239 - Diabetes Type 1 Flashcards
Which of the following symptoms suggests type 1 diabetes in a peadiatric patient?
Weight gain
Weight loss
Oliguria
Diarrhoea
Arthralgia
Weight loss
A patient with known type 1 diabetes is found unconscious. What is the most likely cause?
Diabetic ketoacidosis
Hyperglycaemia
Hypoglycaemia
Meningitis
Post-ictal state
Hypoglycaemia
- Which of the following results supports a diagnosis of type 1 diabetes in a young symptomatic patient?
Random glucose 14.5 mmol/l
Fasting glucose of 6.1 mmol/l
HbA1c 45mol/mmol
Glucose at 120mins 9.6mmol/l
Glycosuria +1
Random glucose 14.5
Q4. The retinal photograph demonstrates?
Pan retinal photocoagulation scarring B
ackground retinopathy
Proliferative retinopathy
Diabetic maculopathy
Retinal haemorrhage
Pan retinal photocoagulation scarring
Q5. A patient with type 1 diabetes attends clinic for annual review. What is the target HbA1c which is generally recommended?
•
a.Below 63 (8.0%) mmol/mol
b.Below 58 (7.5%) mmol/mol
c.Below 53 (7.0%) mmol/mol
d.Below 48 (6.5%) mmol/mol
e.Below 42 (6.0%) mmol/mol
•
•
c.Below 53 (7.0%) mmol/mol
Q6. The most commonly prescribed insulin regime for patients with type 1 diabetes in the UK is?
•
a. Twice daily pre mixed insulin
b. Basal bolus insulin
c. Insulin pump therapy
d. Sensor augmented pump therapy
e. Once daily insulin glargine
Basal Bolus
Q7. The retinal image shows feature of which
type of retinal pathology?
a. Background diabetic retinopathy
b. Diabetic maculopathy
c. Proliferative retinopathy
d. Pre proliferative retinopathy
e. Retinal haemorrhage
Background Diabetic retinopathy
(but because hard exudates in macula area actually maybe should be pre-proliferative)
Q8 Which of the following is an indication for insulin pump therapy?
•
•Recurrent hypoglycaemia
•Elevated HbA1c
•Injection phobia
•Non compliance with blood sugar testing
•HbA1c of 6.0%
Recurrent hypoglycaemia
Q9. This pattern of GFR is seen in which condition?
●
a. Acute kidney injury
b. Classical diabetic nephropathy
c. Diabetic glomerulosclerosis
d. Nephrotic syndrome
e. Reno vascular diabetic disease
Classical diabetic nephropathy
Q10. Which of the following symptoms suggests neuroglycopaenia in a patient with type 1 DM?
a. Chest pain
b. Confusion
c. Dry mouth
d. Sweating
e. Tremor
Confusion
Q12. Which of the following is an adrenergic response to hypoglycaemia?
•
a.Confusion
b.Limb weakness
c.Seizure
d.Slurred speech
e.Sweating
•
Sweating
The image shown represents
a. Background diabetic retinopathy
b. Pre proliferative retinopathy
c. Proliferative diabetic retinopathy
d. Diabetic maculopathy
e. Retinal haemorrhage
Proliferative diabetic retinopathy
Q14. Which of the following cutaneous manifestations is associated with type 1 DM?
- Abdominal striae
- Acanthosis nigricans
- Palmar erythema
- Tendon xanthomata
- Vitiligo
Vitiligo
Q15. Which of the following is most commonly seen in association with type 1 diabetes?
