatic
— TODAY trial: rapid β-cell decline — early aggressive therapy
— Insulin always; pump and CGM standard
— Screen for celiac, autoimmune thyroid at diagnosis and periodically
— Complication screening starts at puberty or 5 years post-diagnosis
— OGTT annually from age 10 — A1c is insensitive
— Insulin only — no oral agents; do not restrict calories
— Prednisone causes postprandial spikes — NPH insulin in morning matched to steroid dose is classic
— Anticipate need; check post-lunch glucose
Board pearl: A pregnant patient on a GLP-1 RA or SGLT2i must stop immediately upon pregnancy confirmation and transition to insulin. These agents are contraindicated in pregnancy.
— Retinopathy: nonproliferative (microaneurysms, hemorrhages, exudates) → proliferative (neovascularization, vitreous hemorrhage, retinal detachment); macular edema can occur at any stage. Treat with anti-VEGF (ranibizumab, aflibercept), panretinal photocoagulation
— Nephropathy: stages by UACR (<30, 30–300, >300 mg/g) and eGFR. Progression: hyperfiltration → microalbuminuria → macroalbuminuria → ESRD
— Neuropathy: distal symmetric polyneuropathy (most common), autonomic (gastroparesis, postural hypotension, ED, bladder dysfunction), mononeuropathy (CN III sparing pupil, median nerve), diabetic amyotrophy
— Coronary artery disease: leading cause of mortality in T2DM; presentation often atypical or silent
— Stroke: 2–4× increased risk
— Peripheral arterial disease: claudication, rest pain, ulcers, amputation
— Diabetes is now a CAD risk equivalent in many risk calculators
— DKA: insulinopenia → ketogenesis; pH <7.3, bicarb <18, anion gap, ketones positive
— HHS: glucose >600, osm >320, minimal ketosis, profound dehydration, altered mentation
— Severe hypoglycemia: <54 mg/dL or requiring assistance; iatrogenic from sulfonylureas/insulin
— Diabetic foot ulcer: combined neuropathy + PAD + minor trauma + infection; offloading + debridement + antibiotics + revascularization
— Charcot neuroarthropathy: warm, swollen, deformed foot in neuropathic patient — total contact casting, immediate offloading
— Infections: increased risk of UTIs, cellulitis, mucormycosis, malignant otitis externa, emphysematous cholecystitis/pyelonephritis
— MASLD/MASH → cirrhosis, HCC
— Cognitive decline, depression (PHQ-9 screen annually)
— Erectile dysfunction: often the earliest CV warning sign in men
CCS pearl: A diabetic patient with fever + facial pain + black nasal eschar + altered mentation = rhinocerebral mucormycosis — order emergent ENT consult, MRI, liposomal amphotericin B, and surgical debridement. Do not wait for cultures.
— DKA suspected: glucose >250 + anion gap acidosis + ketonuria/ketonemia
— HHS suspected: glucose >600 + altered mentation + dehydration
— Severe hyperglycemia >400 with vomiting, inability to tolerate PO
— Severe symptomatic hypoglycemia in elderly or recurrent episodes despite regimen adjustment
— Diabetic foot infection with systemic signs (fever, leukocytosis, lymphangitis), suspected osteomyelitis, gas on imaging, or ischemic limb
— New vision loss, retinal detachment symptoms — emergent ophthalmology
— Acute kidney injury with hyperkalemia or volume overload
— Ophthalmology: dilated exam within 1 month of diagnosis
— Diabetes educator (CDCES) / DSMES program: within 2 weeks
— Registered dietitian / MNT: at diagnosis
— Podiatry: at diagnosis if neuropathy, deformity, prior ulcer, PAD; otherwise annually
— Endocrinology: if T1DM/LADA suspected, A1c >9% despite dual therapy, recurrent hypoglycemia, pump candidacy, pregnancy planning, suspected MODY
— Nephrology: eGFR <30, rapidly declining eGFR, UACR >300 despite optimized therapy, unclear etiology
— Cardiology: known CAD, abnormal stress test, NYHA II+ HF
— Behavioral health: PHQ-9 ≥10, diabetes distress, eating disorder ("diabulimia" in T1DM)
— Office visit (15 min): history, exam, fingerstick, urine dip
— Orders: A1c, CMP, lipids, UACR, TSH, EKG (if indicated), Hep B serology
— Counseling: lifestyle, hypoglycemia recognition, sick-day rules
— Prescriptions: metformin start; glucometer + strips + lancets; statin if indicated; ACEi/ARB if albuminuria or HTN
— Referrals: ophtho, DSMES, MNT, podiatry as indicated
— Vaccines: influenza, pneumococcal, Hep B, COVID, RSV (≥60), shingles (≥50)
— Follow-up scheduled: 2–4 weeks
Step 3 management: Do not initiate or titrate sulfonylureas or insulin without confirming the patient has a glucometer and demonstrated ability to use it. Document this in the chart.
