Diabetes Flashcards
Physical complications of DM
retinopathy, nephropathy, neuropathy cardiovascular disease (including cerebro- and peripheral), and gum disease
physical symptoms of diabetes which would include:
Polyuria
Polydipsia/unquenchable thirst
Weakness and fatigue
Weight loss without trying
History taking
The main aspects of history include the patient‟s knowledge of his glucose control; compliance with diabetes treatment including insulin; his smoking status, and family history including early coronary artery disease.
The candidate should enquire about complications of diabetes that include retinopathy (blurred/impaired vision, cataracts), nephropathy (proteinuria picked up on previous testing), erectile dysfunction/impotence, tooth decay, gingivitis (bleeding/sore gums), gum infection (oral candidiasis) and less commonly dry mouth (xerostomia). Other signs and symptoms include dermopathies (skin that is dry or itchy, frequent infections or cuts and bruises that take a long time to heal). Inquiry should also be made of a history of cardiac problems and risk factors for coronary artery disease (CAD) including hypertension and dyslipidaemia. General complications are more common when coupled with macrovascular disease associated with high cholesterol, hypertension or obesity
Specific to this case, more detailed exploration of the leg discomfort for symptoms of neuropathy and peripheral vascular disease (PVD). As peripheral vascular disease becomes worse, it leads to pain in the muscles of the leg on walking (intermittent claudication). Important aspects of claudication pain are that the pain is reproducible within the same muscle groups on exercise and that it ceases with a resting period of 2-5 minutes. As the disease becomes very severe, more serious problems can develop. (The most worrying symptoms are a continuous pain (rest pain) in the foot especially at night, black toes and ulceration due to ischaemia. In these patients the nocturnal pain is only eased when the leg is dangled down over the edge of the bed. When this happens and tests show reduced blood flow, then critical limb ischaemia has developed and the leg is at risk of amputation).
The symptoms of claudication can be mimicked by many other conditions which cause pain in the legs such as arthritis and nerve problems. Neurogenic claudication, more commonly called lumbar stenosis, is pain in the legs due to compression neuropathy in the spinal cord and can be very difficult to distinguish from claudication due to arterial problems.
Neuropathy is secondary to microvascular disease processes where hyperglycaemic damages to body proteins affect endothelium and basement membranes leading to myelin damage. Neuropathy can affect every organ in the body including hands and feet, digestive tract, bladder and sexual organs. Nerve damage can also affect the ability to feel the symptoms of hypoglycaemia. Neuropathy occurs in highest rates among people who have had diabetes for at least 25 years. It is also more prevalent among people with poor diabetic control.
Symptoms depend on the type of neuropathy and which nerves are affected. Because it develops slowly, mild cases can go unnoticed for a long time. The five most common forms of neuropathy are „glove and stocking‟; autonomic; mononeuritis multiplex (III cranial nerve); radial and peroneal nerve damage (wrist and foot drop); and radicular (pain similar to shingles).The following symptoms can indicate some form of neuropathy:
Numbness, tingling or pain in the toes, feet, legs, hands, arms and fingers
Sensitivity to touch
Indigestion, nausea or vomiting secondary to gastroparesis
Diarrhoea or less commonly, constipation
Dizziness or postural hypotension
Urinary retention
Loss of balance or coordination
Sexual problems, such as erectile dysfunction in men
(Peripheral vascular disease (PVD) may also lead to impotence in men called Leriche syndrome).
Physical exam
should look for atrophy of calf muscles, loss of extremity hair, skin nutrition and evidence of diabetic dermopathies (including cracks, shiny skin, recurrent infections, ulcers), or evidence of venous stasis (itching of the skin and small ulcers on the legs – but not the feet) which are clues to underlying peripheral arterial occlusive disease. Foot examination includes comment on presence or absence of erythema, increased warmth or callus formation that when present would indicate tissue damage. Assessment of peripheral pulses and capillary return in the big toe (and in thumb).
Inspection for hammer toes (soft tissue problems), trauma, poor chiropody, skin integrity especially between the toes and under the metatarsal heads (NB: tinea infections) and Charcots foot (neurogenic arthropathy causing rapidly progressive degenerative arthritis of the joints in the foot affecting pain perception, position sense and muscle support for joints. Loss of motor and sensory nerve functions allows minor traumas like sprains and stress fractures to go undetected and untreated, leading to ligament laxity (slackness), joint dislocation, bone erosion, cartilage damage, and deformity of the foot).
