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GEM - difficult diabetes educational module - part two - clinical case

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

  • 39 yr old woman with a BMI of 32.3 with recurrent thrush has gylosuria ++ and ketones+. She has no symptoms of polyuria or polydipsia. A random BM is 12.
    • this lady has a typical phenotype of a type II diabetic but has ketones in her urine. On closer questioning, this lady has not missed any meals recently. She has no osmotic symptoms. Should she be sent for emergency medical review or managed as a type II diabetic in the community?
    • after review this lady was monitored on the medical admissions unit and then sent home on oral hypoglycaemic medication. What level of fasting glucose at the time of diagnosis would prompt a clinician to starting oral hypoglycaemic medication at the time of diagnosis of type II diabetes?
    • as a newly diagnosed type II diabetic, what is the relevance of the DESMOND programme
    • this lady has further blood tests done at the practice. They reveal cholesterol 6.5, TG 4.1 and a raised ALT at 76 with the rest of her liver function tests normal.
      • what is the significance of a raised ALT in diabetes? what is the association with hepatitis?
      • it is likely that this lady has non-alcoholic fatty liver disease, what current management options are available?
      • an abdominal ultrasound confirmed the presence of a fatty liver. A hepatitis screen was negative. Does this lady's raised ALT have significance in terms of choice of future oral hypoglycaemic medication?
      • a few years later she is taking metformin, glicazide, ramipril and simvastatin, she comes to have her IUCD removed as she want to try for a pregnancy?
        • what preconceptual advice and management should be offered?
        • what are the concerns about the use of an ACEI in pregnancy?
        • why is good glycaemic control during pregnancy important?
        • what about the use of statins in pregnancy?


  1. Royal College of General Practitioners. Curriculum Statement 15.6 Metabolic Problems.

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