A 65 year patient presents at an outpatient clinic for evaluation. She is a diabetic since 20 years and is currently on Insulin (isophane insulin 6 U at night & regular insulin 24-30-22 U before food). She was previously on oral hypoglycemic agents but has been on insulin since 6 years.
What are the possible reasons why OHAs would have been discontinued?
The high dose of insulin suggests that this patient probably
had uncontrolled sugars. If a patient’s sugars are not controlled with
lifestyle modification and metformin, initiation of insulin is an option in Type 2 Diabetes particularly if Glyco Hb > 8.5%.
In addition if a patient has developed contraindications to
OHAs like renal or liver dysfunction this would again be reasons for starting
the patient on Insulin.
In situations of poorly controlled diabetes, while the
optimal strategy is uncertain, a basal bolus regimen seems the best possible
option.
She complains of imbalance while walking. What are the additional signs that you want to look for?
Examination findings to focus on in view of imbalance (cause
maybe predominantly sensory, cerebellar or vestibular)
Motor system: Power tone and reflexes to look for evidence
of stroke or extrapyramidal dysfunction
Sensory system: predominantly posterior column sensations,
rhomberg’s sign
Cerebellar signs
Visual abnormalities
Vestibular dysfunction: Nystagmus, Vestibuloocular reflex
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