Final (new information) Flashcards
What are the 4 criteria for diagnosing diabetes
1) A1C ≥ 6.5%
2) FPG ≥ 126mg/dL (7.0mmol/L)
3) 2-h plasma glucose ≥ 200mg/dL(11.1 mmol/L) after eating 75g of anhydrous glucose dissolved in water
4) Random plasma glucose level ≥200mg/dL (11.1mmol/L) PLUS symptoms of hyperglycemia or hyperglycemic crisis
What are some diseases of the exocrine pancreas that can lead to diabetes?
Pancreatitis
Cystic fibrosis
Hemochromatosis
What are some endocrinopathies that can lead to diabetes?
Acromegaly
Cushing’s syndrome
Pheochromocytoma
Hyperthyroidism
T/F Diabetes can have drug or chemical induced etiology.
True
What is the cause of type I diabetes
Loss of pancreatic beta cells
What are the classic symptoms of diabetes
Polyuria (Peeing a lot)
Polydipsia (Increased thirst)
Weight loss
Polyphagia (Increased hunger)
What is the cause of ketoacidosis in diabetics?
Grossly deficient insulin levels:
1) Lapse in insulin medication
2) Acute infection or trauma that causes a loss of insulin
What can be smelled on the breath of a patient with ketoacidosis?
Acetone
What is metabolic syndrome/insulin resistance syndrome?
It is the clustering of risk factors for type II DM and cardiovascular disease.
What are the risk factors for metabolic acidosis/Insulin resistance syndrome?
1) Excess abdominal fat: apple shaped (>40 inch waist for males, >30 inch waist for females)
2) Insulin resistance (>100 fasting glucose)
3) Elevated serum triglycerides (>150mg/dL)
4) Decreased HDL (
What is the condition that clusters the risk factors for Type II diabetes and cardiovascular disease also puts males at an increased prevalence of sleep apnea and low testosterone/erectile dysfunction?
Metabolic syndrome/insulin resistance syndrome
What condition is associated with hyper-pigmented, velvety plaques located commonly axilla, groin, neck and is also associated with skin tags?
Acanthosis Nigricans
What are the types of Acanthosis Nigricans?
Benign Type : insulin resistance, obesity, predilection of type II diabetes, stimulated by insulin growth factor
Familial Type: Insulin resistance secondary to mutations in the insulin receptors
Malignant type: Associated with several aggressive cancers.
What is the causal mechanism for Type II DM?
Mechanism is unclear, but there is a strong genetic component and most patients are obese (insulin secretion is abnormal and there is insulin resistance at peripheral tissues)
What is the fasting plasma glucose level and random blood glucose level needed to diagnose type II diabetes?
FPG: 7mmol/L
Random PG: 11.1mmol/L
How does nephropathy occur in diabetics?
Glomerular capillaries are occluded by basement membrane-like material (leads to renal failure)
What are the 3 major effects of neuropathy?
1) Distal symmetrical polyneuropathy: impaired touch and pain sensation that starts in the lower extremities.
2) Autonomic neuropathy: Impotence, GI disturbances, neurogenic bladder, orthostatic hypotension.
3) Cranial nerve palsies: usually pupil sparing CNIII and CN VI. Due to vascular occlusions, not neuropathy.
What is the reason why amputations are so common in diabetics?
accelerated artherosclerosis leads to GANGRENE secondary to vascular occlusions of the smaller arteries in the lower extremities
What is the anti-hypertensive drug of choice that is nephroprotective?
ACE inhibitors (“-pril” endings)
By how much can you reduce the risk of diabetic retinopathy if you reduce HbA1C by 2%?
5X reduction in risk!
What is the typical HbA1C goal for diabetics?
If a patient has poor control of blood glucose and has severe NPDR or PDR, what do you have to be concerned about if they decide to strictly control their sugar abruptly?
Sight threatening progression of retinopathy!
Acute hyperglycemia can cause which 2 types of refractive shifts?
Hyperopic and myopic shifts
T/F: Along with Syphilis, DM can cause a Argyll-Robertson pupil
True
Other than NVI, what other iris findings can be found in patients with DM?
Iris atrophy that leads to loss of the iris colarette
What anterior segment finding in DM can lead to glaucoma?
