Diagnosis and Screening Management, Part 1 Flashcards
Condition due to near complete or total absence of circulating insulin
Type I DM
Type I diabetics eventually require ___ to survive
insulin
What causes type II DM?
insulin resistance, decreased insulin secretion, increased hepatic glucose production
“Ominous Octet”
Many signs and symptoms of DM are related to _____, its resultant _____, and ______ associated with diabetes
hyperglyceumia, hyperosmolality, glycosuria
What are the 3 polys in diabetes?
Polyuria
Polydipsia
Polyphagia
S/S of type I DM
3 polys
Weight loss
Postural hypotension
Weakness
Blurred vision
Peripheral neuropathy
Chronic infections, dry skin, poorly healing wounds
Severe: marked dehydration, ketoacidosis
What are risk factors for type I DM?
Family history
Genetics
Geography-further from the equator
4-7 y/o, 10-14 y/o
Low vitamin D, cow’s milk, viral exposure
What are s/s of Type II DM
Insidious onset
Polys
Overweight or obese weight
Blurred vision
Peripheral neuropathy
Chronic infections, dry skin, itching, poorly healing wounds
Severe: marked dehydration, hyperglycemic hyperosmolar state
What are risk factors for Type II DM?
Family history
Native americans, blacks, latino/a, asians, NHOPI
Overweight or obese
Physical inactivity
Gestational DM, IGT, IFG, or A1C >5.6
Women who delivered baby >9 lbs
Metabolic syndrome, acanthosis nigricans, PCOS, CV disease
What are exam findings of DM?
Poorly healing wound/foot ulcer
Candidal vulvovaginitis/balanoposthitis
Rash in intertriginous fold
Acanthosis nigricans
why does hypoglycemia occur in DM?
combination of epinephrine and decreased CNS levels of glucose
What are s/s of hypoglycemia
Neuro
Autonomic
Who should be screened for DM?
Everyone starting at age 45
Any age if overweight or obese, and have 1+ DM risk factors
Gestational DM (1st prenatal visit if risk factors, otherwise at 24-28 weeks)
HIV + patients
Repeat every 3 years
How can DM screening be done?
using A1C, FPG, or 2-hr PG after 75 g OGTT
What are normal fasting plasma glucose levels? A1C?
70-99 mg/dL, 4-5.6%
What is a prediabetic fasting plasma glucose? A1C?
100-125 mg/dL, 5.7-6.4%
What is a diabetic fasting plasma glucose? A1C?
126 mg/dL or higher, 6.5% or higher
what are indications for fasting, capillary BG?
identification of BG levels
Screening or monitoring DM/prediabetes
How does a sample being plasma/whole blood impact the sample?
Plasma will have higher BG than whole blood
If a venipuncture/arterial puncture is used to get BG what is something to keep in mind?
arterial samples tend to be 3-5 mg/dL higher than venous samples
What factors can cause a elevation in blood glucose?
Major physical stressors
Steroids
Caffeine
Hct
Pregnancy
IV fluids containing sugars
What factors can cause a decrease in blood glucose?
Acetaminophen
Alcohol
High uric acid levels
Hct >50%
How could you interpret a high blood glucose other than prediabetes or diabetes?
acute stress response, cushing syndrome, pheochromocytoma, pancreatitis, chronic renal failure
What are indications of hemoglobin A1C?
diagnosis and monitoring of abnormal glycemic states, primarily prediabetes and DM
What can cause hemoglobin A1C to be falsely depressed?
Hemoglobinopathies, in particular high levels of HbF
Young RBCs: shortened erythrocyte survival, decreased mean erythrocyte age, IV iron or erythropoietic drugs
Abnormally low protein levels
What can cause hemoglobin A1C to be falsely elevated other than diabetes?
Old RBCs (splenectomy)
Prolonged or recurrent acute stress response
What are interpretations of high A1C?
Diabetes
Prediabetes
Nondiabetic hyperglycemia
Splenectomy
What are interpretations of low A1C?
hemolytic anemia
chronic blood loss
chronic renal failure
What are indications for glucose tolerance testing?
assist with DM diagnosis, assist with hypoglycemia evaluation
How is glucose tolerance testing done?
Glucose load is administered to patients and glucose measured at start of test and at 30 min, 1 hr, 2 hr, 3 hr, 4 hr
Ideally in AM
What are side effects of glucose tolerance testing?
May cause dizziness, tremors, anxiety, sweating, or fainting
What are patient education points prior to glucose tolerance testing?
Low carb diets can interfere with insulin release and cause abnormal results
Should avoid physical activity and smoking until test is complete
What are interfering factors with glucose tolerance testing?
acute stress response
endocrine disorders
exercise
fasting or reduced dietary intake prior to test
smoking
vomiting
What are indications for C-peptide and C-peptide/insulin ratio
evalutation of beta-cell function; identify causes of hypoglycemia; evaluation of insulinomas
Why might measuring c-peptide be helpful?
If patient has anti-insulin antibodies
Factitious hypoglycemia
Patient on exogenous insulin
Unknown if patient is a type 1 or type 2 diabetic
If a patient has increased c-peptide, what could that means?
Renal failure; sulfonylureas, pancreas transplant
If a patient has decreased c-peptide, what could that means?
destruction of all or part of the pancreas
What are indications for ketones testing?
evaluation for the presence of ketosis either in urine or serum
What are general goals of treating DM?
achieve glycemic control
Reduce or eliminate long-term complications
Maintain quality of life and overall wellbeing: DMSES
What are goal levles for patients with DM/
Hemoglobin A1C <7
Preprandial capillary glucose 80-130 mg/dL
Postprandial capillary glucose <180 mg/dL
Check A1C every 3-6 months
Consider a lower target A1C if
shorter diabetes duration
long life expectancy
T2DM tx with lifestyle or metformin only
No significant CVD/vascular complications
Consider a higher target A1C if
severe hypoglycemic history
Severe disease
Long-term DM patients
How are pediatric glycemic control guidelines different?
A little less stringent, A1C <7.5
At every visit what should you ask about?
Hypoglycemic episodes
Advise patients to carry glucose tablets/gel
Can give glucagon if at risk for severe hypoglycemia
If a patient is conscious what can you do for hypoglycemia?
Give 15-20 g of glucose orally
If a patient is unconscious, what can you do for hypoglycemia?
IV glucose, injectable or nasal glucagon kit
If hypoglycemia is frequent, severe, or no s/s
re-evaluate therapy to reduce hypoglycemia incidence
if pre-exercise glucose is <100 mg/dL, consider ingesting carbs
Self monitoring
What are diet therapy guidelines?
Medical nutrition therapy for all DM patients
Preferred to use a diabetes educator or dietitian who is experienced with DM patients
What are goals of MNT?
Healthful eating pattern to improve overall well-bieng
Achieving goals for glycemic control, weight, BP, and lipids
Delay or prevent DM complications
What are exercise guidelines for DM?
Regular exercise for weight control, improved insulin sensitivity, improved CV health
at least 150 min/week of moderate aerobic exercise divided over 3+ days
No more than 2 consecutive days without exercise
Resistance training 2+ days/week
Try to spend no more than 30-90 minutes at a time in a sedentary position
What are risk of exercise?
hypoglycemia, cardiovascular complications, and injury
What are immunization guidelines for DM?
All patients should receive routine vaccinations
Influenza vaccine
Pneumococcal vaccine
Hepatitis B vaccine
COVID19 vaccine
