Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

Endocrinology (Long) > Diabetes > Flashcards

Diabetes Flashcards

1
Q

Diabetes History? (not PRICMCP!) ****

A

DIABETIC’s Follow-up (or DIABEdIC’s Follow-up)

Date of diagnosis

Insulin & other OHG - when did it start, current treatment, compliance

A1C (HbA1C)

BSL monitoring - how often, when, who, hypo episodes and awareness. What is your symptoms of hypos, do you feel lethargic in the morning, night sweats? (nocturnal hypo)

Education - level of understanding (do you know danger of not monitoring, not checking it before driving, complications long-term, danger of hypos?)

The Diet & exercise. Do they carbo-count (if not, suspect poor health-literacy)

Immediate/short-term complications: Infection, ICU admissions, hospitalisations with DKA/HHS.

  • Hypoglycaemia: how symptomatic? LOC (suspect hypo-unawareness)

Chronic complications: Macro (CVD, CVA, PVD) & Microvascular (retino - any laser treatment, nephro, neuro - erectile dysfunction, fainting, nocturnal diarrhoea, gastroparesis, PN)

Sick day management/Safety: driving, do you have action plan (for hypos)

Follow-up: Endocrinologist/GP, Podiatry 3 monthly, Ophthal 12 monthly.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Give carbo-count example.

A

1 unit of insulin for every 10g of Carbohydrate is an example.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

How would you ask about microvascular complications of diabetes? (for neuro - 4)

A

Retinopathy: when was the last eye-exam, what was the results, any blurred vision?

Nephropathy: did doctors tell you that your kidney function is abnormal? or diabetes affected your kidneys?

Neuropathy:

  • Any numbness, tingling or weakness in legs? (PN)
  • Do you suffer from fainting, or dizzy when you stand up? (autonomic neuropathy)
  • Do you have diarrhoea at night? (nocturnal diarrhoea)
  • Erectile dysfunction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What 3 aspects of safety issues must be addressed?

A
  • Medication – cognition, who supervises them
  • Sick day (and perioperative Mx)
  • Driving (hypoglycaemia and vision)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are the essential components of sick day management? (4)

A
  1. Knowing when to commence an action plan - unwell or BSL >15
  2. ↑ frequency of monitoring – 2-4 hourly
  3. ↑ food & water intake
  • try to maintain normal meal plan, water to prevent dehydration
  • If BSL >15: use sugar free fluids
  • If BSL <15: use oral rehydration solutions (may contain glucose)
  • If unable to tolerate oral fluids & BSL ↓ - seek medical attention
  1. Medication
  • Insulin
    • should generally be continued → see a doctor if BSL >15 on 2 consecutive readings.
    • ↑ long-acting insulin by 10-20% if hyper
    • ↓ short-acting insulin if not eating well
  • OHGs
    • If vomiting / dehydrated → metformin, GLP1 RA may need to be stopped (worsens NV)
    • SGLT-2 inhibitors should be ceased (worsens dehydration & euglycaemic DKA)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are the features of autonomic neuropathy in diabetics? (4)

A

Erectile dysfunction

Postural hypotension

Gastroparesis

Nocturnal diarrhoea

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Diabetes - examinations? (7 areas)

A

BMI

Retinopathy: proliferative or non-proliferative

Acanthosis nigricans & Skin tags (signs of insulin resistance)

Cardio: postural BP, heart failure, peripheral pulses

Abdomen: insulin injection sites / thighs (Lipodystrophy)

LL neuro - monofilament, vibration, reflexes

Foot: Charcot’s (?any collapse of foot arch)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

How do you perform a monofilament test?

A

How: Hold the monofilament perpendicular to the foot and with a smooth, steady motion, touch the skin until the monofilament bends approximately 1 cm. Hold it against the skin for approximately 2 seconds.

Positive test if the patient can’t feel it.

Indicates peripheral neuropathy.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Signs of Charcot’s foot? (4)

A

Foot swelling

Redness

Warm

Deformed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What do you must check before you start a patient on Insulin therapy? (3)

A

Cognition - who will administer them?

Eye sight - visual acuity

Hand function - fine-motor to administer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Insulin – pros (2) and cons (3)?

A

Pros:

  • No ceiling effect
  • Minimal problems in renal or hepatic disease
  • Few non-physiologic adverse effects

Cons:

  • Hypoglycaemia and weight gain
  • Injection only – needs good hands and eyes
  • Can have variable absorption if injection site not rotated
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Metformin – pros (3)& cons (3)?