— Autoimmune β-cell destruction; positive GAD-65/IA-2/ZnT8 antibodies; low C-peptide
— Lean, younger (but can occur at any age), ketosis-prone
— Requires insulin from diagnosis
— Often misdiagnosed as T2DM initially; antibody-positive adult, age 30–50
— Progresses to insulin dependence over months to years
— Avoid sulfonylureas (accelerate β-cell failure); start insulin or GLP-1 RA
— Autosomal dominant, age <25, non-obese, antibody-negative, preserved C-peptide
— MODY 2 (GCK): mild fasting hyperglycemia, no complications, no treatment usually
— MODY 3 (HNF1A): responsive to low-dose sulfonylurea (classic Step 3 vignette)
— Genetic testing confirms
— Cushing syndrome: central obesity, striae, easy bruising, proximal weakness — 1 mg dex suppression
— Acromegaly: enlarged hands/feet, frontal bossing, OSA — IGF-1
— Pheochromocytoma: episodic HTN, headache, palpitations — plasma metanephrines
— Hyperthyroidism: increased gluconeogenesis — TSH
— Glucagonoma: necrolytic migratory erythema + DM + weight loss
— Causes: chronic pancreatitis, pancreatic cancer, hemochromatosis, cystic fibrosis, post-pancreatectomy
— Mixed insulin/glucagon deficiency → labile glycemia
— New diabetes + weight loss in adult >50 = rule out pancreatic adenocarcinoma with CT abdomen
— Hemochromatosis: bronze skin, arthropathy, cirrhosis → ferritin, transferrin saturation, HFE gene
— Glucocorticoids, atypical antipsychotics (olanzapine, clozapine), thiazides (high dose), tacrolimus/cyclosporine, protease inhibitors, β-blockers (mask hypoglycemia + mild ↑ glucose), statins (mild), checkpoint inhibitors (autoimmune insulin-deficient DM — irreversible)
Key distinction: A patient on immune checkpoint inhibitor therapy (pembrolizumab, nivolumab) presenting with new hyperglycemia and DKA has immune-mediated T1DM — antibody status variable, but C-peptide is low and insulin is mandatory permanently. This is increasingly tested.
— Diabetes insipidus (central or nephrogenic): dilute urine (low osm), normal/high serum sodium, normal glucose — water deprivation test, desmopressin challenge
— Primary polydipsia: psychogenic water drinking, dilute urine, low-normal sodium
— Hypercalcemia: nephrogenic DI, fatigue, constipation
— UTI: dysuria, frequency, urgency — urinalysis distinguishes
— BPH/overactive bladder: nocturia without thirst
— Hyperthyroidism (TSH suppressed, increased appetite)
— Malignancy (especially pancreatic, GI, lung)
— Adrenal insufficiency (hyperpigmentation, hyponatremia, hyperkalemia, hypotension)
— Malabsorption (celiac, IBD, chronic pancreatitis)
— Depression, eating disorder
— Tuberculosis, HIV
— Acute illness, MI, sepsis, surgery, glucocorticoid burst
— Transient — recheck A1c after recovery
— Stress hyperglycemia in non-diabetic predicts future T2DM — schedule outpatient repeat A1c at 6–12 weeks
— Falsely high: iron deficiency, B12 deficiency, splenectomy, uremia, hypertriglyceridemia (assay-dependent)
— Falsely low: hemolytic anemia, recent blood transfusion, blood loss, EPO therapy, pregnancy, end-stage liver disease, hemoglobinopathies (HbS, HbC, HbE)
— HbF elevation: variable effect — confirm with fasting glucose or fructosamine
— Corrected Na = measured Na + 1.6 × (glucose − 100)/100
— Don't over-correct based on uncorrected value
Board pearl: Polyuria + polydipsia + normal glucose = think diabetes insipidus. Polyuria + polydipsia + elevated glucose = diabetes mellitus. The Step 3 trap is the patient with both glucose 110 and severe polyuria — measure urine osmolality and serum sodium to separate.
