Exam -1 (DM, HEENT) Flashcards
What is a diabetes care visit usually composed of?
- Assess for glycemic control
- Assess for comorbidities
- Reinforce healthy lifestyle choices
- Assess for barriers
What is a certified diabetes educator?
It is a license held by a health professional with at least 2 years of professional practice and at least 1,000 hours of diabetes/pre-diabetes, prevention, and management experience.
What is the average A1C loss for medical nutrition therapy?
.05-2% A1C reduction
What is the average A1C loss with exercise?
0.66%
What is the common dose of cinnamon for diabetes, and how effective is it?
1-3 g/day, grade C, may lower BG values but is a common allergen; use with caution. Avoid use with anticoagulants.
What is the common dose of prickly pear cactus (Nopal), and how effective is it?
100-600 g/day, may lower BG and cholesterol values. Likely safe, grade C. Avoid use with anticoagulants, anti platelets, and P450’s.
What is the common dose of alpha-lipoic acid, and how effective is it?
300-1600mg/day. Grade A. Assists with diabetic peripheral neuropathy and T2DM. Generally safe.
What is the B-cell centric model of diabetes?
It is a diagram that shows how different organs are affected by beta cell function or dysfunction, including insulin production and beta cell mass.
When would you use double therapy according to the guidelines? Triple therapy?
Use double therapy is A1C is greater or equal to 9%
Use triple therapy if it has been 3 months, and the A1C goal still has not been met.
Use combination injectable therapy if A1C is greater or equal to 10, or if blood sugar levels are at or above 300mg/dL.
Metformin counseling points
GI SE's Decrease hepatic gluconeogenesis and intestinal absorption, increase insulin sensitivity at cellular level Lactic acidosis serious but rare ER formulations and eating with meals may help SE's Check vit B12 levels eGFR restrictions Does not promote weight gain 1st line
Sulfonylureas and Meglitinides (Secretogues) counseling points
High A1C lowering effects Hypoglycemia risk Cheap May only be able to be used for 1 year because of the Beta-cell destruction that they cause Take 15-30 min ac, do not skip meals
Alpha-glucosidase inhibitors counseling points
Slows digestion of CHO’s
Gas, bloating, diarrhea, constipation SE’s
CI in IBS, bowel obstruction
Moderate efficacy
(acarbose hepatically metabolized, miglitol excreted renal unchanged)
TZD counseling points
Efficacious Can take w/o regard for meals Insulin sensitizers LFT needed every 3 months Bone loss, weight gain SE's CI in heart failure because of edema
DPP4 inhibitor counseling points
Moderate efficacy
Weight neutral
SE’s include nasal pharyngitis, joint pain, headaches
Heart failure possibly an issue; don’t understand
Renal adjustments for all except linagliptan
Amylin analog counseling points
See more in T1DM, still in T2DM SE's nausea and weight loss CI's in gastrophoresis Adjunct therapy ONLY SQ injection to be taken with meals Modulates gastric emptying, inhibits postprandial glucagon secretion, increases satiety
GLP-1 receptor agonist counseling points
Good efficacy
Weight loss
Increases satiety
Expensive
SE’s include nausea, diarrhea that should resolve with a few weeks (like metformin)
Gastroparesis, pancreatitis, C cell tumor links
SGLT-2 inhibitor counseling points
Moderate efficacy
Weight-loss
Expensive
Increase sugar in urine/inhibits reabsorption of glucose in the proximal tubule
SE’s: UTIs, genital mycotic infections, euglycemic DKA, renal adjustments, dehydration (symptoms generally resolve within 1st 24 weeks)
Insulin counseling points
Very efficacious
Hypoglycemia big risk
Weight gain
Short shelf life after opening
Different delivery systems (inhalers, pumps, injections from vials or pens)
Different types of insulin (rapid, short, intermediate, long, and mixed)
What drugs target fasting bg levels?
Basal insulin
TZDs
Metformin
What drugs target post-prandial bg?
DPP4
Alpha-glucosidase
Meglitinides
short-acting GLP-1’s
What drugs target both fasting and post-prandial BG?
Long-acting GLP-1s
SGLT-2
Sulfonylureas
What are microvascular complications of DM?
Retinopathy
Nephropathy (albumin - SCr ratio important)
Neuropathy
What are microvascular complications of DM?
Coronary artery disease
Peripheral artery disease
Cerebrovascular disease
How often should screening for nephropathy occur?
How do you treat it? What about with albuminuria?
Annually in T2DM, T1DM after 5 years, and w/ comorbid hypertension.
