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Junior - endo II > 11b - DM Part 2 > Flashcards

11b - DM Part 2 Flashcards

1
Q

when does low glucose become hypoglycemia?

A

<54 mg/dL

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2
Q

What are some common etiologies of hypoglycemia?

A

Behavioral
Counterregulatory
Complications of DM

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3
Q

What behavioral causes lead to hypoglycemia?

A

Insulin dose and carbs not balanced

Drinking ETOH

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4
Q

What causes counterregulatory Hypoglycemia?

A

Impaired glucagon response - DM
Cortisol deficiency - addisons
Sympatho-adrenal blunting - lack of awareness

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5
Q

SS of hypoglycemia?

A

Sympathetic

  • tachycardia
  • palpitations
  • tremulousness
  • sweating

Parasympathetic

  • nausea
  • hunger
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6
Q

What is the function of the exocrine pancreas?

A

Produces digestive enzymes

98-99% of pancreas mass

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7
Q

What is the endocrine pancreas?

A 
Produces hormones: 
B cells-insulin
A cells - Glucagon
D cells - somatostatin
F cells - pancreatic polypeotide, Ghrelin
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8
Q

Insulin function?

A

Lowers blood glucose

Stimulated by high blood sugar

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9
Q

Glucagon function?

A

Raises blood glucose levels

Hepatocytes - convert glycogen
Gluconeogenesis formation

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10
Q

What regulates glucagon and insulin?

A

Blood glucose is the most important regulator

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11
Q

DM complications

A

Acute:

  • hypoglycemia
  • DKA
  • Hyperglycemic hyperosmolar state

Chronic

  • microvascular damage
  • macrovascular damage
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12
Q

When do neuroglycopenic symptoms appear with hypoglycemia?

A

When blood glucose falls to 50mg/dL

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13
Q

Treatment for hypoglycemia

A

Prevention (lol)
Glucose tabs 2-3 tabs
Juice 4-6 oz
Soda 4-6 oz

Follow with complex carbs

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14
Q

What is a glucagon kit?

A

A home treatment of severe hypoglycemia

1 ampule of glucagon

Every pt on insulin should have one

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15
Q

What will the ER do for hypoglycemia?

A 
Establish airway
IV glucose (50ml of 50%)
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16
Q

If no IV glucose is available what are some other therapies?

A

IM glucagon

If stuporous and no glucagon available: honey, syrup etc in buccal pouch or rectally

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17
Q

Is DKA a common occurrence?

A

5-8 episodes/1000 diabetics annually

50-60% of kids will have at least 1

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18
Q

What is the mortality rate for DM?

A

5% mortality < 40 yrs old

>20% mortality in the elderly

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19
Q

What are some risk factors for DKA with DM1 pts?

A 
Infection 30%
Lapse in insulin admin 15-41%
New onset DM 17-25%
Medical illness - 10%
Trauma/alcohol/steroids - 10-20%
Idiopathic
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20
Q

Pathogenesis of DKA?

A

NO insulin -> rapid mobilization of energy stores -> increase flux to live of amino acids for conversion to flucose and ketones

Peripheral utilization of glucose and ketones is reduced

Hyperglycemia and ketonemia occur

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21
Q

DKA S/S?

A 
Signs: 
Polyuria, polydipsisa (1-2 days)
Fatigue
Nausea
Vomiting
Stupor/coma
Hypothermia
Symptoms: 
Dehydration
Kussmaul respirations
Fruity breath
HOTN 
Tachycardia
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22
Q

What will the lab find on DKA pts?

A 
Hyperglycemia 350-900
Serum ketones
Glucosuria 4+
Strong ketonuria
low pH (6.9-7.2)
Low bicarb (5-15 mEq/L)
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23
Q

Less frequent lab findings with DKA?

A 
Hyperkalemia
Hyponatremia
H Amylase
H creatinine
H temp
Leukocytosis w L shift
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24
Q

What causes ketoacidemia?

A

Lack of insulin + H GH, catecolamines, glucagon lead to:

Lypolysis from adipose tissue -> release of FFAs -> ketone bodies in liver

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25
Q

Best way to treat DKA?

A

Prevention

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26
Q

What do DM-1 pts need to do when they get sick?

A

Sick day guidelines

  1. Test urine ketones q 2-4 hrs
  2. Test blood gluose q 4+ times a day
  3. Continue to take insulin and eat (if possible)
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27
Q

DKA treatment

A
  1. Therapeutic flow sheet (bunch of vitals and labs)
  2. Fluids: 4-5L
  3. Insulin replacement (immediate post fluids)
  4. potassium
  5. Sodium bicarb
  6. Phosphate
  7. ABx (if infected)
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28
Q

Fluid therapy for DKA

A

1 L/hr x 1-2 hrs
After 2 L give 300-400ml/hr
When glucose is <250 give 5% glucose to keep serum glucose at 250-300

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29
Q

BOLUS fluid for DKA?

A

Nope, too much (>5L in 8 hrs) cause ARDS and cerebral edema

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30
Q

Why potassium?

A

Polyuria and vomiting lowers levels

Acidosis: shift of K from cells to extracellular space

Once acidosis gets better it goes back leaving them hypokalemic

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31
Q

Who gets sodium bicarb?

A

We only use this with pH < 7 because it may actually be harmful

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32
Q

What is the 2nd MC form of hyperglycemic coma?

A

Hyperglycemic hyperosmolic state

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33
Q

What is hyperglycemic hyperosmolar state?

A

Severe hyperglycemia in absence of significant ketosis

  • mild or undiagnosed DM
  • CHF/CKD
  • drugs
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34
Q

What is the mortality rate of hyperglycemic hyperosmolar state?

A

High mortality due to insidious organ dysfunction and delayed diagnosis

10 x mortality of DKA

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35
Q

Pathogenesis of hyperglycemica hyperomolar state?

A

Partial or relative insulin deficiency reduces glucose utilization by muscle, fat and liver, while promoting hyperglucagonemia and increasing hepatic glucose output

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36
Q

S/S of hyperglycemia hyperosmolar state?

A

Insidious onset:

  • polyuria
  • polydipsia
  • weakness
  • lethargy and confusion -> coma
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37
Q

Hyperglycemia hyperosmolar state respirations?

A

Absence of kussmaul respirations

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38
Q

What labs will you see with hyperglycemic hyperosmolar state?

A 
Severe hyperglycemia 600-2400!!!
Hyponatremia
NO ketosis
NO acidosis
Prerenal azotemia - BUN > 100 mg/dL
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39
Q

Tx of hyperglycemic hyperosmolar state

A
  1. Fluid replacement
  2. Insulin
  3. Potassium
  4. Phosphate

Basically same as DKA

40
Q

How much insulin is needed for hyperglycemic hyperosmolar state?

A

Less than DKA
Initial .15 unit/kg
Then
Infusion 1-2 u/hr to lower glucose by 50-70mg/dL/hr

41
Q

Who gets DKA and who gets Hyperglycemia Hyperosmolic state?

A

DKA is DM 1

HHS is DM 2

42
Q

Vascular complications of DM-1

A

End stage renal disease (40%)
Blindness (retinopathy and detachment)
Diabetic neuropathy

43
Q

DM 1 major cause of death?

A

Complications from end stage renal disease

44
Q

Vascular complications of DM-2?

A

End stage renal disease 20%
Blindness caused by macular edema/ischemia
Diabetic neuropathy

45
Q

major cause of death in DM-2?

A

Macrovascular disease leading to MI and stroke

46
Q

Cigarette effect on DM 1 and 2 complications?

A

Adds significantly to the risk of both microvascular and macrovascular complications in all diabetic patients

47
Q

Chronic DM complications?

A 
A. Ocular complications
B. Diabetic neuropathy
C. Diabetic neuropathy
D. Cardiovascular complications
E. Skin/mucous membrane complications
48
Q

What types of ocular complications do Diabetics get?

A

Diabetic cataracts
Glaucoma
Diabetic retinopathy

49
Q

What are the categories/stages of diabetic retinopathy?

A

Nonproliferative (background)

Proliferative (malignant)

50
Q

What causes nonproliferative retinopathy?

A

Microaneurysms
Hemorrhages
Exudates
Retinal edema

Cotton wool spots are seen pre proliferative

51
Q

What causes proliferative retinopathy?

A

Newly formed vessels from chronic ishemia + macular edema

Increased risk of retinal detachment

52
Q

Treatment for proliferative (malignant) retinopathy?

A

Photocoagulation (laser)

Bevacizumab (avastin) - antivascular injection into eye - stops new growth

53
Q

S/S of diabetic retinopathy?

A 
Acute loss of visual acuity
Diplopia
Fluctuating visual changes
Floating spots
Flashing lights
ocular pain
54
Q

When do DM pts need to get vision screening?

A

DM -1: 3-5 yrs after diagnosis then annually

DM -2: at diagnosis, then annually

55
Q

What % of renal disease pts are diabetics?

A

30%

56
Q

Manifestations of DM renal disease?

A

Microalbuminuria (early)
Proteinuria
Urea and creatine accumulation in blood

57
Q

Will a urine dipstick screen for microalbuminuria?

A

Nope, requires an overnight urine collection

58
Q

What is the albumin/creatinine ratio?

A

Morning spot albumin: creatinine ratio test

Requires 2-3 + tests in 3-6 mo for diagnosis

59
Q

DM 1 and 2 screening for microalbuminuria?

A

DM 1 5 yrs post diagnosis then annually

DM 2 at diagnosis then annually

60
Q

How do we treat microalbuminuria?

A

ACEI (prils):
ARBs (sartans):
Low protein diet
Monitor alb:cr ratio q 6 mos

61
Q

What is seen with progressive diabetic nepropathy?

A

Proteinuria + hypoalbuminemia, edema and increased LDL
Progressive azotemia
HTN and accelerated CVD

62
Q

Tx for progressive diabetic nephropathy?

