Diabetes

Question 1

What are the general risk factors for type 2 diabetes mellitus (T2DM)?

Answer 1

• Pancreatitis or pancreatic cancer
• Obesity
• Advanced age
• Glucose intolerance
• Family history of glucose intolerance or diabetes
• Gestational diabetes
• Sedentary lifestyle
• Certain infections

Question 2

What are the risk factors specific to this case study?

Answer 2

• Previous acute pancreatitis
• Increasing weight/obesity
• Possibly excess alcohol consumption (remember high alcohol consumption increases the risk of glucose intolerance, insulin resistance and therefore possibly type 2 diabetes)

Question 3

What are the general signs and symptoms of T2DM?

Answer 3

• Hyperglycemia
• Glycosuria
• Polyuria
• Prolonged wound healing
• Polyphagia
• Ketoacidosis
• Fatigue
• Polydipsia
• Recurrent infections
• Weight loss

Question 4

What are the signs and symptoms specific to this case study?

Answer 4

• Hyperglycemia
• Glycosuria
• Polydipsia (Ben said he was drinking a lot)
• Polyuria
• Ketoacidosis

Question 5

What is diabetes?

Answer 5

Disease that occurs when levels of blood glucose are too high due to insulin insufficiency. There are two types 1 and type 2

Question 6

What is type 1 diabetes?

Answer 6

When there is total insulin deficiency i.e. the pancreas does not produce an effective amount of insulin

Question 7

What is type 2 diabetes?

Answer 7

Related to an insufficient amount of insulin production and/or insulin resistance.

Question 8

What is hyperglycemia?

Answer 8

excess glucose in the blood

Question 9

What kind of complications can hyperglycemia lead to?

Answer 9

Excess amounts of sugar being filtered at the kidneys. Lead to glycosylation. This leads to glucose transporters for reabsorption becoming saturated, thus glucose remains in the filtrate/urine causing glycosuria and polydipsia due to excess water loss.

Question 10

What can the lack of glucose availability for cellular metabolism lead to?

Answer 10

Increased lipolysis and hyperlipidemia which can lead to cardiovascular complications such as atherosclerosis, and ketoacidosis due to increased use of fats for cellular metabolism

Question 11

What complication of increased lipolysis can lead to atherosclerosis?

Answer 11

Hyperlipideamia
Hypercholesterolemia

Question 12

What complication of increased lipolysis can lead to ketoacidosis?

Answer 12

Increased fatty acid use by cells for ATP generation

Question 13

What is glycosylation?

Answer 13

The deposition of glucose on the basement membrane of blood vessels and neurons. This affects the ability of substances to move into or out of the blood stream effectively

Question 14

What kind of complications can glycosylation lead to?

Answer 14

• Nephropathies
• Rentinopathies
• Neuropathies

Question 15

What is retinopathy?

Answer 15

A common complication of diabetes, blood vessel damage from a diabetic retinopathy can cause vision loss in two ways, Macular oedema or proliferative retinopathy.

Question 16

What is macular oedema?

Answer 16

Retinopathy when fluid leaks into the part of the retina responsible for sharp, straight-ahead vision causing swelling & blurred vision

Question 17

What is proliferative retinopathy?

Answer 17

Fragile and abnormal new blood vessels form which easily break, leading to hemorrhages, scarring & retinal detachment

Question 18

How can diabetes lead to vascular damage in the eye?

Answer 18

Hyperglycemia can lead to glycosylation of blood vessels, whereby glucose gets deposited in the basement membrane of capillaries. This decreases effective gas, nutrient and waste and can lead to localised tissue damage, including microvascular damage. The capillaries of the retina are particularly susceptible to this.

Question 19

What is Nephropathy?

Answer 19

Microvascular damage can also affect the glomeruli of the kidneys, leading to kidney disease. Diabetic nephropathy is the leading cause of renal failure.

Question 20

How does diabetes lead to autonomic nephropathy?

Answer 20

Hyperglycemia leads to glycosylation of neurons. This disrupts normal action potential conduction, and when this occurs on neurons of the autonomic nervous system it can affect a variety of functions.

Question 21

What is the cause of the patients bloating and how has he managed this?

Answer 21

The cause is gastroparesis. He manages this by reducing his meals to only one a day with only one or two small snacks; he avoids a big meal before bed.

Question 22

Which division of the autonomic nervous system is affected by neuropathy in the case of erectile dysfunction?

Answer 22

Parasympathetic nervous system. With a decrease in effective action potential conduction along parasympathetic nerves to the penis, there is a loss of the ability to gain an erection.

Question 23

What symptom does the patient experience related to BP and how is this related to autonomic neuropathy?

Answer 23

Postural (orthostatic) hypotension. Standing up too quickly, especially after lying down can lead to a drop in BP. Normally the sympathetic NS is activated to respond to this drop to quickly stabalise BP. With autonomic neuropathy, there is disruption to the action potential output of sympathetic nerves involved in responding to the drop in BP

Question 24

What is peripheral neuropathy?

Answer 24

Similar to autonomic neuropathy in that glycosylation affects action potential conduction in neurons, however, in this case, it is somatosensory neurons in the periphery (mostly the limbs) that are affected.

Question 25

What complications can peripheral neuropathy have?

Answer 25

Increased susceptibility to tissue damage
Decreased wound healing
Increased infection through a lack of sensory awareness

Question 26

What are some diabetic foot pathologies?

Answer 26

Charcot joints
Hammer toe
Infections
Ischaemia
Ulcers
Edema
Fallen arches

Question 27

What are case specific foot pathologies?

Answer 27

Sweating and dryness
Ulceration
Charcot joints
Fallen arches
Gait alterations
Poor wound healing

Question 28

What is the normal range for blood glucose levels?

Answer 28

3-8mmol/L (Fasting: 3-5mmol/L)

Question 29

What was the management of the patients diabetes initally?

Answer 29

For 6 weeks post initial presentation patient was on insulin and this was subsequently stopped and patient was on no medications for 5 years.

Question 30

What changed that meant the patient had to go onto medication again?

Answer 30

Poor diet and lifestyle led to increased weight and poor glucose levels management

Question 31

What medication was the patient on post the 5 years with no medication?

Answer 31

For 5 years metformin only and following this has been on metformin and Humulin NPH (isophane insulin - long acting insulin), and he supplements this with humalog

Question 32

What is humalog?

Answer 32

A rapid onset, short acting insulin that can be taken before or shortly after meals to lower blood sugar levels

Question 33

What are the advantages and disadvantages of using a chart to calculate insulin requirements?

Answer 33

Using a chart to calculate insulin requirements is easy for people who have trouble figuring out how much insulin to take. A disadvantage is the the cahrt could be generic, and not specific to Ben and how his body handles insulin

Question 34

How does the patient describe HbA1C and why is it a good indicator of glycemic control?

Answer 34

Glycosylated hemoglobin. Hemoglobin accumulates glucose over the lifetime of a RBC and therefore glycosylated hemoglobin/HbA1C reflects the average glucose concentration over the previous few months.

Question 35

What lifestyle changes has the patient made?

Answer 35

800-900 km a month on his bike
1hr swimming a day
HbA1C 7.1 fairly stable