Treat with ACE or ARB. W/o albuminuria, can use TZD or dihydropyridine CCB instead or in addition to ACE/ARB
How often should you screen for peripheral neuropathy in DM?
What is the lifetime risk of developing a foot ulcer with DM?
At least annually.
At least 25%
How would you reduce CV risk in a DM patient?
Aspirin Statin ACE/ARB if hypertensive Empagliflozin or liraglutide In patients with a prior MI, BB at least 2 years after the event
EXCEL
Exenatide trial of CV lowering
SUSTAIN and PIONEER trial
Semaglutide once weekly and once daily oral
What combination of drugs are in the phase III trials?
GLP-1 RA and SGLT-2 I
Currently, what does the US rank in number of DM cases?
Third, at 24.4 million
What is the number of DM cases expected to jump to by 2035?
To 37.3%… a third of the US population
Which guideline is stricter, ADA or AACE?
AACE
What did the 2017 update of the ADA conclude, briefly?
Delivering a 9lb baby was no longer a risk factor
Risk tool
Positive correlation between sleep quality and glycemic control
VB12 levels with metformin use
Noninferiority data with combo therapy
Footware recommendations and neuropathic care
Diagnosis criteria of DM:
A1C >/= 6.5% (pre is 5.7-6.4)
Fasting >126 mg/dL (pre is 100-125)
2 hour fasting >200 (pre is 140-199)
random >200
When should you start testing for DM?
At age 45
BMI >25 w/ 1 additional risk factor
Repeat at min of 3 years if normal results
What level of HDL and TG are modifiable risk factors for DM?
HDL < 35
TG > 250
When should you consider metformin?
BMI >35
Women < 60
Rising A1C despite lifestyle interventions
What does a comprehensive DM medical evaluation encompass?
History
Exam
Lab
Referrals
Patient Care Process
Collect Asses Plan Implement Follow-up
What labs are important to do during a DM visit?
A1C Fasting lipid profile Liver function test Albumin-to-creatinine ratio (AUC) eGFR TSH
When should you have more stringent goals for DM?
Younger patient
New to diagnosis
No complications
Long life expectancy
When should you have less stringent goals for DM?
Older patient Less life expectancy Hypoglycemic risk CVD complications/comorbidities Uncontrolled DM despite interventions
- BP is >140/90
- BP is >120/90
- BP is >160/100
- Lifestyle mods + single BP meds
- Lifestyle mods only
- Lifestyle mods + combo therapy
What type of statin should you use for a DM patient?
If ASCVD is present, then high intensity (unless over 75)
If no ASCVD and 10 yr-risk is less than 7.5, then moderate intensity statin.
If no ASCVD but 10-yr risk is >7.5% then high intensity
What additional cholesterol med can you add if there is high LDL?
Ezetimibe
What are the high-intensity statins?
Atorvastatin 40-80
Rosuvastatin 20-40
When should you use aspirin in DM?
Primary prevention in DM with 1 risk factor (family history, HTN, smoking, dyslipidemia, albuminuria. Not increased risk of bleeding)
Secondary prevention in DM (w/ ASCVD)
When should you not be on aspirin therapy?
Over 75
Bleeding risk
Aspirin intolerance
Use plavix instead of aspirin if allergic
When should you decrease your intake of protein?
When there is kidney disease.
How can you increase satiety?
Increase protein consumption
What should you limit salt content to in DM?
2,300mg per day
What is the general strategy for MNT?
Carb counting/reduction of intake
1 serving of carbs = ? grams
15g
What is an example of 15g of carbs?
1 slice of bread 1 6-inch tortilla 1/3 cup pasta or rice 1/2 cup pinto beans/starchy vegetable 2 small cookies 1/2 cup fruit juice
DD
Diabetes Distress: emotional burdens and worries about managing chronic DM. 18-45% prevalence
MDD
Major Depressive Disorder
Each time there is some transition in a DM patient’s life, what should happen?
DSME
IS it more important to check BG pre- or post-prandially?
Pre-prandially it is most often checked.
At what BG level would you administer glucagon? Eat fast-acting carbs?
Glucagon at 70mg/dL
Fast-acting carbs at 54 mg/dL
When is metabolic surgery indicated? For Asian/Americans?
BMI >30, or >27 for Asian Americans
When should you start weight loss medications with DM?
With BMI over 27
Benefits outweigh risks
If <5% weight loss in 3 months, then DC
Weight loss meds as adjunct to DM meds
How do you start basal insulin?
