Needless to say this man has new onset Diabetes Mellitus. The next question would involve initiating the appropriate therapy given his current presentation. You would begin by educating him about Diabetes Mellitus, emphasizing the acute and long term microvascular and macrovascular complications (3,4). Emphasizing how many of these complications can at least be slowed down in onset with careful adherence to treating his life-long diabetic condition. You would also set up a dietary consultation with a certified Diabetic nutritionist.
Though he probably looks "chronically" ill he does not have ketones in the urine dipstick test to suggest that he is in D.K.A.. He has Diabetes based on his FSG of 250. His last meal being 8 hours ago, he should of already been euglycemic. Doing a formal glucose-tolerance test would be waste of time and resources. Getting a Hemoglobin A1C would be good to have as a baseline value.
As an aside, there is some data to suggest that the HgbA1C may be a better screening tool for picking up Diabetes than the formal oral glucose tolerance test (1,2). However, there needs to a standardized method of measuring the HgbA1C before this becomes approved by the Endocrinologist worldwide.
Recently, the American Diabetes Association put out a "Standard of Medical Care" Guideline for health-care professionals (3). These are just a few of the key points:
As to the initiation of therapy, one has different options but acutely this man is insulin deficient. He has lost 30 pounds and would stand to benefit acutely with insulin to get him euglycemic quickly. Once he is feeling better and has acheived symptom control you could consider switching him to an oral agent.
Be sure to do a retinal examination on this man as well. You will be getting an ophthamology consult but your screening examination will help you decide on the urgency of the consult.
The normal retina looks like this:
What you want to be able to distinquish is between baseline nonproliferative changes associated with Diabetes:
from proliferative changes that might require a STAT ophthamologic intervention if the changes could affect important vision (i.e. the macula or optic disk).
