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Year 3 Medicine > Diabetes > Flashcards

Diabetes Flashcards

1
Q

What is Diabetes Insipidus?

A

Reduced ADH secretion/kidney response to ADH causes passage of large volumes of dilute urine

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2
Q

Give 3 symptoms of Diabetes Insipidus

A

Polyuria
Polydipsia
Dehydration

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3
Q

Give 3 causes of Cranial DI

A

Congenital (ADH genetic defects)
Tumour
Trauma

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4
Q

GIve 3 causes of Nephrogenic DI

A

Inherited
Chronic Renal Disease
Drugs (Lithium, Demeclocycline)

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5
Q

What 4 investigations could you do if you suspected DI?

A

Us and Es (?hypernatraemia)
Glucose (rule out DM)
Plasma:Urine Osmolality (rule out primary polydipsia, urine should be no more that twice as conc)
8hr Deprivation Test (<700)

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6
Q

How would you treat Cranial DI?

A

Desmopressin

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7
Q

How would you treat Nephrogenic DI?

A

Treat underlying causes
NSAIDs (Prostaglandins locally inhibit ADH)
Bendroflumethiazide (inducing hypovolaemia may kickstart RAAS)

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8
Q

Describe the pathophysiology of Type 1 DM

A

Onset in childhood
Autoimmune destruction of pancreatic B cells
HLA association

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9
Q

Describe the pathophysiology of Type 2 DM

A

Decreased insulin secretion/increased insulin resistance
Associated with obesity/sedentary lifestyle
No HLA association
There is an autosomal dominant form affecting young people - MODY

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10
Q

Give 4 other causes of DM

A

Steroids
Pancreatitis
Cushings Disease
Glycogen Storage Disease

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11
Q

What is the triad of DM symptoms

A

Polyuria
Polydipsia
Weight Loss

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12
Q

What are the parameters for diagnosing DM in terms of Venous Glucose?

A

Fasting >7mmol/l
Random >11.1mmol/l

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13
Q

What is the parameter for diagnosing DM using the OGTT?

A

> 11.1mmol/l

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14
Q

What is the parameter for diagnosing DM using HbA1c?

A

> 48mmol/l
6.5%

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15
Q

What are the parameters for ‘Pre-Diabetes’?

A

Fasting glucose of 5.5-6.9mmol/l
HbA1c of 42-47mmol/l (6-6.4%)

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16
Q

What is required for a Diabetes diagnosis?

A

Either
Symptoms and ONE positive blood result
Or
Positive bloods on two separate occasions

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17
Q

What advice would you give patients who are diagnosed with Type 1 DM? Give 4 points.

A

Review and research diet
Try to limit other things contributing to CVS risk
Ensure foot care
Avoid binge drinking (delayed hypoglycaemia)

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18
Q

Name one ultrafast, one medium and one long acting insulin

A

Ultrafast - Novorapid
Medium - Isophane Insulin
Long - Insulin Glargine

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19
Q

Name a premixed insulin

A

Novomix (30% short, 70%long)

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20
Q

Describe 2 different regimens to manage T1DM

A

Basal Bolus - rapid acting at meals and two long acting (determir)
BD - Twice Novomix daily

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21
Q

What could you give patients if they struggle with the insulin regime?

A

Insulin Pump

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22
Q

Give three important pieces of advice for T1DM regarding insulin

A

Vary injection site
Change needles
Continue insulin if ill (and replace lost calories with milk)

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23
Q

Describe the 4 step (up) therapy for T2DM

A

1) Lifestyle and Diet
2) Metformin
3) Dual Therapy (Metformin + another)
4) Triple Therapy or Insulin Therapy

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24
Q

What is Metformin’s action?

A

Biguanide that increases insulin sensitivity

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25
Q

Give 3 SE of Metformin

A

Nausea, Abdo Pain, Lactic Acidosis (in renal impairment)

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26
Q

Name a DPP4 Inhibitor. What is it’s action?

A

Sitagliptin
DPP4 destroys incretins which enhance insulin release

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27
Q

Name a Glitazone. What is it’s action?

A

Pioglitazone
Increases insulin sensitivity

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28
Q

When are Glitazones contraindicated? What are their side effects?

A

CI - Osteoporosis, CCF
SE - Hypoglycaemia, Fractures

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29
Q

Name a Sulphonylurea? What is it’s action?

A

Gliclazide
Increases insulin secretion by binding to ATP sensitive potassium channels, closing them

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30
Q

Name an SGLT2 inhibitor. What is it’s action?

A

Dapaglifozin
Blocks glucose reabsorption in the PCT

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31
Q

Name a GLP1 analogue. What is it’s action?