•
a. Acromegaly
b. Addison’s disease
c. Cushing’s syndrome
d. Psoriasis
e. Ulcerative colitis
Addison’s disease
Q.16 The earliest clinical manifestation of diabetic nephropathy is?
a. Dipstick positive proteinuria
b. Elevated Albumin : Creatinine Ratio
c. Elevated serum creatinine
d. Kimmelsteil Wilson lesions
e. Renal shrinkage on USS
b.Elevated Albumin : Creatinine Ratio
Q17. How often should patients with type 1 diabetes should have a retinal photograph to screen for diabetic retinopathy?
a. Annually
b. Every 5 years
c. At each clinic attendance
d. 6 monthly
e. Every 18 months
Annually
If changes - 3/6 monthly
Q18. In a patient with type 1 diabetes with hypertension what is the recommended first line class of anti hypertensive therapy?
a. ACE inhibitor
b. Beta blocker
c. Calcium channel blocker
d. Diuretic
e. Alpha blocker
ACE inhibitor
Q19. All patients with type 1 diabetes who are actively trying to become pregnant should be treated with which medication?
a. 400mcg of Folic acid
b. 5mg of Folic acid
c. 500mg Metformin
d. Clomiphene
e. 75mg Aspirin
5mg Folic acid
Q20. Which compound is measured when testing blood for ketone bodies?
a. Acetoacetate
b. Beta hydroxybuterate
c. Pyruvate
d. Lactate
e. Succinate
b.Beta hydroxybuterate
Q21. Which of the following biochemical results is consistent with a diagnosis of DKA
●
a. Blood glucose 10.0mmol/l
b.Base excess -2.0
c.Capillary ketones 4.5mmol/l
d.pH 7.31
e.Serum bicarbonate 21.0mmol/l
•
c.Capillary ketones 4.5mmol/l
Q22. A patient is diagnosed with DKA in the medical assessment unit. IV fluid resuscitation is commenced. What rate of IV insulin do you recommend initially?
a. 6 units/hr
b. 20 units/hr
c. 0.1u/kg/hr
d. 1.0u/kg/hr
e. 10% of total daily sub cutaneous dose
c.0.1u/kg/hr
Q23. Which of the following is a common trigger for DKA?
a. Acute infection
b. Dehydration
c. Long haul travel
d. Extreme physical exercise
e. Vomiting
Acute infection
Q24. You are called to a patient with type 1 diabetes who is confused and disorientated. His blood glucose is 2.0 mmol/l. He is able to swallow. Which treatment is most appropriate?
a. X4 Dextrose tablets
b. 50ml of 50% Dextrose IV
c. 1000ml 5% Dextrose
d. X2 Digestive biscuits
e. X2 Glucogel (hypostop) sachet
X2 Glucogel (hypostop) sachet
Q25. After treating an episode hypoglycaemia how long should you wait before checking the glucose response to therapy?
•
a. 5mins
b. 15mins
c. 30mins
d. 1 hour
e. Use clinical assessment
15 minutes
Q26 The structure of insulin is composed of how many polypeptide chains?
•
a.1
b.2
c.3
d.4
e.5
•
2
•Q27 When treating Diabetic ketoacidosis which electrolyte should to be monitored on a 2 hourly basis according to JBDS guidance?
a. Glucose
b. Sodium
c. Potassium
d. Magnesium
e. Bicarbonate
K+
Q28. In a patient with type 1 diabetes who is unable to eat due to nausea and vomiting. How would you manage his blood glucose control?
a.Omit all insulin
b.Omit rapid acting insulin
c.Intravenous insulin according to DKA protocol
d.Intravenous insulin and dextrose according to VRIII protocol
e.2 hours sub cutaneous boluses of insulin
●
d.Intravenous insulin and dextrose according to VRIII protocol
Q29. This patient has chronic deformity of the foot due to ?
a. Charcot neuroarthropathy
b. Diabetic neuropathy
c. Gout
d. Osteomyelitis
e. Peripheral vascular disease
a.Charcot neuroarthropathy
What causes type I diabetes?
Insulin deficiency following autoimmune destruction of pancreatic Beta cells
What auto antibodies can you look for in type I diabetes?
Anti-GAD antibodies
Islet cell antibodies
Z anti-a antibodies
What are the symptoms seen in a young patient presenting with diabetes?
Acute picture
2-6 week history of classical osmotic symptoms
- Polyuria + nocturia
- drowsiness
- dehydration
- Weight loss
What is seen in an older patient presenting with diabetes type I?