Neovascularization of the angle
What is a corneal complication that can be found in patients with DM?
Corneal epithelium has poor healing capabilities and the epithelium is more susceptible to damage.
Which anti-hypertensive medication can mask the symptoms of hyperglycemia?
Beta-blockers
What are the two cataracts associated with DM
PSC and snowflake cataract
What concerns should you have about doing cataract lens extraction with diabetic patients?
It can lead to progression in retinopathy and/or anterior segment neovascularization.
What happens to blood sugar when a diabetic undergoes any type of surgery?
The trauma and stress of the surgery can lead to an increase in blood sugar and the patients should be monitored carefully
What are the findings of asteroid hyalosis and what conditions is it associated with?
Unilateral finding of calcium soaps located in the vitreous in elderly patients. Associated with DM and gout.
What are the findings associated with synchysis scintillans?
Cholesterol crystals found bilaterally in the vitreous in younger patients after trauma. Vitreous is typically liquefied.
What is the mechanism behind cotton wool spot production?
CWS’s are the manifestations of capillary closure due to loss of Autoregulation of retinal vessels which is secondary to damage to Pericytes of the retinal capillaries.
What causes the formation of exudates and retinal edema in diabetic patients?
Microaneurysms and leaky capillaries.
What stage are blot hemes found in dm?
Advanced stages
What are some signs that are associated with proliferative diabetic retinopathy?
IRMA, venous beading, presence of new blood vessels, fibrous proliferation (scaffolding for the new blood vessels), and contraction of the vitreous and fibrous tissues (TRD)
In general, when is macular edema clinically significant in diabetic patients?
When the edema or hard exudates threaten the macula and treatment is necessary.
What is the criteria for treatment of CSME?
1) If edema is CLOSE to the retina (within 1/3DD of the macula)
2) If the edema is ASSOCIATED with the macula (hard exudates within 1/3DD of the macula with adjacent thickening.
3) If the edema is LARGE (if retinal thickening is greater than 1DD and within 1DD of the macula
Ketoacidosis puts diabetics at an increased risk for which life threatening fungal infection?
Mucormycosis
What is the treatment of Mucormycosis?
Amphotericin B
What are the signs of Mucormycosis?
Orbital cellulitis, eyelid edema, proptosis, external ophthalmoplegia, and fever
(not that important of a flashcard
What are the stages of diabetic retinopathy
Mild NPDR: Microaneurisms
Moderate NPDR: More than microaneurisms, but less than severe NPDR
Severe NPDR: 4-2-1 rule (4 quadrants of microaneurisms, 2 quadrants of venous beading, 1 quadrant of IRMA.)
What consists of the 4-2-1 rule?
At least 1 of the following:
4 quadrants of microaneurisms
2 quadrants of venous beading
1 quadrant of IRMA
What is the mechanism of action of Sulfonylureas (Diabetic medication)?
Stimulates insulin secretion and increases sensitivity to insulin.
What drug class is Meformin?
Biguanide
What is the MoA of Metformin?
Decreases hepatic glucose production
Braley’s sign is associated with thyroid orbitopathy. What is this sign?
Patients will have an increase in IOP on up gaze vs. primary gaze. (up to 8 mmHg)
Restrictions of EOMs in 2 directions associated with thyroid eye disease puts the patient more at risk of what?
Optic nerve compression
Patients with thyroid orbitopathy and complaints of diplopia and ptosis should have which tests ordered for them?
Tensilon or ice pack test (MG)
What are some of the ocular signs of hyperthyroidism?
Dilated vessels over the horizontal rectus
Von Greafe sign: Delayed upper lid movement on down gaze
Dalrymple sign: Retraction of the upper eyelids in primary gaze
Choroidal folds can sometimes be present
Restrictive myopathy can occur in patients with hyperthyroidism. List the muscles that are affected from most common to least common.
Inferior, medial, superior, lateral, obliques
(IM SLO)
notes: inferior is more common, but medial is going to be most bothersome because it mimics a CN VI palsy.
What are the typical TSH, T3, T4 test results for some one with mild hypothyroidism?
TSH = High
T3, T4 = Normal
What are the typical TSH, T3, T4 test results for some one with hypothyroidism?