A

Exenatide
Incretin mimics

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32
Q

Name four complications of Diabetes

A

Vascular disease
Nephropathy
Retinopathy
Neuropathy

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33
Q

Give two eye diseases associated with Diabetes

A

Diabetic Retinopathy
Cataracts

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34
Q

Describe the pathophysiology of Diabetic Retinopathy

A

Microvascular occlusion causes retinal ischaemia
Leads to AV shunts, Neovascularisation and Oedema

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35
Q

Describe 3 characteristic features of Diabetic Retinopathy

A

Microaneurysms - physical weakening of vascular walls
Haemorrhages - when weakened vessels rupture, can be small or large (AKA Flame - track along nerve-fibre bundles in superficial retinal layers)
Cotton Wool Spots - Build up of axonal debris

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36
Q

How would Diabetic Retinopathy present?

A

Often gradual painless visual deterioration
If haemorrhages - sudden onset of dark, painless floaters which may resolve over several days.

37
Q

Most Diabetic Retinopathies are not treated, however if they are, give 2 treatment options

A

Laser Treatment - aim is to induce regression of new blood vessels and reduce central macular thickening

Intravitreal Steroids

38
Q

Give 4 possible features of foot neuropathy

A

Reduced sensation in stocking distribution
Absent ankle jerks
Charcot Joint
Claw Toes

39
Q

How would a diabetic ulcer present?

A

Punched out ulcer in area of thick callus

40
Q

Describe 3 non surgical managements of ‘Diabetic Foot’

A

Regular Chiropody
Bisphophonates
Antibiotics

41
Q

Hypoglycaemia is classified as <3mmol/l glucose. Majority of times it’s a diabetic cause, but using the mnemonic EXPLAIN, state 7 non diabetic causes.

A

Exogenous Drugs (ACEI, B Blockers)
Pituitary Insufficiency
Liver Failure
Addisons
Insulinoma
Non pancreatic Neoplasms

42
Q

Give 3 autonomic and 3 neuroglycopenic symptoms of Hypoglycaemia.

A

Autonomic - Sweating, Anxiety, Hunger
Neuroglycopenic - Confusion, Drowsiness, Coma

43
Q

What is Whipple’s Triad?

A

Symptoms + Hypoglycaemia + Resolution as plasma glucose rises

44
Q

Describe the pathophyiology of DKA

A

Without insulin to drive glucose into the cells, the body is forced into starvation state, using ketones for energy and causing acidosis

45
Q

Name three triggers of DKA

A

Infection
Non Compliance
Chemo

46
Q

Name 5 symptoms of DKA

A

Drowsiness
Vomiting
Dehydration
Abdo Pain
Polydipsia

47
Q

Describe 3 diagnostic classifications of DKA

A

VBG pH<7.3
Glucose>11.1mmol/l
Ketonaemia (>3mmol/l) or Ketonuria

48
Q

Describe a four step management plan of DKA

A

1) IV 0.9% NaCL - 1L over an hour
2) Insulin at 0.1 unit/kg/h
3) Monitor K+ - ?add to next bag of fluid
4) Start 5% Dextrose infusion when CBG<15

49
Q

Give 3 complications of DKA

A

Cerebral Oedema
Hypokalaemia
Aspiration Pneumonia

50
Q

What is a Hyperosmolar Hyperglycaemic State?

A

Seen in unwell patients with T2DM
Hx of a weeks dehydration with glucose>30mmol/l
NO KETONE METABOLISM

51
Q

How would you manage Hyperosmolar Hyperglycaemic State?

A

Rehydrate slowly
Replace K+ when urine starts to flow
Only use insulin if glucose isn’t reducing

52
Q

Describe the different between Dry and Wet Gangrene

A

Dry Gangrene - Black ‘mummified’ toes that often autoamputate
Wet Gangrene - indicates infection

53
Q

Describe four features indicating Necrotising Fasciitis from Diabetic Foot

A

Spreading Cellulitis
Black Spots
Dishwater Fluid Appearance
Crepitus (tissue paper sound when pressing - gas gangrene)

54
Q

Describe two features you are looking for on an X-Ray of a diabetic foot

A

Osteomyelitis
Gas Gangrene

55
Q

Why is ABPI generally done on right arm?

A

Steal Syndrome is more common on the left
You generally stand to the right of the patient

56
Q

Explain the ABPI value indicating Diabetic Foot

A

> 1.2
Due to calcification of the peripheral arteries increasing the pressure (NOT because they have superior blood flow to PAD)

57
Q

Describe the Doppler Sounds of vessels

A

Monophasic
Biphasic
Triphasic

Monophasic is diseased, and triphasic is healthy (you can hear the elastic recoil in competent vessels)

58
Q

Using the mnemonic SWOMPD, how would you manage a diabetic foot?

