Diabetes II Flashcards

Question

Describe the treatment regime for nephropathy (have microalbuminuria) [7]

Answer 1

**Control BP:** - ACE inhibitor: **captopril; elanapril; lisinopril; ramipril** - ARB if ACE inhibitor not tolerated; **losartan; valsartan** - Add calcium-channel blocker **amlodopine; felopdipine; nifedipine** and/or thiazide-like diuretic: **hydrochlorothiazide**; and/or beta-blocker **carvedilol; metaprolol** Optomise blood glucose control Manage CV risk factors aggressivey Manage lipid levels: **atorvostatin** **Stop metformin** when eGFR < 30 mls/min Refer to specialist if eGFR < 45 mls/min Renal transplant if giving pancreatic transplant

Answer 2

**Stop metformin when eGFR < 30 mls/min** Refer to specialist if eGFR < 45 mls/min

Answer 3

- **Oral / genital candidiasis** - Skin **abcesses** - **Rhinocerebral mucormycosis** infection - **Fungal** **nail** infections - **Aconthosis nigricans** (sign of insulin resistance) - **Bullosis Diabeticorum** (blisterng) - **Granuloma annulare** - **Necrobiosis Lipoidica Diabeticorum** (pink skin lesion on lower legs)

Answer 4

Granuloma annulare

Answer 5

**Charcot neuroarthopathy:** chronic, devastating, and destructive disease of the bone structure and joints in patients with neuropathy; it is characterized by painful or painless bone and joint destruction in limbs that have lost sensory innervation **Diabetic cheiroarthropathy:** limited mobility of the joints of the hands

Answer 6

**Prayer sign; diabetic cheiroarthropathy**

Answer 7

**Diabetic macular oedema (DMO)** DMO is the commonest cause of visual loss in patients with diabetes **DMO is characterised by oedematous changes in or around the macula**. As the macula is responsible for central vision, affected patients tend to complain of blurred vision when reading or difficulty recognising faces in front of them. DMO is the commonest cause of visual loss in patients with diabetes.9

Answer 8

**Focal/diffuse macular oedema:** * the fluid that escapes from damaged vessels can be well-circumscribed (focal) or more widespread and poorly demarcated in nature (diffuse). **Ischaemic maculopathy**: - patients will be symptomatic with defects in visual acuity due to ischaemia at the site of the macula. These areas are best visualised with fluorescein angiography. **Clinically significant macular oedema (CSMO):** - CSMO describes significant changes associated with retinopathy, such as hard exudates and retinal thickening, found within a certain distance to the fovea or greater than a certain size.

Answer 9

Diabetic ketoacidosis: once blood glucose is < 14 mmol/l an infusion of **10% dextrose should be started at 125 mls/hr in addition to the saline regime**

Answer 10

 **Liver disease**  **Progressive renal impairment**  **Hypoadrenalism** (is associated with Type 1 diabetes)  **Hypothyroidism**  Hypopituitarism (rare)  Insulinoma (rare)

Answer 11

**Neuroglycopenic symptoms– Glucose ~ 2.7 mmol/L**  Confusion  Drowsiness  Slurred speech  Aggression  Visual disturbances

Answer 12

May be improved by “hypo holiday”:  **Strict** **hypoglycaemia** **avoidance** by relaxing glycaemic control  Use of **analogue insulin**  **Continuous Subcutaneous Insulin Infusion** (insulin pump therapy)

Answer 13

**Mild**:  Sugary drink, e.g. lucozade, ordinary coke, orange juice  5-7 glucose tablets, or 3-4 heaped teaspoons of sugar in water **Moderate:**  **Glucogel**® – 1-2 tubes **buccally** (into cheek), or jam, honey, treacle massaged into the cheek.  *Intramuscular glucagon* if needed **Severe (unconscious)**  Do not put anything in the mouth  Place the person in the recovery position **Administer 0.5-1mg glucagon IM**  If carer is unable to administer glucagon, call 999  In hospital, administer **iv glucose:** - Ideally **75mls of 20% glucose or 150mls 10% glucose over 15 mins** - **50mls 50% glucose** can be given, but take care with veins – extravasation can cause chemical burns

Answer 14

** Venous blood gases:** - show acidosis (pH < 7.35, bicarb < 15) ** Capillary Blood Glucose (CBG)** - usually over 14 mmol/L, but can be lower (euglycaemic ketosis or alcoholic ketosis) ** Raised Urea and Creatinine** ** Urine or plasma ketones** - elevated: above 3 mmol/L

