View source for WBR0195

 {{WBRQuestion
|QuestionAuthor=Vendhan Ramanujam
|ExamType=USMLE Step 3
|MainCategory=Primary Care Office
|SubCategory=Endocrine
|MainCategory=Primary Care Office
|SubCategory=Endocrine
|MainCategory=Primary Care Office
|SubCategory=Endocrine
|MainCategory=Primary Care Office
|MainCategory=Primary Care Office
|SubCategory=Endocrine
|MainCategory=Primary Care Office
|SubCategory=Endocrine
|MainCategory=Primary Care Office
|SubCategory=Endocrine
|MainCategory=Primary Care Office
|SubCategory=Endocrine
|MainCategory=Primary Care Office
|MainCategory=Primary Care Office
|SubCategory=Endocrine
|Prompt=A 18 year old boy is brought to the physicians office by his mother, with complains of sweats and headaches during the nights.  Initially he was started on NPH insulin, 30 U each morning and 15 U every night.  But following a persistent morning glycosuria that did not improve, the evening dose was increased to 20 U during his last visit.  His recent lab tests reveal worsening of his morning glycosuria with moderate ketones in his urine.  The next step in management of this patient will be 


|Explanation=Night sweats and headache is due to episodes of [[hypoglycemia]].  The worsening [[glycosuria]] and moderate [[ketones]] in urine is due to rebound hyperglycemia that follows the night episodes of hypoglycemia.  In [[insulin dependent diabetes mellitus]] patients, this response is called as [[Somogyi phenomenon]].  It develops in response to excessive [[insulin]] administration either during evening or night.  An adenergic response to hypoglycemia results in increased [[glycogenolysis]], [[gluconeogenesis]] and diminished glucose uptake by peripheral tissues.  The first step while managing this condition will be documentation of the hypoglycemia episode during night by obtaining blood samples between 2 am and 5 am when the episodes occur.  This will differentiate Somogyi from [[Glossary of terms associated with diabetes#D|Dawn phenomenon]] which also manifests with early morning [[hyperglycemia]].  Following the confirmation, the evening or night insulin dose can be reduced.  Substitution of evening or night [[Insulin#Types|short acting]] or [[Insulin#Types|intermediately acting]] insulin with [[Insulin#Types|rapidly acting]] insulin like [[Insulin lispro|lispro]] may be of some help.

'''Educational objective:'''
Episodic hypoglycemia at night followed by rebound hyperglycemia is called as Somogyi phenomenon, which occurs in insulin dependent diabetes mellitus patients who are on insulin.  The first step in managing this condition will be documentation of hypoglycemia during night.  Following the confirmation, the evening or night insulin dose can be reduced.  Substitution of evening or night short acting or intermediate acting insulin with rapidly acting insulin like lispro may be of some help.


|AnswerA=Increasing the evening dose of insulin
|AnswerAExp='''Incorrect'''-Increasing the evening dose of insulin will only worsen this condition.  
|AnswerB=Switching from NPH to lispro
|AnswerBExp='''Incorrect'''-Switching from [[NPH insulin|NPH]] to lispro is not required now.  It will be the next step only after documenting the hypoglycemia during the night to confirm Somogyi phenomenon.  
|AnswerC=Increasing the morning dose of insulin
|AnswerCExp='''Incorrect'''-Increasing the morning dose of insulin will be necessary only if there was an increase in early morning blood glucose without a hypoglycemic episode during night, which is Dawn phenomenon.
|AnswerD=Obtaining blood glucose levels between 2 am and 5 am
|AnswerDExp='''Correct'''-Episodic hypoglycemia at night followed by rebound hyperglycemia is called as Somogyi phenomenon.  It develops in response to excessive insulin administration during evening or night.  An [[adrenergic]] response to hypoglycemia results in increased glycogenolysis, gluconeogenesis and diminished glucose uptake by peripheral tissues.  The first step will be to document the hypoglycemia episode during the night to confirm the diagnosis.  The other management modalities will follow after this.  

|AnswerE=Decreasing the evening dose 
|AnswerEExp='''Incorrect'''-Only after night hypoglycemia documentation for confirmation, evening insulin dosage is reduced to treat Somogyi phenomenon.

|RightAnswer=D
|Approved=Yes
}}