Endocrinology and Diabetes Flashcards
What is hypoglycaemia?
A reduction in plasam glucose levels low enough to result in signs and symptoms
What levels are classed as hypoglycaemia?
Levels less that 4mmol/l
(2.6-3.8 mmol/l)
However some patients with diabetes can have minimal or no warning signs.
What are the diabetes related causes of hypoylcaemia?
- excessive insulin dose or sulphonylureas (accidental or intential)
- Exercise
- Insufficient food intake/ miseed meals
- Impaired awareness autonmic neuropathy (recognition failure)
Alcohol- inhibiting glycogenolysis
-Reduced renal clearance fo insulin in elderly
What are some other causes of hypoglycaemia?
- Post prandial (reactive ) hypoglycaemia
- Post gastroectomy (dumping syndrom)
- Critical illness: hepatic, renal or cardiac failure or sepsis
- Physiological: Prolonged fasting
- Manurtition
- Hormone deficiencies (growth hormone, cortisol)
- Islet cell (insulinoma)/ non-islet cell tumours
Why does hypoglycaemia occur?
Under normal physiology, glucose levels are regulaed by insulin and glucagon levels
- In fasting states, when blood glucose drops, Insulin is suppressed and counter regulatory hormones (eg glucagon from pancreatic alpha cells, adrenaline, cortisol) are stimulated to enable hepatic gluconeogenesis and glycolysis to maintain normal glucose levels.
- In Diabetetic patients when there is a mismatch between the eccessive amount of insulin required to the amount of insulin needded, hypoglycaemic can occur.
What are the symptoms of hypoglycaemia?
What are the signs of hypoglycaemia?
What is the triad called that determines the diagnosis of hypoglycaemia?
Whipples’ Triad
What doe sthe whipples traid consist of
What is the Classification of hypoglycaemia?
Mild: Plasma glucose between 3-3.9 mmol/l
Moderate: Plasma glucose <3 mmol/l, activating the neuroglycopenic response
Severe: having low blood glucose affecting the mental or physical state, requiring 3rd party assistance
-(can be associated with coma/ seizures/ neurological deficits)
Management
For patients who are conscious, able to swallow and orientated…..
15-20G of carbs: 5 Glucotabs or 200ml of pure fruit juice
- Recheck in 15-20 minutes to ensure that blood glucose is 4mmol/l or above
- Establish resson as to why it happen and implement actions to resolve and prevent this.
Management
For patietns who are conscious, able to swalloe but confused or disorientated…
- 2 tubes of 40% glucose gel or 1M 1mg Glucagon if ineffective
- Recheck in 15-20 minutes to ensure that blood glucose is 4mmol/l or above
- Establish resson as to why it happen and implement actions to resolve and prevent this.
Management
Patients who are unconscious unable to swallow or aggressive
What are the two main diabteic emergencies
DKA
HHS (hyperosmolar hyperglycemic state)
What is the DKA
What are the risk factors for DKA?
- Infection/ Sepsis
- Cardiovascular disease (eg stroke or myocardial infarction)
- Discontinuation of insulin
- New diagnosis of diabtes
- Medication induced: sodium- glucose co transporter 2 (SGLT2) inhibitors
Patho of DKA
-Absolute Insulin Deficiency
- Decreased peripheral glucose update due to lack of insulin in tissues (muscles, fat and liver)
- Glucagon and counter-regulatory hormones is secreted due to cells having no glucose.
- Uninhibted Gluconeogenesis, Glycogenolysis resulting in hyperglycaemia
- Glycosuria + osomtic diuresis results in dehydration (polyrua and polydipsia)
- Lipolysis occurs, generating free fatty acids
- Beta oxidation occurs generating acetyl CoA
- Excess Acetyl CoA, goes into ketogenesis and produces ketone bofdies (acetone. Acetoacetate, B Hydroxybutyrate)
- Ketoe bodies diassociate to release H+
-Metabolic Acidosis
DKA Signs and Symptoms?
Ix of DKA
DKA management
Define HHS?
Hyperosmolar hyperglycaemic State
RF for HHS?
- Infection/Sepsis (pneumonnia/UTI)
- Acute illness (myocardial infarction, stroke, surgery, trauma)
- Dehydration
- New diagnosis of diabetes
Patho of HHS
HHS Clinical features?
How is HHS diagnosed?
Ix for HHS
Management for HHS
Foot ulceration
incidence
Lifetime risk
1-4%
15%
Foot diease
Amputation
Incidence
0.25-1.8
What is the disease that can lead from foot diease
Charcot neuroathropathy
High pressure and neuropathy leads to _____ and ______
damage
ulceration
What are two factors that contibute to foot deformity
Limited joint mobility
motor damage
Due to the foot deformity, the pressure in some areas of the foot will….
increase
Loss of protective sensation in feet fue to neuropathy and increase pressure leads to
ulceration
ischaemia
Features of neuropathic ulcers?
Features of ischeamic Ulcers
Treatment in a multidisciplinary foot clinic
What does debridement mean?
- allows adequate exposure of the ulcer
- converts a chronic non-healing ulcer into an acute, healing wound
- Removes callus around the wound edge
What is the gold standard for pressure relief in foot disease?
What is an alternative for using a total contact casting?
Removal Cast Walker (RCW)
What is an ideal dressing for Foot ulcers?
- non adherent
- removes excess exudate
- maintains humidity
- stimulates healing
- controls infection (eg silver or honey impregnated)
If Foot ulcers are really bad you could use?
Larval therapy
Vacuum assisted closure (VAC)
PICO
What is a Charcot foot
what is it misdiagnosed as?
Red, warm, painless swollen foot
Difficult to diagnose between osteopmyelitis
misdiagnosed as cellulitis, gout, arthritis, DVT
What is Charcot neuroathropathy?
Management for charcot foot?
Cosnider diagnosis
treat as a foot emergency
bed rest
total contact casting or removal walker
What is a rocker bottom foot?
sole of a person’s foot flexes abnormally in a convex position giving the foot a rocker-bottom appearance. For this reason, this condition is often called rocker-bottom foot.