Often subacture picture
Over months/years
LAck of energy
Blurring of vision
Pruritus vulvae or balanitis
Ketonuria
Hyperventillation
What investigations can be done for ? type I diabetes?
Random plasma glucose
Fasting plasma glucose >7
Urine dipstick testing
2Hr glucose >11.5
What are the different insulin regimes available in type I diabetes?
Twice daily free mix - rarely now
Twice daily premix - fast + slow mixed, only 2 imjections a day, good in school age kids.
Basal bolus regime - most common, copies real life, 4 injections/day, more flexible
Insulin pump therapy - Gives consitant delivery of fast acting insulin, used more and more.
Who is an insulin pump indicated for?
Poor control
regular hypos
Pregnancy
Gastroporeisis
Why was inhaled insulin not a sucess?
Increased incidence of lung cancer as insulin is a growth factor
What are complications of s/c insulin delivery?
Lypoatrophy - loss of s/c tissue
Lupohypertrophy - prolifferation of s/c tissue, causes variable absorption of insulin from that area.
Why? impurities in older insulins
Repeated injections into same site - must rotate
What is DKA?
Diabetic Ketoacidosis
Absolute or relative insulin deficiency
When is DKA likely to happen?
A new diagnosis
Omission of insulin
Intercurrent disease - illness is an insulin resistant state
What levels make a diagnosis of DKA?
Hyperglycaemic : >11mmol/l
Ketotic : capillary ketones >3mmol/l or urine ++
Acidotic: pH <7.3, +/- bicarb <15mmol/l
Describe the pathophysiology of DKA
If no insulin is available you can’t use sugar, so it builds up - hyperglycaemia.
The body increases the amount of proteolysis and glyconeogenesis to provide energy, which also increases the glucose int he blood.
This is excreted in the urine, causing glycosuria, dehydration and metabolic disterbances.
As glucose can’t be used, fat is metabolised increasing free fatty acids and ketones are left.
This causes increase in serum ketonacids and metabolic acidosis
What are the symptoms of DKA?
Breathlessness (to blow off CO2 and reduce acid)
N+V
Abdo pain
Thirst
Polyuria
Tachcardia
Hypotensive
reduced Cap refil
Tachypnoea
Drowsy
What is the management of DKA?
Immediate - ACB, IV access, Bloods…
IV saline - 6l in 1st 24hrs
Insuline therapy - act rapid (o.1u/kg/hr) and continue basal insulin
-> fluid + insulin needed for a few days to fully clear ketones.
IV glucose once Blood glucose falls so insulin can still be given
K+ supplements
What monitoring is needed during menagement of DKA?
Hourly glucose and ketones
2 hourly K+
2 hourly venous gas
What are the aims of DKA management?
Reduce ketones
Reduce glucose
Increase venous bicarb
Maintain K+
What happens when blood glucose drops?
If glucose drops, hypothalmus detects and:
- activates Sympathetic NS - increase in epinepherine and acetylcholine
- stimulates ant-pituitary which stimulates adrenal cortex to produce cortisol
- Normally pancrease reduces insulin amount (less gluc pushed into cells) and increases glucagon (to break glyogen down).
Why do we mount a response to low glucose?
The brain can only use glucose - so mount an adrenergic response to make you realise and seek out food
In reduced glucose (<4mmol/l) what are the adrenergic symptoms?
Palpitations
tremmor
Anxiety
Sweating
Hunger
Parasthesia
When blood glucose drops to <2mmol/l what happens?
Neuroglycopaenia
Cognitive impairment
Confusion
Behaviour changes
Pscyhomotor changes
Concentration less
Seizures
Coma
What is the management of a mild hypo? <4mmol/l
Mild: dextrose tablets (around 15g)
Check BM in 15 mins, repeate
What is the management of a moderate hypo?
Pt conscious but confused
sugar <3mmol/l
Gel glucose - glucogel
Check BM in 15 mins
repete if needed
Follow with some complex carbs (biscuits) to last til next meal
What is the management of a severe hypo?
Pt unconscious/fitting/aggresvie
Inject glucagon IM
IV dextrose
don’t omit subsequent insulin
What is the VRIII sliding scale?
