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Internal Medicine > Endocrinology- Glucose > Flashcards

Endocrinology- Glucose Flashcards

1
Q

48 year old woman
Presents with polyuria, polydipsia and fatigue for 4 months
Notably she is having to get up at night 4-5 times to pass urine
He has also more recently been experiencing episodes of blurred vision and dizziness
what do you do next

A

Next Steps:
Conduct a Focused Clinical Assessment:

Take a thorough medical history, including any family history of diabetes, medications, and lifestyle factors.
Perform a Physical Examination:

Check for signs of dehydration, weight loss, or other relevant findings (e.g., skin changes).
Order Laboratory Tests:

Measure fasting blood glucose levels.
If fasting glucose is ≥126 mg/dL (7.0 mmol/L) or random blood glucose is ≥200 mg/dL (11.1 mmol/L), confirm with an A1C test.
Check for urinalysis to assess for glucose and ketones in the urine.
Evaluate for Other Causes:

Assess for potential causes of her symptoms, such as renal issues, urinary tract infection, or other endocrine disorders.
Consider Referral:

Depending on the test results, refer her to an endocrinologist for further evaluation and management if diabetes is confirmed.

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2
Q

Diagnosis of Diabetes

A

FPG ≥7.0 mmol/L
Fasting = no caloric intake for at least 8 hours
or
Random PG ≥11.1 mmol/L
or
HbA1C ≥6.5% (in adults)
or
2hPG in a 75-g OGTT ≥11.1 mmol/L

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3
Q

If there are no symptoms

A

In the absence of symptoms
diagnosis must be confirmed by repeat testing on a different day

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4
Q

What is impaired fasting glucose (IFG)?

A

Impaired fasting glucose is a prediabetic state defined by fasting plasma glucose levels between 6.1 – 6.9 mmol/L.

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5
Q

What are the criteria for diagnosing impaired fasting glucose?

A

The criteria for diagnosing IFG is a fasting plasma glucose level of 6.1 – 6.9 mmol/L.

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6
Q

What is impaired glucose tolerance (IGT)?

A

Impaired glucose tolerance is a prediabetic state characterized by elevated glucose levels during an oral glucose tolerance test (OGTT).

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7
Q

What are the criteria for diagnosing impaired glucose tolerance?

A

The criteria for diagnosing IGT is a 2-hour post-OGTT plasma glucose level between 7.8 – 11.0 mmol/L.

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8
Q

What are other indicators of prediabetes?

A

Other indicators include an HbA1C level between 5.7% and 6.4%.

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9
Q

Why are prediabetic states important to identify?

A

Identifying prediabetic states is crucial because they indicate an increased risk for developing type 2 diabetes and related complications. Early intervention can help prevent or delay progression to diabetes.

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10
Q

What are some management strategies for prediabetes?

A

Management strategies include lifestyle modifications such as:

Weight loss (if overweight)
Increased physical activity
Healthy dietary changes (e.g., reduced sugar and refined carbohydrates)

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11
Q

What are the main classifications of diabetes?

A

Type 1 Diabetes
Type 2 Diabetes
Gestational Diabetes
Other specific types (e.g., genetic forms, drug-induced diabetes)

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12
Q

What is Type 1 diabetes?

A

Type 1 diabetes is an autoimmune condition characterized by the destruction of insulin-producing beta cells in the pancreas, leading to absolute insulin deficiency. It typically presents in childhood or young adulthood.

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13
Q

What are the key features of Type 1 diabetes

A

Usually diagnosed in children or young adults

Symptoms often include polyuria, polydipsia, weight loss, and fatigue

Requires insulin therapy for management

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14
Q

What is Type 2 diabetes?

A

Type 2 diabetes is a metabolic disorder characterized by insulin resistance and relative insulin deficiency, often associated with obesity and sedentary lifestyle. It typically occurs in adults but is increasingly seen in children and adolescents.

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15
Q

What are the key features of Type 2 diabetes?

A

Commonly diagnosed in adults, particularly over age 45

Symptoms may be less pronounced than in Type 1

Can often be managed with lifestyle changes, oral medications, and may require insulin in advanced cases

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16
Q

What is gestational diabetes?