— Statin therapy:
— Age 40–75 with diabetes: moderate-intensity statin (atorvastatin 20, rosuvastatin 10)
— Diabetes + ASCVD or 10-yr risk ≥20%: high-intensity (atorvastatin 40–80, rosuvastatin 20–40)
— Diabetes age <40 with risk factors: consider statin
— LDL target: <70 mg/dL in established ASCVD; <55 mg/dL if very high risk
— Add ezetimibe then PCSK9 inhibitor if not at goal
— ACE inhibitor or ARB: indicated for HTN, albuminuria, or established CVD; not routine if normotensive and normoalbuminuric
— BP target: <130/80 mmHg (ACC/AHA, ADA)
— Aspirin: secondary prevention always (post-MI, post-stroke); primary prevention only if 10-yr ASCVD risk ≥10% and low bleeding risk — shared decision
— ACEi/ARB if UACR ≥30 mg/g — titrate to max tolerated dose
— SGLT2i if eGFR ≥20 with albuminuria — slows CKD progression
— Finerenone (nonsteroidal MRA): add if albuminuria persists on ACEi/ARB + SGLT2i and K+ acceptable
— GLP-1 RA reduces albuminuria as bonus benefit
— Reassess A1c every 3 months until at goal, then every 6 months
— Intensify therapy if A1c above target at 3-month interval
— De-intensify if hypoglycemia or A1c <6.5% on hypoglycemia-prone agents in elderly
— Influenza: annual
— Pneumococcal: PCV15 + PPSV23 or PCV20 for all adults with diabetes
— Hepatitis B: all adults 19–59 with DM; ≥60 case-by-case
— COVID-19 per CDC schedule
— Tdap once, then Td/Tdap q10y
— RSV: ≥60 with risk factors
— Zoster (Shingrix): ≥50
Step 3 management: At every visit, document the ABCs of diabetes care: A1c, BP, Cholesterol (statin), Smoking cessation, Self-management/lifestyle. Forgetting statins in a 55-year-old diabetic is a high-yield error.
— 2 weeks after diagnosis: review home glucose log, tolerance of metformin, education adherence, glucometer technique, hypoglycemia symptoms review, depression screen
— 6 weeks: titrate metformin to target dose; reassess symptoms and weight
— 3 months: repeat A1c, lipid panel, UACR; intensify therapy if A1c above target
— 6 months: routine visit, A1c, foot exam (visual inspection at every visit)
— Annually: comprehensive foot exam, dilated retinal exam (if normal prior and well-controlled, q2y acceptable), UACR, eGFR, lipids, TSH if indicated, dental visit, depression screen (PHQ-9), cognitive screen if elderly, FIB-4 for MASLD
— CGM preferred over fingersticks for: all T1DM, T2DM on insulin (especially multiple daily injections), recurrent hypoglycemia, A1c discordance
— Targets: time in range (70–180 mg/dL) >70%, time below range (<70) <4%, time below 54 <1%
— Fingerstick frequency for non-insulin T2DM: limited evidence; consider paired pre/post-meal testing for behavioral feedback
— Ketone testing strips for T1DM during illness or glucose >250
— Never stop insulin in T1DM during illness — adjust dose
— Hold metformin, SGLT2i, ACEi/ARB, NSAIDs, diuretics during acute illness/dehydration ("SADMANS" rule)
— Check glucose q3–4h, ketones if T1DM or glucose >250
— Stay hydrated; clear liquids if not eating
— Call clinician for persistent vomiting, glucose >300 despite correction, ketonuria
— Weight loss programs: intensive behavioral therapy, GLP-1 RA, bariatric surgery — match to severity
— Exercise prescription: written, individualized, with pre-participation screening for high-risk patients
— Smoking cessation: nicotine replacement, varenicline, bupropion — every visit
— Diabetes distress, depression, eating disorders: screen and refer
— Driving safety: check glucose before driving if on insulin/sulfonylurea; carry rapid carbs
CCS pearl: The post-diagnosis visit at 2 weeks is the single highest-yield handoff — patients who don't return at 2 weeks have 2× higher rates of non-adherence and ED visits. Schedule before they leave the office.