A

Pros:

  • Relatively potent (HbA1c reduction of 1%)
  • hypoglycaemia unlikely
  • weight loss
  • improves cardiovascular outcomes in overweight patients

Cons

  • Renal disease (contraindicated < 30 eGFR)
  • GI side effects (nausea and diarrhea)
  • Lactic acidosis (rare)
  • B12 deficiency – needs regular checking
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Diabetic on Metformin waiting for Contrast-CT scan: any thoughts?

A

It can interact with radiocontrast material

May worsen renal impairment

Stop Metformin on a day of procedure requiring contrast and 48 hours post

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Sulfonylureas – e.g. gliclazides pros (2) & cons (3)

A

Pros:

  • Similar potency to metformin (HbA1c reduction of 1%)
  • Cheap

Cons

  • Hypoglycaemia
  • Weight gain
  • Not safe in renal impairment
  • Worse risk profile in elderly

** High threshold to start de novo, low threshold to cease **

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

DPP-IV inhibitors (Gliptins) – pros? (3)

A
  • Dipeptidyl-peptidase IV inhibitors
  • Good potency (0.5 - 1% HbA1c reductions)
  • Weight neutral
  • Unlikely to cause hypoglycaemia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

DPP-IV inhibitors - what are the precautions related to comorbidities that patient may have? (3)

A
  1. Renal impairment - dose reduce
  2. Heart failure / IHD - increased risk with Saxagliptin
  3. Pancreatitis & Pancreatic Ca - if patient had history of this there is sig recurrence risk
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

GLP-1 agonists (exenatide, liraglutide, dulaglutide) - Pros (4)

A
  • High potency (>1% HbA1c reductions)
  • Weight loss
  • Unlikely to cause hypoglycemia
  • Evidence of CV and renal risk reduction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

GLP-1 agonist cons (4)?

A
  • Injection only
  • Avoid in Pts with pancreatitis or pancreatic Ca (risk of recurrence)
  • Avoid in significant renal impairment
  • Expensive if not PBS funded (needs two+ oral agents)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

SGLT-2 inhibitors pros (3) & cons (2)

A

Pros:

  • Weight loss
  • No hypoglycaemia
  • Excellent CVD (and now renal) risk reduction

Cons:

  • Needs sick day/periop management (risk of EKA)
  • Vulvovaginitis/balanitis
  • UTIs/urosepsis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Problem with Thia-zoledine-diones (TZDs)? 5+

A

Very potent but…

can cause:

  • weight gain
  • peripheral oedema
  • increased risk of heart failure
  • macular oedema (rare)
  • fracture in postmenopausal women (rare)
  • possible increased risk of bladder cancer (pioglitazone)
  • take 6 to 12 weeks to reach maximum effect
21
Q

So why would anyone use TZD (pio/rosiglitazones)?

A
  • Does not require dose adjustment for renal impairment
  • Still 3rd line agent – monitor LFTs
22
Q

So which OHG may also cause weight loss?

A

Weight loss: SGLT2, GLP-1

Weight neutral: Metfomin and DPPIV

23
Q

When would you stop following drugs according to CrCl?

Metformin

Sulfonylurea

TDZ

DPP-IV

GLP-1

SGLT2

A

Generally, 30 or less is a contraindication. There are exceptions however…

Metformin: 30

Sulfonylurea: 30

TDZ: none

DPP-IV: 45-60

GLP-1: 30

SGLT2: 45-60

24
Q

Which oral Hypoglycaemics do not need dose-adjustment for renal impairment? (3)

A

TDZs

Liraglutide (GLP-1, but not others)

Linagliptin (DPP-IV, but not others)

