Download Core Clinical Cases in Medicine and Medical Specialties by Steve Bain, Jeffrey W Stephens, Janesh K. Gupta PDF

By Steve Bain, Jeffrey W Stephens, Janesh K. Gupta

''You've learn your textbook and your direction notes. Now you want to observe your wisdom to actual lifestyles medical events. The problem-solving method of middle medical situations courses you to think about the sufferer as an entire, instead of as a series of unconnected indicators. With its emphasis on daily perform strongly associated with underlying conception, the sequence integrates your wisdom with the realities of managing Read more...

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Extra info for Core Clinical Cases in Medicine and Medical Specialties Second Edition: A problem-solving approach

Sample text

Insulin thus becomes a leading option, especially given the patient’s young age and the development of diabetic retinopathy. Clearly the patient is not keen to go on insulin and the reasons for this need to be explored, because many patients are pleasantly surprised at how painless insulin injections are (compared with HBGM) and feel much better when their glycaemic control improves. A dietary assessment is reasonable because weight gain is highly likely with insulin; for this reason, metformin should be continued (while the sulphonylurea may be withheld).

If a GLP-1 receptor agonist is preferred by the patient (many people hate the idea of insulin, not because of the injections but due to a bad family experience or to fears of hypoglycaemia), then the current options are exenatide or liraglutide. Exenatide can be prescribed as a twice-daily or once-weekly preparation, and liraglutide is given once a day. Both can cause nausea and vomiting. UK guidelines suggest their impact on glycaemic control and weight should be assessed after 6 months, with treatment failure (HbA1c reduction of less than 1% and weight loss of less than 3%) leading to drug withdrawal.

Insulin resistance, the other contributing metabolic abnormality, appears to deteriorate before the diagnosis of type 2 diabetes but then remains relatively fixed. As a result of b-cell failure, dietary change is likely to have a limited and temporary impact, leading to the introduction of oral hypoglycaemic agents and GLP-1 receptor agonists. Ultimately these agents will fail and the patient may need insulin to achieve reasonable glycaemic control. One can argue that if an individual with type 2 diabetes lives for long enough, then insulin is inevitable.

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