Diabetes Flashcards
Symptoms of DKA
Polyuria polydipsia weight loss weakness Nausea vomiting leg cramps blurred vision abdominal pain
Signs of DKA
Kussmaul breathing (deep and laboured breathing), dehydration Hypotension - postural or supine Cold extremities/peripheral cyanosis tachycardia smell of acetone hypothermia confusion, drowsiness, coma
How to differentiate between DKA and HONK
Different to DKA – severe hyperglycaemia = osmotic diuresis and lack of hydration
usually in old people with not enough water or complication of T2D
Causes osmotic diuresis and severe dehydration only (not ketone bodies or acidosis)
no nausea
no vomiting
no kussmaul breathing
Symptoms and signs of Hypoglycaemia
Causes from lack of eating sweating, tachycardia, dizziness, palpitation, Hunger Anxiety CNS confusion (remember back to EM - always check glucose in confused patients) Drowsiness Speech difficulty Inability to concentrate Incoordination Irritability and anger Nausea Tiredness Headache
Retinopathy of diabetes
Non proliferative = Cataract (sorbitol), Microaneursyms (Dots), Haemorrhages (Blots), Hard exudate, Soft/cotton wool infarcts
Proliferative = Neovascularisation, Retina sheet haemorrhages, Retinal detachment.
Nephropathy of diabetes
Nodular glomerulosclerosis
Pyelonephritis
Necrotising papilitis
Renal artery atherosclerosis
Neuropathy of diabetes
Focal demyelination due to microangiopathy and direct glycosylation
PNS - Sensory then motor. Bilateral, distal, pains and needles in glove and sock pattern. Progressive and irreversible
Visceral nerves
- CN = diplopia, bells palsy
- GIT - constipation or diarrhoea
- CNS - Postural hypotension
Dermatopathy of diabetes
Neuropathic ulcer (on pressure point, painless, hyperkeratosis around. Loss of sensation but blood flow not affected) Diabetic Xanthoma (Red, yellow, pruritic, painful) Gangree (most common)
Diagnosis of T2D
FBG >/= 7 on two separate occasions
2 hour postprandial >11 on OGTT on two separate occasions
HbA1c >6.5% on 2 separate occasion
Or symptomatic pt with 1 raised blood level.
Classic symptoms of uncontrolled diabetes
Polyuria (every 1hr or so) Polydipsia Loss of wt if type 1 Tiredness and fatigue Characteristic breath Propensity for infections sep, of the skin and genitals
Ix to order to screen for diabetes
After AUSRISK
FBG or RBG
Then HbA1c as not funded.
Mx of a new diabetic
Advise road traffic authority Assess modifiable risk factors Assess CVD risk PAID tool Refer to diabetes teams Medication - Type 1 - Insulin. Basal bolus and Rapid if needed - Type 2 - Lifestyle, Metformin or sulphonylureas or Alpha glucosidase inhibitors , or glitazones, or meglitinides.
Mx of diabetic
Achieve strict glycemic control 30min/d. Referral to ophthalmologist Goals of management - No smoking - Alcohol - = 2 drinks per day Chronic disease plan
Examination of a diabetic patient
GI - Gait - ask the patient to walk
Overweight, acanthosis nigricans, hemochromatosis coloration. look behind neck
Dehydration. recent wt loss, pigmentation (haemochromatosis)
Vital signs: No change in O2 saturation, RR HR and BP if presenting alone. Increased BSL and increased BMI expected.
Diabetic foot exam
Inspection:
Structure – bunions, hallux valgus, pes-cavus, pes plantus
Vascular – pedal oedema, atrophic shiny skin, hair loss
Infection – check legs and feet for ulcers, including between toes, boils, Cellulitis
Neurological – Charcot’s joint, wasting of quadriceps
Other – necrobiosis lipoidica diabeticorum and diabetic dermopathy.
Top to bottom - Thigh wasting, charcot joint, Loss of hair, thin atrophic, shiny skin, pedal oedema, dry skin, diabetic dermopathy (pigment over skin), skin discolouration, venous stasis, fungal nail, thickening nail, boils, cellulitis, ulcer, hallaux values, bunions, calluses, Pes cavus/Pes planus.
Palpation: Feel warmth of legs, peripheral pulses and CRT.
Light touch at 10 points on foot, sharp touch on dorsum of foot, vibration at distal hallux, proprioception.
Perform a survey of muscle tone, power and bulk.
Perform reflexes at knee, ankle and plantar surface of foot.
For completion
Face - Fundiscopy for proliferative and non proliferative diabetic retinopathy or hypertension retinopathy. cataracts
Mouth - signs of infection and fetor, dehydration
CVS - Cardiomyopathy, IHD
Resp - signs of infection
GIT - injection site and fat atrophy.