A

Gestational diabetes is a form of diabetes that occurs during pregnancy, typically diagnosed through screening tests. It is characterized by glucose intolerance that develops or is first recognized during pregnancy.

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17
Q

What are the key features of gestational diabetes?

A

Usually diagnosed in the second or third trimester

May resolve after delivery, but increases the risk of developing type 2 diabetes later in life

Requires monitoring of blood glucose levels and management to ensure healthy pregnancy outcomes

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18
Q

What are some other types of diabetes?

A

Other types of diabetes include:

Genetic forms of diabetes (e.g., MODY, neonatal diabetes)

Drug-induced diabetes (e.g., due to glucocorticoids, antipsychotics)

Rare diseases such as pancreatitis or cystic fibrosis-related diabetes

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19
Q

What are the major risk factors for Type 2 diabetes?

A

Obesity or being overweight

Sedentary lifestyle (lack of physical activity)

Age (risk increases with age, particularly after 45)

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20
Q

How does family history contribute to diabetes risk?

A

A family history of diabetes increases the risk due to genetic predisposition and shared lifestyle factors. Individuals with a first-degree relative (parent or sibling) with diabetes are at higher risk.

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21
Q

What comorbid conditions are associated with an increased risk of diabetes?

A

Hypertension (high blood pressure)
Dyslipidemia (abnormal lipid levels)
Polycystic ovary syndrome (PCOS)
History of gestational diabetes

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22
Q

What hormonal factors can increase diabetes risk?

A

Insulin resistance associated with conditions like acromegaly or Cushing’s syndrome

Hormonal changes during pregnancy that may lead to gestational diabetes

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23
Q

What are microvascular complications of diabetes?

A

Microvascular complications arise from damage to small blood vessels and include:

Diabetic retinopathy
Diabetic nephropathy
Diabetic neuropathy

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24
Q

What is diabetic retinopathy?

A

Diabetic retinopathy is a condition characterized by damage to the retina’s blood vessels due to prolonged high blood glucose levels, leading to vision impairment or blindness.

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25
Q

What is diabetic nephropathy?

A

Diabetic nephropathy is kidney damage caused by diabetes, often leading to proteinuria, decreased kidney function, and potentially end-stage renal disease.

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26
Q

What is diabetic neuropathy?

A

Diabetic neuropathy refers to nerve damage due to diabetes, which can cause symptoms such as pain, tingling, and numbness, particularly in the feet and hands.

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27
Q

What are macrovascular complications of diabetes?

A

Macrovascular complications involve damage to large blood vessels and include:

Cardiovascular disease (e.g., ischemic heart disease (heart attacks))
Cerebrovascular disease (Strokes)
Peripheral arterial disease (PAD)- Gangrene

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28
Q

How does diabetes contribute to cardiovascular disease?

A

Diabetes increases the risk of cardiovascular disease through mechanisms like atherosclerosis, leading to coronary artery disease, heart attacks, and strokes.

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29
Q

What is peripheral arterial disease (PAD)?

A

Peripheral arterial disease is a condition caused by narrowed arteries, reducing blood flow to the limbs, which can lead to pain, ulcers, and in severe cases, gangrene

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30
Q

What are common diabetic emergencies?

A

Diabetic ketoacidosis (DKA)
Hyperglycemic hyperosmolar state (HHS)
Hypoglycemia

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31
Q

What is diabetic ketoacidosis (DKA)?

A

DKA is a life-threatening condition resulting from insulin deficiency, leading to high blood glucose, ketone production, metabolic acidosis, and often requiring emergency treatment.

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32
Q

What is hyperglycemic hyperosmolar state (HHS)?

A

HHS is a severe complication of diabetes characterized by extremely high blood glucose levels without significant ketone production, leading to dehydration and altered mental status.

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33
Q

What is hypoglycemia?

A

Hypoglycemia occurs when blood glucose levels drop too low, leading to symptoms such as shakiness, confusion, sweating, and in severe cases, loss of consciousness or seizures.

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34
Q

Symptoms of Diabetes

A
  • Frequent urination
  • Excessive thirst
  • Blurry vision
    -Extreme fatigue
    -Increased hunger
  • Weight loss
  • Sensation of pins and needles in the feet
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35
Q

What is diabetic retinopathy?

