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Year 2 > Case 17 > Flashcards

Case 17 Flashcards

1
Q

First line drugs for T2DM

A

Metformin

Gliclazide

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2
Q

Effect of Metformin

A

Increases insulin-dependent glucose uptake into tissues.
Inhibits gluconeogenesis in liver.
Inhibits GI absorption of CHOs

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3
Q

Route of Administration of metformin

A

Oral

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4
Q

MOA of Metformin

A

Activates AMP-dependent protein kinase in liver.

Potentiates effects of endogenous insulin.

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5
Q

What class of drug is Metformin?

A

Biguanide class hypoglycaemic drug

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6
Q

ADRs of metformin

A

Abdominal pain
Anorexia
Diarrhoea

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7
Q

Contraindications of Metformin

A

Renal, liver or heart failure

Hypoxaemia

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8
Q

Route of administration of Gliclazide

A

Oral

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9
Q

Effect of gliclazide

A

Enhances insulin secretion

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10
Q

MOA of Gliclazide

A

Blocks K+ efflux from beta cells of pancreas.
Beta cells become depolarised.
Depolarisation causes Ca2+ influx.
Results in IP3 mediated enhanced secretion of insulin.

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11
Q

What class of drug is Gliclazide?

A

Sulfonylurea class hypoglycaemic drug

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12
Q

ADRs of Gliclazide

A

Haematological disorders

Hypoglycaemia in overdose

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13
Q

Contraindications of Gliclazide

A

Severe hepatic impairment

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14
Q

Route of administration of Saxagliptin

A

Oral

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15
Q

Effect of Saxagliptin

A

Enhanced insulin secretion

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16
Q

MOA of Saxagliptin

A

Inhibits dipeptidyl peptidase-IV

Enzyme which breaks down incretins

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17
Q

Effect of incretins

A

Enhance insulin secretion

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18
Q

Effect of DPP-IV

A

Rapidly breaks down incretins

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19
Q

ADRs of Saxagliptin

A 
Dizziness
Dyspepsia
Fatigue 
Gastritis 
Gastroenteritis 
Headache
Hypoglycaemia
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20
Q

Contraindications of Saxagliptin

A

Severe hepatic impairment

Sensitive to DPP-IV inhibitors

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21
Q

Route of administration of Exenatide

A

Subcutaneous injection

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22
Q

Effect of Exenatide

A

Increased insulin secretion
Suppresses glucagon secretion
Slows gastric emptying

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23
Q

MOA of Exenatide

A

Mimics incretins.

Acts on GLP-1 receptors causing enhanced insulin secretion.

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24
Q

ADRs of Exenatide

A

Hypoglycaemia
Injection-site reactions
Abdominal pain
Weight loss

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25
Q

Contraindications of Exenatide

A

Ketoacidotic

Severe GI pathologies

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26
Q

Drugs which can be coprescribed with metformin

A

Saxagliptin

Exenatide

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27
Q

Drugs which can be coprescribed with Gliclazide

A

Saxagliptin

Exenatide

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28
Q

The ‘thrifty’ genotype

A

Less active

Storing more energy

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29
Q

Heritability

A

Proportion of observed differences between members of a population that are due to genetic factors

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30
Q

Onset of MODY

A

<25yrs

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31
Q

Inheritance pattern of MODY

A

Autosomal Dominant

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32
Q

Distinguishing clinical features of MODY

A

No obesity
No ketosis
No beta-cell autoimmunity
Onset < 25yrs

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33
Q

Mutation which causes MODY 2

A

Mutation in Glucokinase (GCK)

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34
Q

Function of glucokinase

A

An enzyme which catalyses phosphorylation of glucose.

Controls rate limiting step of glycolysis.

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35
Q

Treatment of MODY

A

Diet management only

Have a mild, stable fasting hyperglycaemia without complications.

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36
Q

Mutation responsible for MODY3

A

HNF1A

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37
Q

Mutation responsible for MODY12

A

ATP-Binding Cassette (ABCC8)

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38
Q

Mutation responsible for MODY13

A

Potassium channel KCNJ11

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39
Q

MODY12 and MODY13 are associated with…

A

Neonatal diabetes

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40
Q

Features of Permanent Neonatal Diabetes

A 
IUGR
Symptomatic hyperglycaemia 
Onset < 6 months 
With ketoacidosis 
Lack of insulin throughout life (requires  insulin treatment)
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41
Q

Features of transient neonatal diabetes

A

Severe IUGR
Symptomatic hyperglycaemia
Onset < 1 month
Lack on insulin which resolves by 18 months
Intermittent childhood hyperglycaemia during illnesses
~50% risk of T2D as adult

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42
Q

Potassium channel structure in beta cells of pancreas

A

4 Kir6.2 subunits forming the channel pore.

Surrounded by 4 sulphonylurea receptors (SURs) that regulate pore activity.

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43
Q

How do potassium channels affect insulin release?

A 
Glucose enters pancreatic beta cell.
Causes ATP to increase in cells.
ATP binds to and closes K+ channel 
Cell depolarises due to build up of K+
Depolarisation causes insulin.
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44
Q

MELAS

A

Mitochondrial Myopathy
Encephalopathy
Lactic Acidosis
Stroke-like episodes

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45
Q

Common presenting features of MELAS

A 
Diabetes
Deafness
Exercise Tolerance
Muscle weakness
Seizures
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46
Q

Donahue Syndrome

A

Mutation in insulin receptor causing profound insulin resistance

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47
Q

Inheritance pattern of Donahue Syndrome

A

Autosomal recessive

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48
Q

Distinctive features of Donahue Syndrome

A 
Pre and postnatal growth failure 
Low subcut adipose 
Aged face
Thick lips 
Low set ears 
Acanthosis Nigricans 
Hyperandrogenism (Hirtsutism, enlarged male genitalia, cystic ovaries)
Early mortality
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49
Q

Epigenetics

A

Stable, heritable modification of chromosomes, without alterations in DNA sequence

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50
Q

Transient neonatal diabetes inherited due to…

A

Overexpression of imprinted genes at 6q24 e.g. PLAG1

Usually due to paternal UPD or duplication of paternal chromosome

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51
Q

T2DM is more likely to be inherited from (mother/father)

A

Mother

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52
Q

Intergenerational Effects

A

Both the foetus and her offspring can be affected by poor nutrition/toxic exposure of mother

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53
Q

Transgenerational Effects

A

Epigenetic changes that persist for multiple generations.

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54
Q

Tolbutamide is recommended for…

A

Elderly

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55
Q

Gliclazide is recommended for…

A

Renal impairment

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56
Q

MOA of Meglitinides

A

Insulin secretogogues

Closure of K+ ATP channels in beta cells

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57
Q

Incretins

A

GIP and GLP-1

Enhance secretion of insulin

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58
Q

MOA of statins

A

Inhibition of HMG-CoA reductase

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59
Q

Who is prescribed statins?

A

Secondary prevention - those at risk of MI and stroke due to atherosclerotic disease (post MI/Stroke, Angina)

Primary prevention - those at high risk of arterial disease due to elevated serum cholesterol.

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60
Q

Common ADRs of statins

A 
Myalgia 
GI disturbance 
Raised liver enzymes 
Insomnia 
Rash
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61
Q

Severe ADRs of statins

A

Myositis

Angioedema

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62
Q

Contraindications for statins

A

Pregnancy

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63
Q

Treatment of Familial Hypercholesterolaemia

A

Atorvastatin

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64
Q

Sensitivity

A

No. of True positives/No. of people with the condition

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65
Q

Specificity

A

No. of true negatives/No. of people without the condition

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66
Q

Borders of the femoral triangle

A

Inguinal ligament
Sartorius
Adductor Longus

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67
Q

Contents of femoral triangle

A

Femoral nerve
Femoral artery
Femoral vein

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68
Q

Where can the femoral artery be palpated?

A

Midway between ASIS and pubic tubercle

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69
Q

Femoral nerve lies within a fascial compartment along with…

A

Iliopsoas

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70
Q

Femoral sheath

A

Fascial extension of abdomen, within which the femoral nerve and artery are contained

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71
Q

Contents of Femoral canal

A

Lymphatic vessels
Deep lymph node
Empty space
Loose connective tissue

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72
Q

What is the function of the empty space in the femoral canal?

A

Allows for distension of the femoral vein so that is can cope with increased venous return.

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73
Q

What is the femoral canal?

A

A rectangular shaped compartment within the femoral triangle.

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74
Q

How can you distinguish between a femoral and direct inguinal hernia?

A

Femoral = lateral to pubic tubercle

Direct inguinal = medial to pubic tubercle

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75
Q

Meralgia Paraesthetica

A

Compression of lateral cutaneous nerve as it passes through the inguinal ligament. Causing altered sensation in lateral thigh.

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76
Q

Cutaneous innervation of medial thigh

A

Obturator nerve

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77
Q

Cutaneous innervation of lateral thigh

A

Lateral cutaneous nerve of thigh

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78
Q

Cutaneous innervation of posterior thigh

A

Posterior cutaneous nerve of thigh

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79
Q

Cutaneous innervation of anterior thigh

A

Femoral nerve

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80
Q

Cutaneous innervation of anteromedial lower leg

A

Saphenous nerve

81
Q

Cutaneous innervation of anterolateral lower leg and dorsum of the foot

A

Superficial branch of common fibular nerve

82
Q

Motor component of common fibular nerve

A

Biceps femoris

Lateral and anterior compartments of lower leg

83
Q

Cutaneous innervation of heel

A

Tibial nerve

84
Q

Cutaneous innervation of posterolateral lower leg

A

Sural nerve (tibial)

85
Q

Saphenous nerve branches from..

A

Femoral nerve

86
Q

Motor component of femoral nerve

A

Hip flexors - pectineus, iliacus, sartorius

Knee extensors - quadriceps femoris

87
Q

Sensory component of femoral nerve

A

Anteromedial thigh

Medial lower leg and foot

88
Q

Motor component of obturator nerve

A

Medial compartment of thigh - adductor

89
Q

Sensory component of obturator nerve

A

Skin of medial thigh

90
Q

Motor component of sciatic nerve

A

Posterior thigh muscles

91
Q

Motor component of tibial nerve

A

Posterior compartment of lower leg

92
Q

Sensory component of tibial nerve

A

Posterolateral side of the lower leg.
Lateral side of foot
Sole of foot

93
Q

Motor component of common fibular nerve

A

Short head of biceps femoris

Anterior and lateral compartments of leg

94
Q

Sensory component of common fibular nerve

A

Skin over upper lateral and lower posterolateral leg.

Skin of anterolateral leg and dorsum of foot

95
Q

Sensory component of superficial fibular nerve

A

Skin over dorsum of foot

Anterior and lateral aspect of inferior third of lower leg

96
Q

Motor component of superficial fibular nerve

A

Lateral compartment of lower leg

97
Q

Sensory component of deep fibular nerve

A

Triangular region of skin between 1st and 2nd toes

98
Q

Motor component of deep fibular nerve

A

Anterior compartment of lower leg

Some intrinsic muscles of the foot

99
Q

Blood supply to anterior compartment of leg

A

Anterior tibial

100
Q

Nerve supply of anterior compartment of leg

A

Deep fibular

101
Q

Blood supply of lateral compartment of leg

A

Common fibular

102
Q

Nerve supply of lateral compartment of leg

A

Superficial fibular

103
Q

Blood supply of posterior compartment of leg

A

Posterior tibial

104
Q

Nerve supply of posterior compartment of leg

A

Tibial nerve

105
Q

Nerve supply of posterior compartment of thigh

A

Sciatic nerve

106
Q

Nerve supply of anterior compartment of thigh

A

Femoral nerve

107
Q

Nerve supply of medial compartment of thigh

A

Obturator nerve

108
Q

Surgical intervention for compartment syndrome

A

Fasciotomy

109
Q

Compartment syndrome

A

Bleeding into one of the osteofascial compartments of limb .

Causes an increase in pressure which risks ischaemia of the structures in the compartment

110
Q

Muscles of lateral compartment of the foot

A

Fibularis longus and brevis

111
Q

Action of fibularis longus and brevis

A

Evert foot and weakly plantar flex ankle

112
Q

Superficial muscles of posterior compartment of leg

A

Gastrocnemius
Soleus
Plantaris

113
Q

Deep muscles of posterior compartment of leg

A

Popliteus
Flexor digitorum longus
Flexor hallucis longus
Tibialis posterior

114
Q

Action of superficial posterior muscles of leg

A 
Plantar flexion (weakly)
Support longitudinal arch of foot
115
Q

Effect of rupture of achilles tendon

A

Unable to plantar flex foot against resistance

116
Q

Osteofascial Tunnel Posterior to Malleolus

Tom Dick And Very Nervous Harry

A 
Tibialis Posterior 
Flexor Digitorum 
Artery
Vein
Nerve 
Flexor Hallucis Longus
117
Q

Lateral and medial plantar arteries arise from…

A

Posterior tibial artery

118
Q

Vein most commonly affected by varicosities

A

Great Saphenous Vein

119
Q

Venous supply which is most at risk in a fracture of proximal femur

A

Medial and lateral circumflex veins which arise from profunda femoris

120
Q

Ankle-Brachial Index

A

Ratio of systolic blood pressure in ankle compared to that of the brachial artery

Used to diagnose peripheral artery disease

121
Q

Borders of popliteal fossa

A

Superomedial: Semimembranosus
Superolateral: Biceps femoris
Inferomedial: Medial head of gastrocnemius
Inferolateral: Lateral head of gastrocnemius and plantaris

122
Q

Contents of popliteal fossa

A

Popliteal artery
Popliteal vein
Tibial nerve
Common fibular nerve

123
Q

Where can the posterior tibial artery pulse be palpated?

A

Posterior to medial malleolus

124
Q

Where can the dorsalis pedis pulse be palpated?

A

Lateral to extensor hallucis longus tendon

125
Q

Endocrine pancreatic secretions

A

Insulin
Glucagon
Somatostatin
Pancreatic polypeptide

126
Q

Exocrine secretions

A

Digestive enzymes

Bicarbonate

127
Q

Fasting plasma glucose

A

4-6mmol/L

128
Q

Plasma glucose 2hrs after eating

A

7.8mmol/L

129
Q

GLUT2

A

Low affinity transport of glucose into cells

130
Q

Secretion of Insulin

A 
Glucose enters cells via GLUT2
Glucokinase acts on Glc to produce ATP
ATP inhibits K+ efflux via SUR1/Kir6.2 channels 
Depolarisation causes Ca2+ influx
High Ca2+ causes insulin release
131
Q

Insulin Receptor

A

Transmembrane Tyrosine-Kinase-Linked Receptor

132
Q

When insulin binds to its receptor….

A

The receptor is autophosphorylated by tyrosine kinase.

Results in autophosphorylation of insulin receptor substrates which act globally to reduce plasma glucose.

133
Q

Insulin activates:

A 
Protein synthesis 
K+ uptake 
Glycogen synthesis 
Glucose uptake 
Glycolysis
134
Q

Insulin inhibits:

A 
Lipolysis
Gluconeogenesis
Glycogenolysis
Proteolysis
Ketogenesis
135
Q

Advanced Glycation End-Products

A

Produced by Hb glycation

Cause oxidative damage and impaired macromolecular function

136
Q

HbA1c is a measure of

A

Glycated Hb

137
Q

Normal HbA1c

A

<42mmol/mol OR <6%

138
Q

Values of hypoglycaemia

A

<4mmol/L

139
Q

Values of hyperglycaemia

A

> 6.9mmol/L

140
Q

Lifestyle factors which increase risk of T2DM

A

Poor diet
Low levels of exercise
Stress

141
Q

Genes associated with T2DM

A

FTO

KCNJ11

142
Q

FTO

A

encodes alpha-ketoglutarate-dependent dioxygenase

143
Q

KCNJ11

A

encodes the islet ATP-sensitive K+ channel Kir6.2

144
Q

GLUT2 is found in

A

Pancreatic cells

Liver cells

145
Q

GLUT4 is found in

A

Adipocytes

Muscle cells

146
Q

MOA of Pioglitazon

A

Thiazolidinedione

Forms a complex with PPAR-gamma. Complex is an adipocyte gene transcriptional regulator resulting in increased glucose uptake

147
Q

Effects of Pioglitazon

A

Adipocyte differentiation
Increased lipogenesis
Increased fatty acid uptake
Increased glucose uptake

148
Q

ADRs of Pioglitazon

A 
GI disturbance 
Weight gain 
Oedema 
Anaemia 
Headache 
Visual disturbance 
Impotence 
Haematuria
149
Q

Contraindications of Pioglitazon

A

Hx of Heart failure
Haematuria
Previous or active bladder cancer

150
Q

Disease of exocrine pancreas associated with diabetes mellitus

A

Pancreatitis
CF
Haemochromotosis

151
Q

Endocrinopathies associated with Diabetes Mellitus

A

Cushing’s Syndrome
Acromegaly
Hyperthyroidism

152
Q

Drugs which may induce DM

A

Glucocorticoids
Thiazides
Beta blockers
Atypical Antipsychotics

153
Q

Genetic Syndromes associated with DM

A

Down’s Syndrome
Klinefelter Syndrome
Wolframs Syndrome

154
Q

Autonomic symptoms of hypoglycaemia

A

Sweating
Palpitations
Shaking
Hunger

155
Q

Neuroglycopenic symptoms of hypoglycaemia

A

Confusion
Drowsiness Odd behaviour
Speech Difficulty
Incoordination

156
Q

Symptoms of hypoglycaemia

A

Sweating, Palpitations
Odd behaviour, incoordination and speech difficulty
General malaise - headache, nausea

157
Q

Diagnostic criteria for DKA

A

BG >11mmol/L or known diabetes
HCO3- < 15mmol/L +/- venous pH less than 7.3
Ketonaemia >3mmol/L or significant ketonuria (> 2+)

158
Q

Causes of DKA

A

Poor compliance with tx
Infection or intercurrent illness
Medical/Surgical/Emotional Stress
MI

159
Q

DKA normally occurs in

A

T1DM

160
Q

Hyperosmolar Hyperglycaemic State normally occurs in

A

T2DM

161
Q

Diagnostic criteria for HHS

A

BG > 30mmol/L without hyperketonaemia and acidosis

162
Q

DR: Microaneurysms

A

Small red spots, caused by swelling of small capillary vessels

163
Q

DR: Haemorrhages

A

Red spots caused by small bleeds within retina

164
Q

DR: Cotton Wool Spots

A

White and fluffy patches caused by scarred nerve fibres near surface of retina

165
Q

DR: Hard exudates

A

Small, shiny, pale, white or yellow spots

Sharp edged

Caused by fatty deposits (due to leaking fluid)

166
Q

DR: Venous loop

A

Loop in blood vessel due to poor blood flow

167
Q

Definition of Diabetic Nephropathy

A

Proteinuria >0.5g/24hrs

168
Q

Risk factors for diabetic nephropathy

A 
Genetic and familial predisposition
Elevated blood pressure
Poor glycaemic control 
Smoking 
Hyperlipidaemia 
Microalbuminuria
169
Q

Stage I Diabetic Nephropathy

A

GFR>90
Hyperfiltration
Increased blood flow through kidney
Early renal hypertrophy

Normal renal function

170
Q

Stage II Diabetic Nephropathy

A

GFR>60-89
Glomerular lesions
Mild reduction of renal function

171
Q

Stage III Diabetic Nephropathy

A

GFR 30-59 (moderately reduced)
Microalbuminuria
Albumin:Creatinine Ratio 30-300mcg/mg/day

172
Q

Stage IV Diabetic Nephropathy

A

GFR 15-29 (severely reduced)
Proteinuria > 500mg/24hrs
Creatinine clearance <70ml/min

173
Q

Stage V Diabetic Nephropathy

A

End Stage Renal Disease
GFR<15
Creatinine Clearance <15ml/min

174
Q

Pathophysiology of Diabetic Nephropathy

A

Renal hypertrophy associated with increased GFR.
Vasodilation of afferent arteriole - raised glomerular pressure.
Damage to glomerulus = mesangial cell hypertrophy and secretion of mesangial matrix.
Eventual glomerulas sclerosis - thickening of basement membrane, no longer acts as an effective filter.
Leakage of large proteins.

