Diabetes

Question 1

what 3/4 features support a diagnosis of hyperosmolar hyperglycaemia syndrome?

Answer 1

• hypovolemia
• hyperglycaemia
• no ketones or acidosis
• osmolality usually >320 mosmol/Kg

Question 2

what type of diabetes (I or II) is HHS more common in?

Answer 2

type II diabetes

Question 3

what can precipitate a patient getting HHS?

Answer 3

• cardiac event
• infection/sepsis
• fall
• stroke
  (can take days to develop)

Question 4

what is the immediate management of HHS?

Answer 4

• IV fluids (crystalloids - given over 2/3 days)
• normalise blood glucose by giving IV insulin
• anticoagulation
• monitor potassium and renal function

Question 5

what are the main complications of HHS?

Answer 5

• central pontine myelinolysis
• CCF from fluid overload if previous CVD
• cerebral oedema
• thrombosis

Question 6

what is diabetic ketoacidosis?

Answer 6

a condition that occurs most commonly in T1DM patients where they dont have enough insulin and ketones start to build up due to enhanced lipolysis

Question 7

what are teh main features that support a diagnosis of ketoacidosis?

Answer 7

• acidosis
• hyperglycaemia
• ketonaemia

Question 8

what is the immediate management of DKA?

Answer 8

• fluids FAST @ fixed rate
• insulin to reduce ketones
• potassium - as falls when insulin given
• correction of electrolyte imbalances using fluids

Question 9

when is a patient moved from IV insulin to subcutaneous after DKA?

Answer 9

when their ketone level is <0.6mmol/L and they are ready to eat

Question 10

what investigations need to be doen when a patient comes in suspected of having DKA?

Answer 10

• blood ketones
• capillary blood glucose
• venous plasma glucose
• U+E’s
• venous blood gases
• FBC
• blood cultures
• ECG
• CXR
• urinalysis and culture
• continous cardiac monitoring

Question 11

what are the clinical features of a diabetic foot?

Answer 11

• painless ulcer
• cellulitis possibly
• redness
• changes to skin, nails
• foul smell
• discharge
• swelling

Question 12

what are the investigations needed when assessing a diabetic foot?

Answer 12

• clinically
• doppler
• angiography
• xray (if bone deformity/osteomyelitis)
• FBC, swab and blood cultures (if infection)

Question 13

what is the management fo a diabetic foot ulcer?

Answer 13

• remove callus/tissue debridement and washout
• regular chiropody
• bed rest
• therapeutic shoes
• if cellulitis then ABx

Question 14

what are teh most common types of organisms cuasing diabetic foot ulcers? and what ABx therefore needed to treat?

Answer 14

• staphs and streps

- benzylpenicillin and flucloxacillin +/- metronidazole

Question 15

name some chronic complications of diabetes?

Answer 15

• diabetic foot ulcer
• nephropathies
• neuropathies
• retinopathy

Question 16

what are teh clinical features of a charcots foot?

Answer 16

pes cavus, claw toes, loss of transverse arch, rocker-bottom sole

Question 17

what is the main investigation for diabetic nephropathy?

Answer 17

albumin:creatinine ratio (≳3mg/mmol in microalbuminuria but urine dipstick -ve for proteins)

Question 18

what is the management of diabetic nephropathy?

Answer 18

• ACEi
• lifetsyles managament
• BP control
• glycaemic control
• low protein diet

Question 19

what investigations are done to test for diabetic neuropathies?

Answer 19

clinical diagnosis
fasting blood glucose
HbA1c
serum thyroid-stimulating hormone

Question 20

what is the clinical plasma glucose level for hypoglycameia?

Answer 20

<3mmol/L

Question 21

what are teh clinical features of hyoglycaamia?

Answer 21

• sweating
• palpitations
• shaking
• hunger
• confusion
• drowsiness
• speech difficulty
• incoordination
• headache
• nausea
• seizures
• coma

Question 22

what are teh causes of hypoglycaemia? in diabetics and non diabetics?

Answer 22

↑activity, missed meal, accidental or non-accidental overdose, insulinoma

non diabetics: alcohol, starvation, lvier fialure, addisons, pituitary insufficeincy, certain medication e.g. aspirin, ACEi,,

Question 23

what is the whipples triad for hypoglycaemia?