A

Diabetic retinopathy is a diabetes-related eye disease that results from damage to the blood vessels in the retina, potentially leading to vision loss or blindness.

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36
Q

What are the early signs of diabetic retinopathy?

A

Microaneurysms (small bulges in blood vessels)

Retinal hemorrhages (bleeding in the retina)

Hard exudates (lipid deposits from serum leakage)

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37
Q

What are microaneurysms in diabetic retinopathy?

A

Microaneurysms are small, localized dilations of retinal capillaries and are often the first sign of diabetic retinopathy, appearing as small red dots on the retina.

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38
Q

What types of retinal hemorrhages are associated with diabetic retinopathy?

A

Dot-and-blot hemorrhages (deeper, rounded)

Flame-shaped (linear, superficial) hemorrhages

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39
Q

What are hard exudates in diabetic retinopathy?

A

Hard exudates are yellow-white lesions with well-defined edges, resulting from lipid deposits that occur due to serum leakage from damaged blood vessels.

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40
Q

What are cotton wool spots?

A

Cotton wool spots are soft, fluffy white patches on the retina, representing localized retinal ischemia due to nerve fiber layer damage.

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41
Q

What characterizes proliferative diabetic retinopathy (PDR)?

A

PDR is characterized by:

Neovascularization (formation of new, abnormal blood vessels)
Vitreous hemorrhage (bleeding into the gel-like substance of the eye)
Risk of tractional retinal detachment

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42
Q

What symptoms might a patient with diabetic retinopathy experience?

A

Symptoms may include:

Blurred or distorted vision
Difficulty seeing at night
Floaters or spots in vision
Sudden vision loss (in advanced cases)

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43
Q

How is diabetic retinopathy managed?

A
  • Tight blood glucose control
  • Laser therapy (photocoagulation) for PDR
  • Anti-VEGF injections for neovascularization
  • Regular monitoring and follow-up
44
Q

What is atherosclerosis?

A

Atherosclerosis is a condition characterized by the buildup of plaques (fatty deposits) in the arteries, leading to reduced blood flow and increased risk of cardiovascular diseases.

45
Q

How does diabetes contribute to atherosclerosis?

A

Diabetes accelerates atherosclerosis through mechanisms like insulin resistance, elevated blood glucose levels, increased inflammation, and dyslipidemia, leading to endothelial dysfunction.

46
Q

What is the pathophysiology of atherosclerosis in diabetes?

A

Atherosclerosis involves:

Endothelial injury from high glucose levels
Lipid accumulation in arterial walls
Inflammation and immune response
Plaque formation and instability

47
Q

What clinical manifestations are associated with atherosclerosis in diabetes?

A

Clinical manifestations can include:

Angina (chest pain)
Claudication (leg pain with exertion)
Myocardial infarction (heart attack)
Stroke
Peripheral artery disease (PAD)

48
Q

How is atherosclerosis managed in patients with diabetes?

A

Management includes:

Medications (e.g., statins, antihypertensives)
Lifestyle modifications (diet, exercise)
Regular monitoring and follow-up
In some cases, revascularization procedures (e.g., angioplasty, bypass surgery)

49
Q

What are the complications associated with atherosclerosis in diabetes?

A

Complications can include:

Increased risk of heart attack and stroke
Heart failure
Severe PAD leading to limb ischemia and potential amputation

50
Q

: Why is glycemic control important in managing atherosclerosis?

A

Good glycemic control helps reduce the risk of atherosclerosis progression by minimizing endothelial damage, inflammation, and associated metabolic disturbances.

51
Q

What is HbA1c?

A

HbA1c (glycated hemoglobin) is a form of hemoglobin that is chemically linked to glucose. It reflects the average blood glucose levels over the past 2 to 3 months.

52
Q

Why is HbA1c important in diabetes management?

A

HbA1c is crucial for monitoring long-term glycemic control, assessing the effectiveness of diabetes treatment, and predicting the risk of diabetes-related complications.

53
Q

How is HbA1c measured?

A

HbA1c is measured through a blood test, which can be performed in a laboratory or with point-of-care devices. Results are expressed as a percentage of total hemoglobin.

54
Q

What are normal HbA1c levels?