Start at 10u/day or 0.1-0.2 U/kg/day
Adjust 10-20% or 2-4 units once or twice weekly
If hypo, address reasons, then lower by 4 units or 10-20%
When do you use the rule of 450? Rule of 500?
450 with regular insulin
500 with rapid insulin
Divide this by the TDD of insulin
Result is how many grams of carbs are covered by 1 unit of insulin (insulin-to-carb ratio)
How do you calculate mealtime coverage dose?
Take the expected carbs, and divide by the insulin-to-carb ratio to get the amount of insulin you need to cover that meal
How do you calculate insulin sensitivity factor?
Rule of 1500
Rule of 1800
Use if BG is above pre-meal target
Rule of 1500 (regular)
Rule of 1800 (rapid)
Divide this by TDD, and get the BG that will decrease with 1 unit of insulin
How do you calculate correction dose?
Premeal reading - goal
Divide by insulin sensitivity factor
Get the amount of insulin needed to be given in order to get to the goal, and add to the scheduled prandial dose.
What is the total bolus dose?
The sum of the scheduled injection plus the correction
When is sliding scale used?
Usually in inpatient over outpatient
What are some primary headaches?
Migraine
Tension
Cluster
What are some examples of secondary headaches?
Sinus Rebound Refraction Glaucoma Hemorrhage Neoplasia Meningitis Post-concussion
What other questions would you want to ask about the head?
Headache (primary/secondary) Trauma Melanoma (ABCDE) Lice Sun damage
What are the headache red flags?
SNOOP Systemic symptoms/secondary risk factors Neurologic Onset (like a thunderclap) Older (40 or older) Positional/prior/papilledema
What are the questions you would want to ask about eyes?
History Allergy (single - infection, both eyes = allergy) Watch for red flags (sudden loss of vision, floaters, pain, red eye)
What are the questions that you would want to ask about the ears?
History of infections Pain/drainage Onset Noise/quiet words Understanding of spoken words Tinnitus Med rec
What meds do you want to watch ototoxicity with?
Neomycin, gentamycin, vancomycin, salicylates, quinine, furosemide
Grave’s disease is associated with…
hyperthyroid
Sensitivity to high temperatures/sweaty is associated with…
hyperthyroid
Weight gain, constipation, and heavy periods are associated with…
hypothyroid
Strep throat symptoms and signs:
Symptoms: Fast onset pharyngitis fever HA abdominal pain N/V
Signs:
Enlarged thyroid and lymph nodes
Positive culture and rapid strep test
People can be carriers and not be affected… do not treat them.
What is sensorineural hearing loss?
Having to do with the inner ear, cochlea, or auditory nerve. Neurological.
What is conductive hearing loss?
Cerumen impaction, middle ear fluid, or ossification.
What is presbycusis?
Loss of hearing at higher frequencies, in crowded rooms, tinnitus, associated with aging. High risk vaccination schedule.
What is Kiesselbach’s plexus associated with?
Anterior nose bleeds
With nasal trauma, what should you always consider?
Broken bones
What can Hib cause in HEENT?
Epiglottitis, which can be life-threatening
What are the five criteria for pharyngitis?
This is strep!!
- Sore throat without cough
- Fever
- Tonsillary exudates
- Swollen lymph
- Age less than 14 (-1 for over 45)
0-2 No strep, don’t treat
3-4 Rapid strep test, treat?
What eye condition can be caused from rapidly going from a bright day outside to a dark movie theater?
Acute closed-angle glaucoma
Cornea has steamy look
What should you do if someone comes in with what looks like blood pooled under their iris?
it is probably hyphema. Monitor for increased pressure, but otherwise let it resolve. Don’t use NSAIDs.
What condition can an irritating contact lens or herpes cause on the eye?
Keratitis/corneal ulcer (white of the eye looks all red/has been stained blue and can see a tree)
What conditions should you refer?
Viral/bacterial conjunctivitis (antibacterial) Uveitis (steroids) Acute angle-closure glaucoma Keratitis/corneal ulcer Scleritis subconjunctival hemorrhage in babies Pterygium/pinguacula Entropion (may need surgery) Cellulitis Epiglottitis Possibly strep if 0-2 points Peritonsillar access Oral herpes outbreak
What form of cellulitis can be life-threatening?
Orbital rather than peri-orbital/pre-septal
What eye conditions can be treated at home without a primary care visit, or are self-limiting?
Allergic conjunctivitis Subconjunctival hemorrhage in adults Dacrocystitis Allergic rhinitis Epistaxis (unless broken bones) Possibly strep if 3-4 points Mouth ulcers, unless extreme