A

Sepsis
Wound Management
Offloading (Orthotics)
Mechanical (Orthopaedics input)
Perfusion (Lifestyle, Meds, Surgical)
Diabetic Control

59
Q

What antimicrobials would you use for MILD Diabetic Foot?

A

Flucloxacillin

60
Q

What antimicrobials would you use for MODERATE Diabetic Foot?

A

Flucloxacillin, Ciprofloxacin and Metronidazole

61
Q

What antimicrobials would you use for SEVERE Diabetic Foot?

A

Piperacillin, Tazobactam and Vancomycin

62
Q

What investigation should you do if atypical features for diabetes?

A

C Peptide

63
Q

Give three scenarios where HbA1c cannot be used

A

Haemoglobinopathies
Children
CKD

64
Q

What is impaired glucose tolerance?

A

OGTT more than 7.8 but less than 11.1

65
Q

Describe T1DM monitoring

A

HbA1c three monthly
Self monitoring QDS
Aim for 4-7mmol/l

66
Q

What medication could you add to overweight patient’s T1DM medication?

A

Metformin

67
Q

Describe the sick day rules for diabetes

A

Monitor CBG more frequently
Have access fo phone
Don’t change hypoglycaemic/insulin dose (stop metformin if dehydrated)

Can consider corrective dose if rising glucose/insulin - 10-20%

68
Q

What diet measures should you encourage in T2DM

A

High fibre
Low glycaemic index
Low fat

Target weight loss 5-10%

69
Q

When should you start dual therapy in T2DM?

A

When HbA1c is 58mmol/l

70
Q

With what oral hypoglycaemic agent are you permitted a higher target HbA1c?

A

Sulphonylureas (eg Gliclazide) as can cause hypoglycaemia

71
Q

How can the GI side effects of Metformin be minimised?

A

Titrate up slowly

Modified release

72
Q

If Metformin is contraindicated what can be used first line?

A

Gliptins (DPP4 inhib)
Glitazones
Gliclazide (Sulphonylureas)

Can use Glifozins if CVD profile

73
Q

What should be added to Metformin in patients with significant cardiac history?

A

Glifozins (SGLT2 inhib)

74
Q

When can GLP1 analogues be trialled?

A

If failure of triple therapy and insulin

Or unsuitable for insulin

75
Q

What are the recommended adjustments during Ramadan for diabetic patients?

A

High carbohydrate meal before sunrise
Splitting oral hypoglycaemic dose so majority is post sunrise
Regular monitoring

76
Q

What are the DVLA rules regarding Diabetics

A

Have to have no hypoglycaemic episodes and have full glycaemic awareness if on insulin

HGV drivers must also provide regular glucose monitoring

77
Q

Name three GI neuropathic manifestations of diabetes

A

Gastroparesis
Chronic Diarrhoea
GORD

78
Q

Describe diabetic foot screening

A

Annual screening for pulses and sensation

If moderate to high risk of diabetic foot - refer to local diabetes centre

79
Q

How would you manage Hypoglycaemia?

A

Alert - quick-acting glucose/glucogel, use of hypobox

Unconscious - IM glucagon, or if good access 20% glucose

80
Q

At what BGC do you experience neuroglycopenic symptoms?

A

<2.8

81
Q

What should be done about patients long-term insulin during DKA?

A

Stop short-acting, continue long-acting

82
Q

When has a DKA resolved?

A

pH>7.3
Bicarb>15
Ketones<0.6

Can start short-acting once eating and drinking
If not resolved in 24h - endocrinologist

83
Q

What is the process behind Hyperosmolar Hyperglycaemic State?

A

Osmotic Diuresis

84
Q

Why should you give VTE prophylaxis in HHS?

A

Hyperviscocity can result in MI/Stroke

85
Q

Why is HHS more deadly than DKA?

A

Happens gradually over a few days therefore electrolyte disturbances are normally more severe

86
Q

Name three criteria to indicate HHS

A

Marked Hypovolaemia
Serum Osmolaltiy > 320 (high osmolality)
No ketonaemia

87
Q

When should insulin be administered in HHS?

A

Only if significant ketones or glucose refractory to fluids

Glucose between 10-15 is satisfactory

88
Q

Why should fluid be administered carefully?

A

Risk of Cerebral Pontine Myelinolysis due to fluid shifts

aim to give 3-6L over 12h

89
Q

Describe the water deprivation test for Diabetes Insipidus

A

Prevent patient from drinking and take hourly osmolalities
After deprivation : Cranial and Nephrogenic Insipidus still have low urine osmalality
Primary Polydipsia has high (as can concentrate urine)

High concentration after desmopressin = cranial

Year 3 Medicine (10 decks)

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