A

Normal HbA1c levels are typically below 5.7%. Levels between 5.7% and 6.4% indicate prediabetes, while 6.5% or higher suggests diabetes.

55
Q

What are the target HbA1c levels for individuals with diabetes?

A

The general target HbA1c level for most adults with diabetes is below 7%, but individualized goals may vary based on age, health status, and risk of complications.

56
Q

What factors can affect HbA1c levels?

A

Blood glucose levels
Red blood cell lifespan (e.g., anemia, hemoglobinopathies)
Recent blood transfusions
Certain medications

57
Q

How do you interpret HbA1c results?

A

< 5.7%: Normal

5.7% – 6.4%: Prediabetes

≥ 6.5%: Diabetes

Adjust targets based on individual patient circumstances.

58
Q

What are the limitations of HbA1c testing?

A

May not accurately reflect glucose levels in certain conditions (e.g., hemolytic anemia, kidney disease)

Cannot provide day-to-day fluctuations in blood glucose

59
Q

How is HbA1c related to diabetes complications?

A

Higher HbA1c levels are associated with an increased risk of microvascular (e.g., retinopathy, nephropathy) and macrovascular (e.g., cardiovascular disease) complications.

60
Q

How often should HbA1c be monitored?

A

HbA1c should be monitored at least twice a year for stable patients meeting treatment goals and quarterly for those not meeting goals or whose therapy has changed.

61
Q

Treatment of Type 1 diabetes

A

INSULIN
diet
weight loss
exercise

62
Q

What is the primary treatment for type 1 diabetes?

A

The primary treatment for type 1 diabetes is insulin therapy, which involves administering insulin through injections or an insulin pump to regulate blood glucose levels.

63
Q

What are the different types of insulin used in type 1 diabetes?

A

Types of insulin include:

Rapid-acting (e.g., lispro, aspart) for mealtime control

Short-acting (e.g., regular insulin) for meal coverage

Intermediate-acting (e.g., NPH) for basal coverage

Long-acting (e.g., glargine, detemir) for stable blood glucose levels throughout the day

64
Q

What are common insulin regimens for managing type 1 diabetes?

A

ommon regimens include:

Basal-bolus therapy: Using long-acting insulin for basal control and rapid-acting insulin for meals.

Continuous subcutaneous insulin infusion (CSII): Using an insulin pump for continuous insulin delivery.

65
Q

How often should blood glucose levels be monitored in type 1 diabetes?

A

Blood glucose levels should be monitored multiple times daily, typically before meals and at bedtime, and more frequently during illness or changes in routine.

66
Q

What is continuous glucose monitoring (CGM)?

A

CGM involves using a sensor placed under the skin to continuously measure glucose levels, providing real-time data and trends for better management.

67
Q

How important is diet in managing type 1 diabetes?

A

A balanced diet is crucial for managing blood glucose levels. Carbohydrate counting and understanding the impact of different foods on glucose levels are essential components.

68
Q

What should be done in case of hypoglycemia?

A

In case of hypoglycemia, consume fast-acting carbohydrates (e.g., glucose tablets, juice) to quickly raise blood glucose levels. Follow up with a snack containing protein and carbohydrates.

69
Q

What are common oral medications used in type 2 diabetes management?

A

Metformin: First-line therapy that improves insulin sensitivity.

Sulfonylureas: Stimulate insulin secretion from the pancreas.

DPP-4 inhibitors: Increase incretin levels to reduce blood glucose.

SGLT2 inhibitors: Promote glucose excretion in urine.

70
Q

When is insulin therapy indicated in type 2 diabetes?

A

Insulin therapy may be indicated for individuals who do not achieve adequate control with oral medications, those with severe hyperglycemia, or during periods of acute illness.

71
Q

How is cardiovascular risk managed in patients with type 2 diabetes?

A

Management includes controlling blood pressure and cholesterol levels, encouraging smoking cessation, and using medications like ACE inhibitors or statins as needed.

72
Q
A
73
Q

What regular health screenings are recommended for people with type 2 diabetes?

A

Annual eye exams for diabetic retinopathy.
Foot examinations to prevent ulcers and infections.
Kidney function tests to monitor for nephropathy.

