DM- Clinical Presentation

Question 1

Hypoglycemia common risk factors

Answer 1

• Longer duration of diabetes
• Older age
• ↓ glycemia with medications
• Erratic timing of meals & missed meals
• History of recent hypoglycemia
• Exercise
• Alcohol ingestion
• Chronic kidney disease
• Malnutrition/glycogen depletion

Question 2

Characteristics needed to fulfill Whipples triad for hypoglycemia?

Answer 2

Signs and symptoms suggestive of hypoglycemia (neuroglycopenic and/or neurogenic)
Low plasma glucose levels at time of suspected hypoglycemia
Symptom resolution with plasma glucose correction

Question 3

Hypoglycemic Associated Autonomic Failure in DM I leads to __ Sympathoadrenal response

Answer 3

↓

Question 4

Hypoglycemia leads to a ___ Epinephrine response

Answer 4

↓
Epinephrine & neurogenic symptoms are attenuated in insulin-deficient - T1DM &
advanced T2DM

Question 5

Hypoglycemia – Pathogenesis DM I

Answer 5

Failure of physiological & behavioral
defenses
↓
Brain glucose deprivation
↓
Behavioral change, confusion, seizure,
loss of consciousness

Question 6

Hypoglycemia – Pathogenesis DM II

Answer 6

Failure of physiological & behavioral
defenses
↓
Brain glucose deprivation
↓
Behavioral change, confusion, seizure,
loss of consciousness

Question 7

Symptoms DM I & II

Answer 7

Palpitations, tremor, sweating,
behavior or mental status changes

Question 8

First Aid in DM I & II if patient is Conscious

Answer 8

Oral glucose (15-20 gm po)
* Glucose tablets (~4 gm/tablet)
* 4 oz Juice/Soda acceptable
* 1 tbsp of sugar, honey, corn syrup
* Check q15 minutes
* Repeat until corrected

Question 9

First Aid in DM I & II if patient is unconscious

Answer 9

Adults
* IV dextrose 50% in water (D50)
Adolescents
* 20-50 mL 50% solution
6 mo. – Children
* IV 25% dextrose 2-4 mL/kg IV
bolus then continue IV until able
to eat

Question 10

Prevention strategies for DM I & II

Answer 10

Rx glucagon for all patients at risk of
severe hypoglycemia & instruct
caregivers/family members on its use
* Review S/S of hypoglycemia &
response
* Instruct pts to carry carbohydrates
* Caution pts about driving risk
* Wear medical alert ID

Question 11

Hyperglycemia – Early Symptoms
(Insidious Onset)

Answer 11

The 3 “Polys”
1. Polydipsia
2. Polyphagia
3. Polyuria

Others
* Fatigue
* Blurred vision
* Unexplained weight loss (DM I)

Question 12

Diabetic Ketoacidosis (DKA): Cause = ↓ Insulin secondary to ____

Answer 12

1. Inadequate insulin treatment in pts with DM
2. New onset DM
3. Concurrent infection
4. Most Common = Pneumonia or UTI

Question 13

Diabetic Ketoacidosis common signs and symptoms

Answer 13

• Polydipsia
• Polyuria
• Nausea & vomiting
• Weakness & lethargy
• Dehydration
• Fruity odor on breath
• Kussmaul respirations - deep respirations 2° severe acidosis
• Mental status changes

Question 14

Normal anion gap =

Answer 14

<12 mEq/L

Question 15

Causes of anion gap acidosis (unmeasured anions) include:

Answer 15

– Ketoacidosis (diabetic, alcoholic)
– Lactic acidosis (lactate [underperfusion, sepsis])
– Uremia (phosphates, sulfates)
– Poisonings/overdoses (methanol, ethanol, ethylene glycol, aspirin,
paraldehyde)

Question 16

Initial testing for DKA

Answer 16

• Serum glucose (>250 mg/dL)
• Electrolytes (K+ loss)
• Serum Beta-hydroxybutyrate
  (serum ketones)
• Not commonly available
• Anion gap (>12 mEq/L)
• good measure of recovery
• Blood gases (↓ pH, ↓ PCO2)
• CBC with differential (infx?)
• Urine dipstick for ketones (↑)
  & urinalysis (Acetoacetate,
  Acetone)
• Urine or blood culture (infx?)
• ECG (possible arrhythmias)
• Renal & liver function tests
• Chest x-ray (clues for infx)

Question 17

DKA - Management in ICU

Answer 17

1. Fluid resuscitation
2. Electrolyte replacement (K+, Na+, PO3, Mg, NaHCO3)
3. Short acting IV Insulin (hold if K+ is low)
4. Extracellular K+ → intracellular from insulin can lead to hypokalemia
   Stable Management
5. Transition from IV to multi-dose SQ insulin

Question 18

HHS =

Answer 18

Hyperglycemic Hyperosmolar State

Question 19

DKA vs. HHS

Answer 19

DKA: Absolute (or near-absolute) insulin deficiency, results in:
* Severe hyperglycemia
* Ketone body production
* Systemic acidosis
Develops over hours to 1-2 days

HHS: Severe relative insulin deficiency, results in:
* Profound hyperglycemia & hyperosmolality
(urinary water loss)
* No significant ketone production or acidosis
Develops over days to weeks, higher mortality rate

Question 20

DKA is most common in ____ diabetes while HHS typically presents in ____ diabetes

Answer 20

Type 1; type 2