Answer 15

**Sodium chloride 0.9%** * 1 Litre stat * 1 Litre in 1 hour * 1 Litre over 2 hours (+20 mmol potassium chloride) 1 Litre over 4 hours (+potassium chloride) * 1 Litre over 4 hours (+potassium chloride) **5% or 10% Glucose** * Start when the CBG is < 12 mmol/L and continue at 125ml/hr * 10 % glucose may be necessary to increase insulin infusion Increase infusion rate if glucose falls below 6.0 mmol/L`

Answer 16

For the first 1-2 bags fluid, **give no potassium** as fluid is given too rapidly For every subsequent bag of NaCl 0.9% or glucose 5% use a bag of fluid containing KCl as follows according to serum K+: - < 3.5: **May need additional K+ and delay insulin** - 3.5-5.5: **20-40 mmol/l** - > 5.5: **none**

Answer 17

 Due to the significant fluid deficit, the **initial management** requires **fluid resuscitation** to restore circulating volume: - **0.9% NaCl** and at least **1 litre** should be **given over an hour** (quicker in the presence of significant hypotension). - **Fluid replacement alone with 0.9% sodium chloride solution will result in falling blood glucose** - Further fluids can be given aiming for a **positive fluid balance based on hourly measurement of urine output**. A proposed target is **2-3 litres positive by 6 hours.**  **Insulin**: - **IVI as for DKA** – but consider slower fluids if elderly / heart failure - much **lower dose insulin** – (maybe) **no insulin for 1st 12 hours**, then very low doses : rate of **0.05 units/kg/hour** if blood ketones (beta-hydroxybutyrate) are ≤3.0 mmol/L and the patient is not acidotic

Answer 18

Serum K+ > 5.5 mmol/L: **Nil potassium replacement** Serum K+ 3.5-5.5 mmol/L: **40 mmol potassium replacement** Serum K+ < 3.5 mmol/L: **Senior review for more invasive potassium replacement**

Answer 19

 Rapid shifts in glucose should be avoided due to risk of rapid fluid / sodium shifts, and risk of **central pontine myelinolysis** (CPM): - destruction of the layer (myelin sheath) covering nerve cells in the middle of the brainstem (pons).

Answer 20

**12hrs** Insulin treatment prior to adequate fluid replacement may result in **cardiovascular collapse** as **water** moves **out** of the **intravascular** **space**, with a **resulting decline in intravascular volume**

Answer 21

**Hypophosphataemia and hypomagnesaemia are common in HHS.**

Answer 22

All patients should receive **prophylactic low molecular weight heparin (LMWH)** for the full duration of admission unless contraindicated Higher risk of VTE: (DM is a risk factor; hospitilisation; hypovolaemia)

Answer 23

**Mild NPDR:** - Characterized by the presence of at least **one** **microaneurysm**. At this stage, the disease might not be apparent to the patient. **Moderate NPDR**: - More extensive microaneurysms are present, along with haemorrhages and hard exudates. The retina may also exhibit cotton-wool spots, which are areas of nerve fibre layer infarctions. **Severe NPDR:** - Defined by the **'4:2:1 rule'**. This means there are either **more than 20 intraretinal haemorrhages in each of 4 quadrants (4)**, definite **venous** **beading** in **2 or more quadrants (2)**, or prominent i**ntraretinal microvascular abnormalities (IRMA) in 1 or more quadrant (1).**

Answer 24

**Early PDR**: - New vessels **less than 1/3 of the disc area**, **no vitreous haemorrhage**, and **no tractional retinal detachment.** **High-risk PDR**: - Characterized by any of the following: **neovascularization** **of the disc (NVD)** greater than or equal to **1/3 of the disc area**, any **NVD associated with vitreous or preretinal haemorrhag**e, or **neovascularization elsewhere (NVE) greater than or equal to 1/2 disc area with vitreous or preretinal haemorrhage.**

Answer 25

A 32 year-old woman with diabetes mellitus undergoes a retinal screen and is found to have maculopathy. Which is the most characteristic of diabetic maculopathy? A single cotton wool spot **Dot and blot haemorrhages at the fovea** Flame shaped haemorrhages Hard exudates at the optic disc Neovascularisation