74
Q

What causes hypoglycemia in diabetic patients

A

Too much medication
Too little food
Food and Medication timing mismatch
Exercise
Illness

75
Q

How does the American Diabetes Association (ADA) define hypoglycemia in patients with diabetes?

A

The ADA defines hypoglycemia as all episodes of an abnormally low plasma glucose concentration (with or without symptoms) that expose the individual to harm.

76
Q

What is the significance of a plasma glucose level of 3.9 mmol/L?

A

A plasma glucose level of 3.9 mmol/L is the lower limit of the physiological fasting nondiabetic range, the level at which counterregulatory hormone secretion starts, and the highest low glucose level reported to reduce sympathoadrenal response.

77
Q

What glucose level did the International Hypoglycemia Study Group propose as clinically significant?

A

In 2017, the International Hypoglycemia Study Group proposed that a glucose level of 3 mmol/L is sufficiently low to indicate serious, clinically important biochemical hypoglycemia.

78
Q

What are common symptoms of hypoglycemia?

A

Common symptoms include sweating, shaking, dizziness, confusion, irritability, and palpitations. Severe hypoglycemia can lead to seizures or loss of consciousness.

79
Q

What is the initial management for hypoglycemia?

A

The initial management involves consuming fast-acting carbohydrates, such as glucose tablets, juice, or candy, to rapidly raise blood glucose levels.

80
Q

Severe hypoglycaemia

A

An event requiring the assistance of another person to actively administer carbohydrate,resuscitation or glucagon.

81
Q

Documented symptomatic hypoglycaemia

A

An event during which typical symptoms of hypoglycaemia are accompanied by a measured glucose level < 3.9 mmol/L

82
Q

Asymptomatic hypoglycaemia

A

An event not accompanied by typical symptoms of hypoglycaemia but with a measured glucose level ≤ 3.9 mmol/L.

83
Q

Probable symptomatic hypoglycaemia

A

An event during which typical symptoms of hypoglycaemia occur but glucose level no measured.

84
Q

Pseudohypoglyceamia

A

An event during which the person with diabetes reports typical symptoms of hypoglycaemia but has a measured glucose level > 3.9 mmol/L

85
Q

Is remission possible in type 2 diabetes?

A

Yes, remission is possible in type 2 diabetes, particularly through significant lifestyle changes and interventions.

86
Q

What were the findings of the DiRECT trial regarding remission?

A

The DiRECT trial found that new type 2 diabetes patients on a very low-calorie diet targeting a weight loss of at least 15 kg achieved sustained remission at 24 months in about one-third of participants.

87
Q

What is the relationship between weight loss and remission in type 2 diabetes?

A

Sustained remission in type 2 diabetes is closely linked to the extent of sustained weight loss; greater weight loss increases the likelihood of achieving remission.

88
Q

How does metabolic or bariatric surgery impact remission rates in type 2 diabetes?

A

Metabolic or bariatric surgery can achieve long-term remission in 23% to 60% of patients, depending on the baseline severity and duration of their diabetes.

89
Q

What factors influence the likelihood of remission in type 2 diabetes?

A

Factors include the degree of weight loss, baseline severity of diabetes, duration of the condition, and individual patient characteristics.

90
Q

Why is early intervention important for achieving remission in type 2 diabetes?

A

Early intervention, including lifestyle modifications and weight management, can significantly increase the chances of remission, especially before diabetes becomes more severe.

91
Q

A 54-year-old man presents for review of his hypertension. He is screened for type 2 diabetes and his random glucose is 11.3mmol/L. He is asymptomatic.

What should the next step in his management be?

A. Treat for diabetic ketoacidosis
B. Repeat a fasting blood glucose the following morning
C. Initiate insulin therapy
D. Start Metformin

A

B. Repeat a fasting blood glucose the following morning

92
Q

A 32-year-old woman who has struggled with obesity all her life presents complaining of fatigue. She has no polyuria or polydipsia. Her random glucose is 10.8 mmol/l and BMI is 32 kg/m2. The rest of her examination is normal.

Which of the following would be the most appropriate initial management?

A. Metformin + Sulphonylurea
B. Insulin therapy
C. Metformin
D. Lifestyle modification

A

D. Lifestyle modification

93
Q

A 28-year-old woman who is a poorly-controlled asthmatic, requiring multiple admissions and oral corticosteroid therapy now presents complaining of polyuria, polydipsia and fatigue. Her random glucose is 16mmol/l.