A

BP control (captopril 50% reduction in death/transplant)
Protein sparing diet
Renal transplant
Dialysis is of limited value

63
Q

How fast does kidney failure happen with DM once it starts?

A

W/in 5 yrs 50% of pts will have 50% decline in GFR

3-4 years after that 50% will have ESRD and required a new kidney

64
Q

Should DM pts get contrast radiographic studies?

A

Think twice

Can do if needed but hydrate them really well

65
Q

What is the MC diabetic peripheral neuropathy?

A

Distal symmetric polyneuropathy

66
Q

Types of peripheral neuropathy?

A

A. Distal symmetric polyneuropathy
B. Isolated peripheral neuropathy
C. Painful diabetic neuropathy

67
Q

Types of diabetic neuropathies?q

A
  1. Peripheral neuropathy

2. Autonomic neuropathy

68
Q

What is distal symmetric polyneuropathy?

A

Bilateral symmetrical nerve involvement

“Glove and stocking”

69
Q

Is distal symmetric polyneuropathy sensory or motor

A

Can be both but sensory is always there
- initially dullness of vibration, pain, temp
-Pain ranging from mild - incapacitation
-

70
Q

What is the problem for distal symmetric polyneuropathy with decreased pain?

A

Decreased pain threshold -> repetitive stress -> callouses and ulcerations

71
Q

What is charcot foot arthropathy?

A
  • Rocker bottom deformity

- Joint subluxation and periarticular fx

72
Q

What do pts need to do to avoid distal symmetric polynephropathy problems?

A 
Early detection 
-distal reflexes
-distal vibration senses
- distal light touch
Foot wear and daily inspections
Tight glucose control
73
Q

Is isolated peripheral neuropathy reversible?

A

Yes it is acute and reversible

Usually in 6-12 weeks

74
Q

What causes isolated peripheral neuropathy?

A

Vascular ischemia or traumatic damage

Femoral and cranial neves MC

75
Q

What is painful diabetic neuropathy?

A

Hypersensitivity to light touch

Sever burning pain at night

76
Q

Tx for painful diabetic neuroopathy?

A

TCAs - amitriptyline or desipramine
Gabapentin or pregabalin
Duloxetine (SNRI)
Capsaicin cream

77
Q

What is autonomic neuropathy?

A

Neuropathy of autonomic system

Affects:

  • BP and pulse
  • Gi tract
  • bladder function
  • ED
78
Q

What is the MC autonomic neuropathy?

A

GI tract

79
Q

Who gets autonomic neuropathy?

A

Usually its pts with a long hx of DM

80
Q

GI tract autonomic neuropathy presentations

A

Gastroparesis
Gastric dysmotility
Constipation
Diarrhea

81
Q

GI tract autonomic neuropathy tx?

A

Treat the symptoms as normal

82
Q

What are ED therapies for autonomic neuropathy?

A

Meds: PDE5 inhibitors
Mechanical therapy (pumps)
Surgery (prostheses)

Big difference between this and normal ED is that it is often persistent

83
Q

What is the leading cause of death for DM2?

A

Myocardial infarction

84
Q

DM cardiovascular complications

A 
PVD: 
Ischemia of lower extremities
Erectile dysfunction 
Intestinal angina
Gangrene of feetq
85
Q

BP recommendations for DM pts?

A

140/90

86
Q

DM PVD management?

A 
BP < 140/90
Low dose aspirin
Tobacco cessation
Lipid control
Exercise
87
Q

Diabetes amputations?

A

Dm causes 1 million amputations each year

88
Q

Prevention of diabetic foot problems?

A

Comprehensive foot exam annually:

Visual: skin, tissue, shoes, biomechanics
Palpation: pulses
Sensation: monofilament, vibration, pinprick, ankle

89
Q

Foot problems are categorized as low risk or at risk, what is at risk?

A 
Loss of protective sensation
absent pedal pulses, 
foot deformity, 
hx of foot ulcer, 
prior amputation, 
smokers, 
hx of retinopathy, 
neuropathy, 
receiving anticoagulants
Cannot see/reach feet
90
Q

What do you do with at risk vs low risk pts?

A

At risk: refer to podiatry

Low risk: counsel/educate

91
Q

Can DM pts wear sandals?

A

I mean its a free country but they shouldn’t if they like keeping their feet

92
Q

Skin complications that are common with DM?

A 
Insulin hypertropy/atrophy
Candida (thrush)
Xanthelasma
Vitiligo
Necrobiosis lipidica diabeticorum
Dupytrens contracture
93
Q

Consults for DM pts

A 
Diabetic education class
Dietary consult
Optometry
Podiatry
94
Q

Fasting glucose and HbA1C goals for diabetics?

A

Glucose: 110-120

HbA1C <7.0% (6.5 if otherwise healthy)

95
Q

Annual things with your DM pts?

A 
BP/pulse/height/wt (every visit)
Foot exam
Lipid profile
Fasting glucose
HbA1C 2-4 times/yr
Microalbumin
Pneumovax/flu shot
96
Q

What kind of band plays snappy music?

A

A rubber bad

Junior - endo II (7 decks)

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