WBR0920

Author	PageAuthor::Vendhan Ramanujam
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Community Medical Health Center, MainCategory::Primary Care Office, MainCategory::Inpatient Facilities
Sub Category	SubCategory::Endocrine
Prompt	[[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. Several consecutive nights glucose monitoring was done and it revealed hypoglycemia. Somogyi phenomenon is diagnosed. What will be the next best step in management of this patient]]
Answer A	AnswerA::Increasing the evening dose of insulin
Answer A Explanation	AnswerAExp::'''Incorrect'''-Increasing the evening dose of insulin will only worsen this condition.
Answer B	AnswerB::Switching from NPH to lispro
Answer B Explanation	[[AnswerBExp::Incorrect-Switching from NPH to lispro will not be required now.]]
Answer C	AnswerC::Increasing the morning dose of insulin
Answer C Explanation	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 at night, which is Dawn phenomenon.
Answer D	AnswerD::Switching from NPH to regular insulin
Answer D Explanation	[[AnswerDExp::Incorrect-Switching from intermediately acting NPH insulin to short acting regular insulin might not be effective since both have a duration of action above 12 hours following their evening or night administration leading to nocturnal hypoglycemia.]]
Answer E	AnswerE::Decreasing the evening dose of insulin
Answer E Explanation	AnswerEExp::'''Correct'''-After documentation of hypoglycemia during night and confirmation of Somogyi phenomenon, reducing the evening or night insulin dose (short acting or intermediate acting) is the first appropriate step in management.
Right Answer	RightAnswer::E
Explanation	[[Explanation::Early morning rebound hyperglycemia in insulin dependent diabetes mellitus patients follows episodic hypoglycemia at night. This response is called as Somogyi phenomenon. It develops in response to excessive insulin administration. An adenergic response to hypoglycemia results in increased glycogenolysis, gluconeogenesis and diminished glucose uptake by peripheral tissues. The first step in managing this condition will be documentation of hypoglycemia during night. Following the confirmation, the evening or night insulin dose (short acting or intermediate acting) can be reduced. Further more, substitution of evening or night short acting or intermediate acting insulin with rapidly acting insulin like 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. Furthermore, substitution of evening or night short acting or intermediate acting insulin with rapidly acting insulin like lispro may be of some help. Educational Objective: References: ]]
Approved	Approved::Yes
Keyword	WBRKeyword::Somogyi phenomenon
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::