25
Caution for using ACEi and DPP-IV together?
Increased risk of ACEi induced angioedema
26
How would you go about starting insulin in outpatient for type I diabetic patient?
**Goal**: minimise ketosis while avoiding hypoglycaemia * Insulin requirement is usually between **0.4 – 1.0** unit/kg/day * So 70kg man’s requirement should be ~35-70 units/day * **Start small** – **0.25u/kg/day**. For 80kg man – this would be 20 units per day. **Type 1** - consider * **Basal – bolus** regime: OD Lantus + TDS Novorapid with meals * **Continuous** SC infusion via **insulin pump** + **extra-insulin at meal times** after calculation of insulin: carb ratio and based on BSL
27
How would you go about starting insulin in outpatient for T**II**DM patient?
Goal: minimise ketosis while avoiding hypoglycaemia * Insulin requirement is usually between 0.4 – 1.0 unit/kg/day * So 70kg man’s requirement should be ~35-70 units/day * Start small – 0.25u/kg/day. For 80kg man – this would be 20 units per day. **TIIDM** – reasonable starting point would be **10-12 units of lantus** _plus_ normal **OHG** Increase 1-2 weekly **Aim BSL 4-7** throughout day and night If not achieving the goal then consider changing to pre-mixed insulin BD
28
Definition of insulin resistance in terms of insulin requirement?
•Insulin requirement **\>200** units per day
29
What are the causes of treatment-resistant diabetes (with insulin) how would you approach this? (3)
Exclude **lipodystrophy** & **compliance** issues Investigate for circulating **antagonist** **hormones** – *_GH, Cortisol, Thyroxine, and Glucagon (i.e. anything that promotes growth)_* **Insulin antibodies** (uncommon – but an indication for more purified insulin)
30
What is Somogyi (somoji) & dawn effect and how would you address these?
**Somogyi** effect = nocturnal hypo → rebound hyper in the morning * Due to release of counter-regulatory hormones * Treatment = *reduce* the evening insulin dose **Dawn** effect = normal nocturnal BSL → hyper mane * Treatment = increase the evening insulin dose
31
What are the causes of hypoglycaemia in previously stable diabetics on insulin? (6)
↓ oral intake ↑ exercise Injection errors – suspect **cognitive** problems Diabetic **nephropathy** Under secretion of counter-regulatory hormones: i.e. ↓cortisol, T4, **pan-hypopituitarism** **Insulinoma** (rare)
32
You saw him in a few months time and BSL target has not been yet – not even close. What is your approach? (4)
1. Check **compliance** 2. **Educate** – make sure patient understand the point of treatment & complications thereof if poorly controlled 3. **Exclude infection** or review if any **new medications** (e.g. steroids) was started 4. Consider **diet, weight, exercise** program
33
What is your approach to the management of this patient's diabetes?
**_Goals_**: 1) improve glucose control, 2) avoid hypoglycaemia, 3) prevent micro/macrovascular complications. **_C_**onfirm Dx: OGTT (2h postprandial ≥11), fasting glucose (≥7), HbA1C (6.5%) **_A_**: screen & treat secondary causes * *Endocrinopathies* (Acromegaly, Cushing's, Obesity) * *Pancreatic* insufficiency (*CF, Haemochromatosis*, Pancreatitis) * *Drug-induced* (antipsychotics, antiretrovirals, NODAT if transplant) **_S_**creen for Complications * Micro: review previous Opthalmology records, UACR/UPCR, NCS guided by symptoms * Macro: ECG (LVH), Stress Test, TTE (RWMA), ABPI/dopplers (PVD), CTB/Carotids * Autonomic: postural BP, gastric emptying if hx suggestive of gastroparesis _**T:** non-pharm_ * **CV risk factor** mx: weight loss, exercise (exercise program enrolment), Mediterranean diet, smoking/ETOH cessation. These increases insulin sensitivity and improves BSL and lipids profile * Losing weight is hard & previous attempts have failed, I would start by getting patient to join a **walking group or hydrotherapy** * **Education**: involve diabetic educator, teach the importance of close monitoring in preventing life-thretening short & long term complications * **Safety!:** Sick day plan: have it documented & provide, Glucagon kit (family must know how to use it) * **infection** prophylaxis: hygiene, vaccinations, avoiding contacts, foot care _**T:** pharm_ * Specific to each case with regards to pharmacological regime * Consider Bariatric surgery if obesity is the cause * Complications: BP/Lipid Mx, symptom Mx for neuropathy (e.g. lyrica), consider transplant for ESRF. **_I_**nvolve: dietician, diabetic educator, diabetes group/society for continuing support & motivation **_C_**: monitor EUC, UACR/UPCR, vision, PN, ECG, bruits. If nephropathy - check Hb, Calcium/Vit D, PTH...etc. **_E_**nsure F/U and appropriate F/U are organised - 3 monthly podiatry, 12m ophthal (check safety to drive!). If Charcot's consider referral to high-risk foot clinic (very MDT - ID, endo, vascular teams), PT/Rehab
34
What is your advice on this diabetic patient's diet? (5)
The principle is to **minimise** saturated fats, cholesterol, whilst **increasing** fibre, healthier carbohydrates and protein in the diet. _Aim: 50% Carb, 20% Protein, 10% Poly-unsat fat, \<10% sat fat, \<300mg Chol, \>30g fibre._ 1. **Healthier Carbohydrate**: whole grains, brown rice, avoid processed cereals 2. **Healthier fats**: avocado, oily fish, olive oil, unsalted nuts instead of butter, ghee 3. **Salt restriction** 4. Eat **less red/processed meats**, swap for poultry, unsalted nuts, fish. 5. **Increase fruit & veg** (sugar is natural, not added sugar. Not juice with added sugar)