Assessment for loss of protective sensation is best done by assessment of vibration sense (in this exam using a 128Hz tuning fork), or pinprick sensation, or ankle reflexes (note, while use of microfilament for assessment of sensation is current practice, the equipment is not available in this OSCE station). Balance and gait may also be assessed.
Additional assessment, to be discussed in the third task, would include a comprehensive skin examination including insulin injection sites for lypohypertrophy (and less commonly, fat necrosis). The candidate should comment on pulse and blood pressure (hypertension or postural hypotension), lens status (cataracts), pupils (unequal if 3rd nerve lesion) and iris (rubeosis – new vessel formation).
The candidate should also comment on the need to examine the eyes for visual acuity (Snellen chart) and perform fundoscopy (better candidates may note that this examination is done with dilated pupils), and should recommend weight and calculation of BMI and/or hip-to-waist ratio.
Investigations
The candidate should comment on the need to include specific blood screening for fasting blood glucose, HbA1C (to determine recent historical diabetic control with <7%, or 48-59mmol/mol, indicating good control), fasting cholesterol and triglycerides, and renal function tests (e.g. urea and creatinine), random urine for total protein: creatinine and albumin:creatinie ratios, and possibly estimated glomerular filtration rate (est GFR). (Dipstix urine for glucose, protein, ketones or blood is a sensitive test alongside additional urine analysis). Additionally, ECG for evidence of cardiovascular disease (MI or other ischaemic changes on ECG), given his risk factors for coronary artery disease (diabetes, smoking, hypertension, family history of cardiac disease).
Duplex ultrasonography is a useful method of evaluating the status of a patient‟s vascular disease. Duplex scanning has the advantage of being noninvasive and requiring no contrast media, but duplex scanning is very technician dependent. Angiography is the criterion standard arterial imaging study used in the diagnosis of peripheral arterial occlusive disease and can be considered after ultrasonography.
Managements
Initial management for this patient includes the following aspects: review of current treatment, including insulin, regular monitoring of blood glucose and blood pressure whilst on ward, and requesting consult-liaison advice from a physician and/or diabetes nurse educator plus a dietician if available about these issues. Check that recommended options of antihypertensives are being prescribed - in people presenting with Type II diabetes and blood pressure above target (130/80 in diabetes), angiotensin converting enzyme inhibitors (e.g. Perindopril) and angiotensin receptor blockers can be used as initial therapy in order to prevent or attenuate macrovascular and microvascular complications. β-blockers are primarily helpful in heart disease but can reduce awareness of hypoglycaemia secondary to blockade of adrenergic symptoms.
Insulin sometimes does need to be added to oral medications in Type II DM. This generally occurs after many years as the β-cells progressively die. This accounts for the dual process occurring where there is insulin resistance plus a slow reduction in insulin secretion over time. Most people with Type II DM will continue oral medications like Metformin, though doses can be reduced or even stopped with time. Indicated treatment regimes are usually long-acting nocte doses (to provide basal/background levels of insulin), starting at about 20units nocte and increasing according to response. Use of ultra-short acting insulin boluses prior to meals are less much commonly prescribed in Type II DM than in Type I. Home blood glucose testing should be done every morning in Type II (and pre-meal if using ultra-short acting insulin). Levels should ideally be between 4- 7mmol/L and clients are encouraged to keep levels below 10mmol/L and aim for at least below 8mmol/L.
Research has shown (e.g. Gæde et al) that the following are the most important part of any management plan. The candidate should take some responsibility for psychoeducation with the patient with regard to the importance of:
Managing blood glucose levels in the recommended range
Keeping blood pressure within a healthy range (<130/80 for diabetes, lower with proteinuria)
Stopping smoking
Getting physical activity every day
Losing weight into the recommended range
Controlling cholesterol and triglycerides through a healthy meal plan
Choosing lean meats and foods with lower salt and fat
Talking to their case manager, psychiatrist or GP about any concerns
Maintaining his low levels of alcohol consumption.
Discharge arrangements should be in conjunction with his GP should prioritise the need for a foot check with a podiatrist or similar due to the presenting complaint. Other specific aspects include: discussion with the GP and patient around arrangements for annual optometrist appointments to look for cataracts and glaucoma and undertake a dilated-eye exam to assess for proliferative and non-proliferative retinopathy; reducing the risk of complications by ensuring review by specialised diabetes clinic or similar and ongoing access to counselling regarding lifestyle interventions (diet, weight loss, increased physical activity, smoking cessation); regular dental checks to assess for periodontal disease, gingivitis and possibly oral candidiasis, or tooth decay from xerostomia.