Variable Rate Intravenous Insulin Infusions
If pt. is vomiting, NBM or decompensated
Allows close control
- Glucose infusions
- Fluid
- Insulin - amount varies along a scale depending on how close to the target range of BM 6-10 you are.
What are the microvascular complications of Type I diabetes?
Retinopathy
Nephropathy
Neuropathy
What changes occur in diabetic retinopathy?
Microaneurysms - red dots
Occlusion
Leakage - hard exudates or soft
New vessel formation - near optic disk
Haemorrhage - dot, blot or flame
What are the 4 stages of diabetic retinopathy?
Background
preproliferative
proliferative
Maculoapthy
What changes are seen in background diabetic retinopathy?
microaneurysm(s), haemorrhage(s) +/- any hard/soft exudates
What changes are seen in pre-proliferative retinopathy?
venous beading/duplication,
IRMAs,
multiple deep, round haemorrhages,
cotton wool spots (>5)
What changes are seen in proliferative diabetic retinopathy?
new vessels on disc (NVD),
new vessels elsewhere (NVE),
preretinal or vitreous haemorrhage,
preretinal fibrosis
+/- tractional retinal detachment
What changes are seen in maculopathy in diabetic retinopathy?
exudate within a disc area (DA) of fovea,
retinal thickening within DA of fovea,
microaneurysm or haemorrhage within DA of fovea (reducing central vision)
What are differentials for diabetic retinopathy?
Hypertensive retinopathy: A-V nipping, ‘silver wiring’, flame shaped haemorrhages, hard and soft exudates
- Retinal vein thrombosis: haemorrhages, tortuous veins, macular oedema, new vessels (“blood and thunder” retina)
- Macular drusen (associated with AMD)
phospholipid crystals
How can you manage diabetic retinopathy?
Prevent - good contol
Screening
Referal
Treat with Argon laser:
Pan photocoagulation
macular grid/focal laser treatment
anti VEGF injection into orbit
What happens in diabetic nephropathy?
Increase in glomerular blood flow and pressure -> increase GFR
Basement membrane thickening + tubular function worsens
Microalbuminurea
overt clinical nephropathy, albuminurea, decreased GFR, rising creatinine
end stage renal failure
What is diabetic nephropathy?
Diabetic nephropathy is a clinical syndrome characterised by persistent albuminuria (>300 mg/day) on at least two occasions; almost invariably associated with hypertension and usually with retinopathy, leading to renal failure
What are the normal levels of albuminuria?
<20mg/l urine
<30mg/day
Or use albumin creatinine ration:
male <2.5
Female <3.5
What is microalbuminuria?
30-300 mg/24hrs urine
or ACR:
Male 2.5 - 30 mg/mmol creatinine
Female: > 3.5 – 30 mg/mmol creatinine
What value is used to stage chronic kidney disease/
GFR
Stage 1>90
Stage 5 (end stage) <15
How do you manage diabetic nephropathy?
Manage Bp
ACEi
ARB (more for type II)
What are the characteristics of diabetic neuropathy?
Glove and stocking
Sensory loss
Pain
Tendon reflexes reduced
Motor deficit slightly
How do you manage diabetic neuropathy?
Amitriptyline
Duloxitine
Pregabalin/gabapentin
Opiates
What does diabetic neuopathy put the pt at risk of?
Diabetic foot disease
Leading cause of mortality
Due to both sensory (insensitivity) and motor neuropathy (change in foot position and pressure points)
What occurs in diabetic foot disease?
Supervening ulceration and infection
• Small vessel and large vessel ischaemia, resulting in gangrene and amputation.
What is charcot neuropathy?
Warm, swollen, insensitive foot without ulceration
Pathological fracture(s), joint dislocations, deformities, progressive destruction of bone, “bag of bones”
- can become “rocker foot” - arch is lost
- needs weight offloading and MDT approach
What autonomic neuropathies are seen in diabetes?
Erectile dysfunction
Gastroparesis
Postural hypotension