35
What is insulin pump? (3)
**Continuous infusion** of _very short acting insulin_ + mealtime boluses Only used in **T1DM**, studies have shown mild improvement (0.2%) improvement in HbA1c **Need to carb count**
36
On a follow-up you note that urine ACR is 30. What do you do? (short, 1 word answer) do you know what are the cut off values for micro, macro, nephrotic range proteinuria? (UACR)
UACR * \<3 normal * 3-30 microalbuminuria * 30-300 macroalbuminuria * \>300 Nephrotic range proteinuria Treat microalbuminuria with ACEi or ARB.
37
What is the progression rate to ESRF in patients with proteinuria?
•They will progress to ESRF in 5-10 years – this is inevitable. So need to think/plan-ahead about dialysis
38
How would you manage Charcot’s joints?
Exclude other pathology – OM, septic joint, gout/pseudogout (XR, CT) Non-pharm: Acute attack – N**WB for 8 weeks** until resolution or oedema and erythema Chronic – regular podiatry appointment to prevent ulcers. Consider surgery.
39
How often would you monitor for retinopathy?
Opthalmoscopy +/- retinal photography **1-2 yearly** If anything **more than minimal** disease = **6-12 monthly** Refer to ophthalmology if Moderate non-proliferative Proliferative Macular involvement
40
What are the HbA1C, BP, Lipids targets in diabetics?
HbA1C - \<**7 for most** patients - \<6.0 if no CVD and only on metformin/ lifestyle - \<6.5% if no CVD and on OHGs but NO insulin - \<7.0 if on insulin - \<**8 if previous hypoglycemic** events or in older patients with limited life expectancy BP - \< 130/80 if no proteinuria - \<125/75 if proteinuria Lipids -LDL \<2.0 (\<1.8 if known IHD) **-HDL \>1.0** **-TG \<1.5** -Total chol \<4.0 Exercise At least 30min of brisk walking, five or more days per week
41
Diabetic patient with dynamic bone disease from nephropathy with fracture – would you give anti-resorptive therapy? How would you approach this?
Difficult issue because it is hard to distinguish whether this is **adynamic bone disease** (renal osteodystrophy – where turn over is very low which decreases osteoblast & osteoclast) or high-turn over ⇒ **ALP** (and **P1NP**) can be useful If **ALP or P1NP** is **elevated, argument for** starting anti-resorptive therapy In renal impairment, these should really be elevated In normal, high normal range would be enough to start
42
What is your approach to managing this patient's erectile dysfunction? (3)→
**Exclude alternative** diagnosis: check pituitary / primary hypogonadal pathologies / depression à address these **Non-pharm**: Sexual therapists & Sexual health specialist **Pharm**: Cautious use of **sildenafil** ⇒ hypotension and type II injury. So if history of IHD, consider **intra-cavernosus injection**
43
Foot care – what would you advise the patient from practical view point?
To **regularly check** his feet Continues to have good **footwear** **Orthodics review** to ensure his footwear is appropriate **Custom shoes** to offload pressure site **Podiatrist 6 weekly**
44
Which investigations are useful to distinguish between type I vs II diabetes? (5)
C-peptide (will be low in TIDM due to endogenous insulin deficiency) Antibodies: ZnT8 (Zink-transporter), GAD (glutamic acid decarboxylase), Islet cell, Anti-Insulin
45
When would you consider advising against driving? (3)
Significant retinopathy or neuropathy Recurrent hypoglycaemia
46
What is the problem with Haemodialysis in patients with diabetic retinopathy + ESRF?
Retinopathy can get worse by HD. PD is better.
47
Pregnancy and Diabetin on insulin. What are important considerations you need to think of?
Due to effects of HPL (human placental lactogen), the insulin requirement goes up in the 2nd + 3rd trimester (as much as by 50%) After delivery, there is dramatic reduction of insulin requirement - watch for hypo and reduce the dose. Aim to normalise HbA1C prior to pregnancy - to minimise complications such as congenital malformations, IU death, imaturity...etc. Especially in poorly controlled diabetics, involve NICU and paediatrics early.
48
The implication of poor vision in diabetics?
Driving - often a big implication for jobs/employment and risk factor for social isolation. Bring it up!
49
Sick day rules for diabetics?\*\*\* Gold for long case
**_SICK_** _**S**ugar_: explain that BSL will increase during illness - increase freq of monitoring _**I**nsulin_: NEVER stop insulin. WH Metformin & SGLT2 but others should continue. _**C**arbohydrate_: maintain adequate oral hydration and carbo intake. If vomiting → replace meals to sugary fluids. - If BSL **\>13**, _sugar free_ fluids + _increase insulin by X_ (provide **chart** attached) - _If \<13_, sugary fluids + **insulin as normal**. _**K**etones_ - if TIDM, monitor ketones 2-4 hours + extra Novorapid if ketone present. **If vomiting and unable to keep fluids down, persistently high BSLs or ketones → come to ED.**

Endocrinology (Long) (9 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions