Diabetes Care Visit Flashcards
What is a not so obvious historical fact to check on when doing an evaluation for diabetes?
Dental caries
Organ systems affected by chronic hyperglycemia
Blood vessels
- Heart
- Brain
- Kidney
- Eyes
- Nerves
What is the leading cause of death in diabetic?
Cardiovascular disease
- CAD & CVA
- 2 to 4 times more likely to have a stroke
- Equivalent risk as having prior MI
What iWhat is the prevalence of retinopathy in poorly controlled diabetic who require insulin within 5 yrs of diagnosis ?
40%
- Good control with oral agents: 24%
Prevalence of background retinopathy in patients with 15 yrs of type I or type II diabetes?
Type I: Almost all
Type II: 2/3
What is the prevalence of proliferative retinopathy in diabetics with 25 years of disease?
25%
Classifications of neuropathy
Focal Diffuse Sensory Motor Autonomic
Prevalence of neuropathy (via ankle jerk reflexes) at 1 yr? 25 yrs?
7%
50%
(Type I & Type II)
What percentage will develop nephropathy?
20 to 40%
How does hyperthyroidism play a role in diabetes?
It can unmask underlying glucose intolerance
Adversely affect glucose control & lipid management
How can hypothyroidism complicate diabetes?
Dyslipidemia
Depression
Fatigue
ADA recommendations for diabetes screening
BMI 25+ with 1+ risk factors
- Numerous risk factors are considered
- HTN
- High risk race
- Dyslipidemia (HDL or TG)
- Acanthosis nigricans
When to screen if no risk factors are present (ADA)?
45 yrs
How often to screen if results are normal (ADA)?
q3 years
- More frequent if risk factors are present
USPSTF recommendations for diabetes screening
Asymptomatic Adults with sustained BP > 135/80 (B rating)
- If BP
3 Methods of Dx diabetes
Fasting glucose > 126 Random glucose > 200 - Requires symptoms of hyperglycemia A1C > 6.5 - Must be confirmed on different day unless symptomatic
High risk ethnic groups
Native Americans African Americans Asian Americans Latin Americans Pacific Islanders
What is the role of laser photocoagulation in the treatment of retinopathy?
Slow progression and reduce vision loss
- Cannot restore vision
Why are eye exams so important in diabetics?
Retinopathy begins for the symptoms appear
- Goal of treatment is to preserve vision
You less remembered finding on fundoscopic exam that is significant for diabetic retinopathy.
Microaneurysms
What is the hallmark of proliferative retinopathy?
Neovascularization
What is the optimal range for blood glucose in a diabetic?
Fasting: 80 to 120
Non-fasting:
No so obvious causes of hyperglycemia
Dehydration
Infection/Illness
Stress
LEARN
Listen: Empathy Explain: Perceptions and treatment plan Acknowledge: Differences & Similarities Recommend: Based on patients wishes Negotiate
Two main contributors to diabetic foot ulcers?
Impaired sensation: distal symmetric polyneuropathy
Impaired perfusion: vasculopathy and PVD
What is the benefit of improve glycemic control in diabetes?
Slow progression of neuropathy
- Cannot reverse damage
Components of foot exam
Test protective sensation - 10 gm monofilament - 128 hz tuning fork or Pinprick or Ankle reflexes Pedal pulses Inspection
Familismo
Family is primary support
- Patients may wish to include them in making decisions about health care
Respeto/Simpatia
Respect for elders and authority figures
- Patient may be reluctant to contradict or ask questions
Personalismo
Value warm, friendly relationships over impersonal/institutional formality
Fatalismo
Control is external to self
- Nothing can be done
Faith/Religion
Variable affect on diabetes
Body image
Clean and not too thin
Complementary/Alt Health Practices
Hot or Cold properties of illness or treatments
- Need to balance the hot or cold out
HHS vs DKS: Mortality
Both increase with age
HHS increases with serum osmolarity
HHS vs DKS: Serum pH
HHS: No acidosis
DKA: Metabolic gap acidosis
HHS vs DKS: Plasma glucose
HHS: > 600
DKA: 250
HHS vs DKS: Ketones
HHS: Absent or mild elevation
DKA: Ketosis
HHS: Physical findings
Severe dehydration (excess of 9 L)
Sr osmo > 320
Requires fluid replacement
HHS: Precipitating factors
Infections - Often compounded by poor fluid intake Stroke MI PE
How often should A1C be checked in an already diabetic?
At least 2 times per year if patient is stable and meeting their goal
How often should a spot urine albumin-to-creatinine ratio be done in a diabetic?
Annually
When to check FSBS?
If symptomatic at acute visits
What is another common side effect of metformin that can also be checked via labs?
B12 deficiency
When should TSH be checked in relation to diabetes?
New dx of type I
New dyslipidemia
Women over 50 yrs
- Part of a complete diabetes evaluation
Management of ASCVD risk factors
- Smoking
- HTN
- CAD
- Dyslipidemia
- TLC
Quit smoking
BP
Do african americans, or any patient with diabetes need to be on an ACEI?
Not unless there are signs of kidney damage
What is the recommended statin intensity for diabetics with LDL > 70
If only diabetic moderate intensity is fine
If ASCVD risk is >/ 7.5% go with high intensity
ASA therapy recommendations in diabetics (ADA)
Secondary prevention if hx of CVD
Primary prevention if 10 year ACSVD risk is > 10%
- Most men > 50 & women > 60 with at least 1 risk factor
Multiple risk factors, but risk of only 5 to 10%
ASA therapy (USPSTF)
Use in men 45 to 79
- Reduce risk of MI
Women 55 to 79
- Reduce risk of stroke
What can be used for CVD if the patient is allegic to ASA
Clopidogrel 75 mg/day
Affect of lowering A1C below 7%
Prevent microvascular damage
- Affect on macrovascular level is unknown
Step 1 in management of diabetes
TLC & Metformin
Step 2 in management of diabetes
- If A1C > 8%
TLC + Metformin + Sulfonylurea or Glimepiride or Basal insulin or intermediate-acting insulin
Step 3 in management of diabetes
- If A1C > 8%
TLC + Metformin + Basal insulin or intensify insulin therapy
- Discontinue sulfonylurea
Step 4 in management of diabetes
- If A1C > 8%
Go to 2nd Tier therapies
- rapid acting insulin
- Thiazolidinediones
- Meglitinides
- GLP-1 Analogs
- DPP-4
- Amylin analog
- Alpha-glucosidase inhibitors
Down side of using thiazolidinediones
Increase risk of heart failure, edema, and bone fractures
When should patients get pneumococcal vaccine?
Patient with diabetes over 2 years old One time revaccination when over 64 if - First vaccine was given > 5 years ago - Nephrotic syndrome - CKD - Immunocompromised
When should type 1 diabetics have their first eye exam
5 years after diagnosis
- Type IIs needs it at time of diagnosis
What areas of their feet should diabetics not apply lotion to?
Between the toes