Answer 23

it confirms a diagnosis of hypoglycaemia:

symptoms or signs of hypoglycemia + ↓plasma glucose + resolution of symptoms or signs post glucose rise

Question 24

what investigations are done when a patient presents with hypoglycaemia?

Answer 24

• whipples triad
• DHx to exlude liver failure
• document BM during attack

Question 25

what is the treatment for hypoglycaemia?

Answer 25

If conscious, and able to swallow, give 15–20g of quick-acting carbohydrate snack and recheck blood glucose after 10/15mins (repeat snack up to 3 times). If conscious but uncooperative, squirt glucose gel between teeth and gums. In unconscious patients, start glucose iv or give glucagon Once blood glucose >4.0mmol/L and patient has recovered, give long-acting carbohydrate

Question 26

what are the main acute complications of diabetes?

Answer 26

- DKA - HHS - hypoglycaemia

Question 27

what are the clinical features of a fundoscopy for diabetic retinopathy?

Answer 27

1. Microaneurysms (dots), haemorrhages (blots), and hard exudates (lipid deposits) 2, Cotton-wool spots (eg infarcts), haemorrhages, venous beading 3. New vessels form

Question 28

what are the features for a diagnosis of diabetes mellitus?

Answer 28

- Symptoms of hyperglycaemia (eg polyuria, polydipsia, unexplained weight loss, visual blurring, genital thrush, lethargy) and raised venous glucose detected once—fasting ≥7mmol/L or random ≥11.1mmol/L OR * Raised venous glucose on two separate occasions—fasting ≥7mmol/L, random ≥11.1mmol/L or oral glucose tolerance test (ogtt)—2h value ≥11.1mmol/L OR * Hba1c ≥48mmol/mol

Question 29

management of TIDM?

Answer 29

insulin

Question 30

what are the four mian types of subcut insulin?

Answer 30

1 Ultra-fast acting (Humalog; Novorapid); inject at start of meal, or just after 2 Isophane insulin (variable peak at 4–12h): CHEAP 3 Pre-mixed insulins (NovoMix 30 = 30% short-acting and 70% long-acting). 4 Long-acting recombinant human insulin analogues (insulin glargine) are used at bedtime in type 1 or 2 dm. There is no awkward peak, so good if nocturnal hypoglycaemia is an issue. Caution if considering pregnancy. Insulin detemir is similar and has a role in intensive insulin regimens for overweight type 2 dm.

Question 31

what are the three different types of insulin regimes?

Answer 31

* ‘bd biphasic regimen’: twice daily premixed insulins by pen (NovoMix 30®)—useful in type 2 dm or type 1 with regular lifestyle. * ‘qds regimen’: before meals ultra-fast insulin + bedtime long-acting analogue: useful in type 1 dm for achieving a flexible lifestyle * Once-daily before-bed long-acting insulin: a good initial insulin regimen when switching from tablets in type 2 dm. Consider retaining metformin (±pioglitazone)

Question 32

WHat is DAFNE?

Answer 32

dose adjustment for normal eating: a course that aims to help adults with type 1 diabetes lead as normal a life as possible, whilst also maintaining blood glucose levels within healthy targets, to reduce the risk of long-term diabetes complications

Question 33

how should insulin dosing chnage in a T1DM patient with an acute illness

Answer 33

advise patietns to stop insulin during an episode of acute illness, need to : Check blood glucose ≥ 4 times a day and look for ketonuria. Increase insulin doses if glucose rising. Advise to get help from a specialist diabetes nurse or gp if concerned

Question 34

when are insulin pumps needed?

Answer 34

Consider when attempts to reach Hba1c with multiple daily injections have resulted in disabling hypoglycaemia or person has been unable to achieve target Hba1c despite careful management

Question 35

what HbA1c is aimed for in diabetes?

Answer 35

<48mmol/mol or 53 if two or more agents

Question 36

name the 6 different types of oral hypoglycaemics (briefly mention their action)

Answer 36

1. biguanide - metformin (increase insulin sensitivity) 2. glitazones - pioglitazone (increase insulin sensitivity) 3. DPP-4 inhibitors - sitagliptin (increase incretin - hormone that triggers insulin release) 4. sulfonylurea - glicazide (increase insulin secretion) 5. SGLT2 inhibitors - dapagliflozin (increased glucose excretion) 6. GLP-1 receptor agonists - exenatide (incretin mimetic)