— Initiating insulin or sulfonylureas requires explicit hypoglycemia counseling — document discussion of symptoms, treatment with rapid carbs, glucagon use, and driving precautions
— Off-label GLP-1 RA prescribing for weight loss in non-diabetic patients raises insurance and supply-chain concerns; document indication clearly
— CDL holders with insulin-treated DM must meet FMCSA exemption requirements: stable control, no severe hypoglycemia in past 12 months, ophtho clearance, endo certification annually
— Pilots (FAA), commercial fishermen, and law enforcement may have restrictions
— You are not generally mandated to report, but you must counsel and document; some states have impaired-driver reporting laws — know yours
— Use teach-back for medication and glucometer instructions
— Address food insecurity (screen with Hunger Vital Sign); refer to SNAP, food pantries — uncontrolled DM in food-insecure patients often improves with social intervention alone
— Cost of medications: insulin, GLP-1 RA, SGLT2i can exceed $500/month — use patient assistance programs, Medicare Part D LIS, biosimilars, and the $35/month insulin cap under Medicare
— Language-concordant DSMES improves outcomes
— Hospital discharge after DKA/HHS or new diagnosis: confirm outpatient appointment within 1–2 weeks, ensure prescriptions filled before discharge, glucometer in hand, written sick-day plan
— Medication reconciliation: hold/restart SGLT2i, metformin appropriately around procedures and acute illness
— Pediatric to adult transition: structured transfer at 18–21; failure to coordinate leads to lapses and DKA admissions
— Diabetes management in teens may involve sensitive issues (eating disorders/insulin omission, contraception, substance use); know state laws on minor consent
— In advanced dementia or hospice, deprescribe insulin and tight glycemic control; target A1c <8.5%, focus on comfort, avoid hypoglycemia
— Sliding scale insulin alone is rarely appropriate
Board pearl: A patient with recurrent DKA admissions and erratic adherence in a young woman with T1DM should prompt screening for insulin omission for weight loss ("diabulimia") — refer to multidisciplinary eating disorders program. This is a tested ethical/safety scenario.
— FPG ≥126, 2-hr OGTT ≥200, A1c ≥6.5%, random ≥200 + symptoms
— Prediabetes: FPG 100–125, A1c 5.7–6.4%, OGTT 140–199
— GDM 3-hr OGTT: ≥2 abnormal of fasting 95 / 1-hr 180 / 2-hr 155 / 3-hr 140
— ASCVD → GLP-1 RA or SGLT2i (CV-proven)
— HFrEF/HFpEF → SGLT2i (empagliflozin, dapagliflozin)
— CKD → SGLT2i; finerenone for persistent albuminuria
— Obesity → tirzepatide > semaglutide > liraglutide
— MASLD → pioglitazone, GLP-1 RA
— Cost → metformin + sulfonylurea + NPH/regular insulin
— Pioglitazone: HF NYHA III/IV, bladder cancer, osteoporosis high-risk
— GLP-1 RA: personal/family MTC, MEN2, gastroparesis
— SGLT2i: recurrent UTIs/genital infections, T1DM (off-label use), euglycemic DKA history
— Metformin: eGFR <30, decompensated HF, severe hepatic disease, contrast within 48 hr if high-risk
— Lean adult with "T2DM" rapidly failing oral therapy → check antibodies (LADA)
— Adolescent, lean, family hx 3 generations DM → MODY (HNF1A, treat with sulfonylurea)
— New DM + weight loss in age >50 → pancreatic cancer workup
— Diabetic on SGLT2i with abdominal pain, glucose 180 → euglycemic DKA
— DM patient on β-blocker with sudden sweating, no tremor → masked hypoglycemia
— Bronze skin + DM + cirrhosis → hemochromatosis
— Metformin causes B12 deficiency — check after 4–5 years
— Glyburide is the worst sulfonylurea in elderly
— Linagliptin needs no renal adjustment
— Liraglutide reduces CV events; lixisenatide does not
— Empagliflozin and dapagliflozin used down to eGFR 20 for renal protection
— A1c <7% (most adults), <6.5% if safe, <8% if frail
— BP <130/80
— LDL <70 if ASCVD; <55 if very high risk
— UACR <30 mg/g
Key distinction: A patient with glucose 90 mg/dL but A1c 7.2% likely has post-prandial hyperglycemia missed by FPG — order OGTT or check 2-hr post-meal glucose; consider GLP-1 RA or rapid-acting prandial agent.