175
Q

Symmetric Polyneuropathy

A

Pain, paraesthesia, loss of vibration sense in lower extremities (can eventually affect hands).
Can cause unrecognised trauma.

176
Q

Most common form of neuropathy

A

Symmetric polyneuropathy

177
Q

Acute Painful neuropathy

A

Burning, crawling pains in feet, shins and anterior thighs

178
Q

Mononeuropathy

A

Isolated nerve palsies.

Commonly affects CNIII and CNVI which supply external eye muscles.

179
Q

Diabetic Amyotrophy

A

Painful wasting of quadriceps.
Knee reflexes absent or diminished.
Usually in older men.

180
Q

Autonomic Neuropathy

A

Often Asymptomatic.

CV System - tachy at rest, arrhythmia, postural hypotension, warm foot with bounding pulse (peripheral vasodilation)

GI Tract - gastroparesis (D+V)

Bladder - loss of tone , incomplete emptying

Male erectile dysfunction

181
Q

Pathophysiology of Diabetic Retinopathy

A

Hyperglycaemia damaged retinal pericytes.
Weak capillary walls - microaneurysms.
More permeable capillary walls - exudates and macular oedema.
Ischaemia - cotton wool spots and new vessels (VEGF)
Thin walled new vessels prone to bleeding - vitreous haemorrhage.
Fibrotic bands of collagen along margins of new vessels can contract - retinal detachment

182
Q

Pathophysiology of Neuropathy

A

Hyperglycaemia causes formation of sorbitol and fructose in schwann cells. Loss of structure and function of schwann cells.

Segmental demyelinisation (reversible but becomes irreversible)

183
Q

Major risk factor for diabetic foot ulcers

A

Distal Symmetric Neuropathy

184
Q

Symptoms of ischaemic in diabetic foot

A

Claudication

Rest pain

185
Q

Symptoms of neuropathy in diabetic foot

A

USUALLY painless - unrecognised trauma

Some forms of neuropathy are painful

186
Q

Examination of ischaemia in diabetic foot

A

Dependent rubor - dusky red colouration except when elevated above heart
Trophic changes - soft tissue changes
Cold
Pulseless

187
Q

Examination

A 
High arch
Clawing of toes 
No trophic (soft tissue) changes)
Warm
Bounding pulse
188
Q

Ischaemic ulceration in diabetic foot is usually…

A

Painful

In heels and toes

189
Q

Neuropathic ulceration in diabetic foot is usually…

A

Painless

Plantar

190
Q

Why is the response to infection less efficient in patients with diabetes?

A

Vascular disease and neuropathies
Hyperglycaemia
Depression of adherence, chemotaxis and phagocytosis of neutrophils.

191
Q

Why does poor control of diabetes increase susceptibility to infection?

A

Depression of adherence, chemotaxis and phagocytosis of neutrophils.

192
Q

Usual test for diagnosis of microalbuminuria

A

Albumin:Creatinine Ratio (Spot collection)

193
Q

Criteria for diagnosis of microalbuminuria

A

ACR >30mg/min on 2 out of 3 occasions in a 3-6 month period

194
Q

Causes of false positive test for microalbuminuria

A 
Short term hyperglycaemia 
Exercise 
UTI
Marked hypertension
Heart failure
Acute febrile illness
195
Q

Urine sample for Albumin:Creatinine Ratio must not be….

A

First void of the day due to diurnal variation in albumin secretion

196
Q

Screening for diabetic eye disease

A

Annual DR screening service

+ Visual acuity

197
Q

First line treatment of T2DM

A

Metformin

198
Q

Treatment for Diabetes when Metformin is contraindicated/not tolerated

A

DPP-4 inhibitor e.g. Saxagliptin OR
Pioglitazone OR
Sulphonylurea e.g. Gliclazide

199
Q

Why is wound healing impaired in T2DM

A

Impaired migration, proliferation and differentiation of keratinocytes.
Impaired eNOS activation causing impaired EPC synthesis.
Limited SDF-1alpha expression therefore EPCs not recruited to site.
Fewer EPCs at wound site, reduced neovascularisation (ischaemic wound)

Year 2 (17 decks)

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