Neuro - peripheral and central neuropathy
Q to ask a known diabetic
- Age of Dx
- Insulin required from the start?
- Presentation that lead to Dx
- what previous and current tx r u on?
- Diet?
- Self monitoring? ranges?
- Previous hypos? sweating, confusion, malaise or LOC?
- Does pt know what to do if hypo or hyper happens?
- Hx of DKA and hospital admission?
- Cx of diabetes e.g. eyes, nerves BV, kidneys
- Any regular testing for Cx
- How is the pt and their family coping
- Ability to work?
Symptoms of Diabetes
Polyuria Polydypsia Polyphagia with hyperglycemia \+/- fatigue and infections (e.g. candida) altered peripheral sensations, frequent infections, visual changes and changes in skin pigmentation. Weight loss
Causes of secondary diabetes
Excess hyperglycaemic stimulus =
Cushings, Phaeochromocytoma, acromegaly, steriod therapy
Beta cell destruction =
Pacnreatitis/ Tumors/Hemochromatosis (Bronze diabetes)
Infectious - congenital rubella, CMV, TB
Endocrinopathy, Down Syndrome
Risk factors for T2D
Increase waist circumfance W=>88cm, M=>102cm
Increase BP >140/90
Increase triglycerides>1.7mmol/L
What is metabolic syndrome
Central obesity
Hypertension >/=130
Hyperglycaemia FBG >5.5
dyslipidaemia = High TG and low HDL
risk factors for insulin resistance
Metabolic syndrome Obese Asians TB drugs, SSRI Pregnancy Acromegaly, cushing Renal failure Cystic fibrosis Polycystic ovary Werner's syndrome
Treatment aim for T2D
Address vascular risk factors Quit smokers and excess alcohol Structured education on targets and motivation MDT Foot care Pre conception advice Life style changes first Medication - metformin, Statins and antihypertensive Self monitoring RV 3-6 months and evaluated yearly
Cardiovascular risk factors
Modifiable risk factors
HTN, Tobacco, High blood glucose, unhealthy diet, cholesterol/lipids, over Wt/obesity
Non-modifiable risk factors
Age, male gender, fmHx.
Targets for blood test for diabetes
FBG - 6-8 Pre-prandial blood glucose 6-8 Post prandial blood glucose 6-10 Hb1Ac 1 Total cholesterol
Counsel a pt on metformin
Biguanide
Aim - increase insulin sensitivity and help wt
MOA - Reduces hepatic gluconeogenesis and hence insulin requirements
SE - nausea, diarrhoea, abdominal pain. No hypoglycaemia
Precautions - Avoid if eGFR 7 on highest dose 16wks after starting then add Sulfonylurea. Severe heart failur, liver disease or renal failure=Lactic acidosis and fatal metabolic Cx.
Dose - Immediate release 500g BD up to 1g TDS. Extended release 1g with evening meal up to 2g.
Other pharmacological options other then metformin
Sulfonylureas - increase insulin secretion. risk of hypoglycaemia. DPP 4 inhibitor GLP 1 agonist Basal insulin Thiazolidinediones
What is done at the 3-6 month RV
Symptoms and SMBG results HbA1c BP Wt +/- waist circumference Foot examination (high risk pt)
What is done at the yearly RV
Blood lipids Microalbuminuria and plasma creatinine/eGFR Eye RV (2yrly if no retinopathy) Foot examination (low risk pt) Look at Mx goals Smoking healthy eating Physical activity Self care education Medications Immunisation T1D - autoimmune screen for TFT and coeliac.
Tx of metabolic syndrome
Exercise Statins wt loss antihypertensives hypoglycaemic medications Explain benefits as close relationship between depression and insulin resistance
Symptoms of mild to moderate hyperglycaemia
Asymptomic Thirst, poly uria and poly dipsia Blurred vision balanitis in men and pruritus vulvae in women Lethargy adn somnolence Weight loss and weakness Anorexia and nausea Recurrent skin infections
Symptoms of severe hyperglycaemia
Severe thirst
Drowsiness or coma
Vomiting
Classic presentation of T1D
Short Hx of severe symptoms
Sometimes with DKA
Common presentations of T2d
Detected on screening
Or a long history of less severe symptoms.
Or as a complication
Eg infections, visual impairment, arterial disease, neuropathy, renal failure
Diagnostic criteria for diabetes
1 abn blood test if symptomatic or 2 if asymptomatic
RBG equal to or greater than 11mmol/L
FBG equal to or greater than 7 mmol/L
OGTT 2hr equal to or greater then 11 mmol/L
Criteria for impaired glucose tolerance
FBG less then 7
OGTT 2hr - between 7.8 to 10.9
*impaired fasting glycaemia if FBG is 6.1 to 6.9