What is the most likely diagnosis?

A. Glucocorticoid induced Diabetes
B. Impaired glucose tolerance
C. Type 2 Diabetes
D. Type 1 Diabetes

A

A. Glucocorticoid induced Diabetes

94
Q

Which of the following is the commonest form of diabetes?

A. Type 1 diabetes mellitus
B. Type 2 diabetes mellitus
C. Post pancreatitis
D. Gestational diabetes
E. Diabetes insipidus

A

B. Type 2 diabetes mellitus

95
Q

Which of the following is not a macrovascular complication of diabetes?

A. Diabetic ketoacidosis
B. Transient Ischaemic attack
C. Peripheral vascular disease
D. Myocardial infarction (coronary artery disease)

A

A. Diabetic ketoacidosis

96
Q

A 78-year-old man with known type 2 DM, two previous myocardial infarctions and chronic kidney disease stage 3, is brought in by his family complaining of worsening hyperglycaemia.

What target range HbA1C would you consider acceptable in this patient?

A. 7.1-8.5%
B. 6-6.5%
C. 6.5-7 %
D. 7-7.5%

A

A. 7.1-8.5%

97
Q

A 48-year-old woman presents complaining of polyuria and polydipsia. Her fasting blood glucose is 6.5mmol/l. A 75g oral glucose tolerance test reveals a 2-hour glucose of 11.5mmol/l.

What category of glucose metabolism does this patient have?

A. Diabetes mellitus
B. Normal glucose tolerance
C. Impaired fasting glucose
D. Impaired glucose tolerance

A

A. Diabetes mellitus

98
Q

A 42-year old woman with type 2 DM presents for review. On examination she has 1+ proteinuria on urine dipstick and her HbA1c is 6,8%. Below is an image of her retina on fundoscopy.
What is seen on fundoscopy?

A. Retinal detachment
B. Proliferative diabetic retinopathy
C. Diabetic retinopathy stage 2
D. Non-proliferative diabetic retinopathy

A

D. Non-proliferative diabetic retinopathy

99
Q

Which of the following is not a microvascular complication of diabetes?

A. Nephropathy
B. Neuropathy
C. Retinopathy
D. Cerebrovascular disease

A

D. Cerebrovascular disease

100
Q

Which of the following is responsible for the highest mortality in the diabetic population?

A. Neurological disease
B. Renal disease
C. Malignancy
D. Sepsis
E. Cardiovascular disease

A

E. Cardiovascular disease

101
Q

A 58-year-old woman with a background history of type 2 diabetes mellitus presents with abdominal pain, vomiting and deep laboured breathing. Her blood glucose level is 18mmol/L and her urine dipstick shows 2+ glucose and 3+ ketones.

What is the most likely diagnosis?

A. Hyperosmolar non-ketotic coma (HONK / HHS)
B. Diabetic ketoacidosis
C. Acute kidney injury
D. Sepsis
E. Dehydration

A

B. Diabetic ketoacidosis

102
Q

Which of the following is not a feature of diabetic retinopathy?

A. Cotton wool spots
B. New vessel formation
C. Cataract formation
D. Hard exudates

A

C. Cataract formation

103
Q

What did the Accord study demonstrate?

A. Tight glycaemic control was associated with an increase in mortality
B. Type 2 diabetics on Insulin therapy had reduced mortality
C. Tight glycaemic control was associated with a reduction in mortality
D. Intense exercise can reduce hypoglycaemic episodes

A

A. Tight glycaemic control was associated with an increase in mortality

104
Q

A 45-year- old woman known with Polycystic Ovarian Syndrome (PCOS) is screened for type 2 diabetes. Her fasting glucose is 6.5mmol/L.

What is the most likely diagnosis?

A. Impaired fasting glucose
B. Type 2 diabetes mellitus
C. Diabetes Insipidus
D. Genetic diabetes

A

A. Impaired fasting glucose

105
Q

What is the mechanism of action of Metformin?

A. Decrease glucose uptake
B. Decreased hepatic glucose production
C. Increased lipolysis
D. Increased glucagon secretion

A

B. Decreased hepatic glucose production

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