— 52 y/o obese woman, BMI 33, BP 138/86, incidental A1c 7.4% on annual labs, no symptoms
— Best initial step: lifestyle counseling + metformin 500 mg BID; statin (moderate intensity); ACEi if BP/albuminuria; schedule 3-month follow-up
— Trap: choosing insulin (not indicated); skipping statin
— 38 y/o thin man, A1c 9.8%, failed metformin + glipizide in 6 months, modest weight loss
— Next test: GAD-65 antibody and C-peptide
— Treatment: insulin; consider endocrinology
— 64 y/o man, new DM at A1c 8.2%, 15-lb weight loss, vague epigastric pain, painless jaundice
— Order: CT abdomen with pancreatic protocol, CA 19-9
— 60 y/o post-op patient on empagliflozin, nausea/abdominal pain, glucose 178, pH 7.21, anion gap 22
— Diagnosis: euglycemic DKA; stop SGLT2i, IV fluids, insulin drip, dextrose-containing fluids
— 78 y/o on glyburide with confusion, glucose 42
— Action: D50 IV, hospital observation (long-acting sulfonylurea — recurrent hypoglycemia for 24+ hr); discontinue glyburide, switch to glipizide or non-hypoglycemic agent
— 28 y/o at 27 weeks, 1-hr 50-g glucose 165 → 3-hr 100-g abnormal at fasting and 1 hr
— Treatment: nutrition + monitoring; insulin if targets not met
— Postpartum: 75-g OGTT at 4–12 weeks
— Patient on prednisone 40 mg for PMR, fasting glucose 110, post-lunch 320
— Add NPH insulin in morning matched to steroid; titrate
— 22 y/o lean college student, mild FPG 130, A1c 6.8%, mother and grandmother had DM dx in their 20s
— Genetic testing; HNF1A-MODY → low-dose sulfonylurea
— Probe-to-bone positive, ESR 90, MRI shows marrow edema
— Treatment: surgical debridement + 6 weeks IV/oral targeted antibiotics; revascularization if PAD
Board pearl: When a stem mentions "failed oral agents in <1 year in a non-obese adult," the answer is almost always check autoimmune antibodies (LADA) — not "add another oral agent."
New-onset diabetes is an outpatient, longitudinal diagnosis: confirm with FPG ≥126, A1c ≥6.5%, OGTT ≥200, or random ≥200 + symptoms; classify (T1/T2/LADA/MODY/secondary); start lifestyle + metformin in most T2DM, with SGLT2i or GLP-1 RA layered in for ASCVD, HF, CKD, or obesity; and immediately wire in statin, BP control, ACEi/ARB if indicated, complication screening, vaccines, DSMES, and structured follow-up at 2 weeks and 3 months.
— Compelling-indication prescribing is the new paradigm: ASCVD/HF/CKD → SGLT2i ± GLP-1 RA regardless of A1c; obesity → GLP-1 RA/tirzepatide; cost-limited → metformin + sulfonylurea/insulin
— Always classify before treating: lean, ketotic, rapid failure, or antibody-positive = T1DM/LADA → insulin from the start; misclassification is a tested error
— Day-0 bundle at diagnosis: A1c, lipids, CMP, UACR, EKG (if indicated), dilated eye exam referral, foot exam, DSMES + MNT referral, statin (age 40–75), ACEi/ARB if albuminuria/HTN, vaccines (flu, pneumo, Hep B), glucometer, hypoglycemia + sick-day teaching
— Follow-up cadence: 2 weeks for adherence/tolerance, 3 months for A1c + intensification, annual comprehensive complication screen; deintensify in frail elderly to avoid hypoglycemia
Step 3 management: Treat new-onset diabetes as a whole-patient cardiometabolic syndrome, not a glucose number — points are scored on the bundle (glycemia + BP + lipids + albuminuria + lifestyle + vaccines + screening + education + follow-up), and the highest-yield omission errors on the exam are forgetting the statin, ACEi/ARB, foot/eye exam, or 2-week return visit.