TSH = High T3 = Low or normal T4 = Low
What are the typical TSH, T3, T4 test results for some one with mild hyperthyroidism?
TSH = Low
T3, T4 = Normal
What are the typical TSH, T3, T4 test results for some one with hyperthyroidism?
TSH = Low
T3, T4 = High or normal
What are the typical TSH, T3, T4 test results for some one with nonthyroidal illness, or pituitary (secondary) hypothyroidism?
TSH = Low
T3, T4 = Low or normal
What are the typical TSH, T3, T4 test results for some one with thyroid hormone resistance syndrome?
TSH = Normal
T3, T4 = High
What is the disease process behind hypothyroidism?
Chronic autoimmune inflammation of the thyroid gland with lymphocytes.
What is myxedema madness?
Depression, poor memory, hyper-solmnescence and psychosis
How do you interpret test results of low calcium levels and high levels of parathyroid hormone?
The parathyroid is acting normally. Additional testing should be done to see why the patient is hypocalcemic
How do you interpret test results of low calcium levels and low or normal levels of parathyroid hormone?
Parathyroid is not working properly. Probably have hypoparathyroidism
How do you interpret test results of high calcium levels and high levels of parathyroid hormone?
Parathyroid is producing too much parathyroid hormone. Do imaging for hyperparathyroidism
How do you interpret test results of high calcium levels and low levels of parathyroid hormone?
Parathyroid is responding correctly. Do additional testing for hypercalcemia
How do you interpret test results of normal calcium levels and high levels of parathyroid hormone?
Mild hyperparathyroidism
What is the most common cause of hypercalcemia?
Excessive parathyroid hormone secretion
What are some common causes of secondary hyperparathyroidism?
Renal failure
Osteogenesis imperfecta
Paget’s disease of the bone
What are ocular signs of hyperparathyroidism?
Calcification of the conj and sclera.
Calcification of the cornea and band keratopathy.
What is a common systemic cause of hyperparathyroidism that features extreme pain in the bladder and urethra?
Kidney stones
What effects can occur in the CNS with hyperparathyroidsism?
Increased intracranial pressure
What effects can occur in the mucocutaneous system with hyperparathyroidism?
Enamel hyperplasia
Coarse hair
Brittle nails
What is a key ocular concern for patients with hypoparathyroidsm?
Papilledema
What is multiple endocrine neoplasia syndrome (MENS)?
Syndrome characterized by tumors of the endocrine glands.
Which type of multiple endocrine neoplasia syndrome (MENS) has specific ocular signs?
Type 2b
What is multiple endocrine neoplasia syndrome (MENS) type 1 (Werner’s syndrome)?
Characterized by pituitary tumors, pancreatic islet cell tumor, and parathyroid hyperthyroidism
what is multiple endocrine neoplasia syndrome (MENS) type 2 (Sipple’s syndrome)?
Characterized by medullary carcinoma, pheochromocytoma, and parathyroid hyperplasia.
What is the ocular finding of multiple endocrine neoplasia syndrome (MENS) 2b?
Ganglioneuromas on the lids and conj. Bundles of enlarged corneal nerves.
Pheochromocytoma is a tumor located where? What is a systemic concern with pheochromocytoma?
Tumor located in the adrenal medulla that secretes catecholamines. Pheochromocytoma causes HTN.
What is the most common cause of symptoms in patients with pituitary adenomas?
Symptoms arise from the complications of have too much hormone secretions
What type of symptoms occur in craniopharyngioma?
Symptoms of hypopituitarism
What are the symptoms of excess luteinizing hormone and Follicle Stimulating Hormone?
Menstrual changes, low testosterone in males, and loss of libido
What are the symptoms of reduced luteinizing hormone and Follicle Stimulating Hormone?
Amenorrhea, infertility, and decreased libido.
What are the clinical manifestations of excess growth hormone?
acromegaly, gigantism, bony hypertrophy, sweating, HTN, and DM
What are the clinical manifestations of decreased growth hormone?
Growth arrest and deficient lactation.
What are the clinical manifestations of excess ACTH hormone?
Symptoms associated with Cushing syndrome (chronic elevated serum cortisol)
What are the clinical manifestations of decreased adrenal function?
Symptoms associated with Addison’s disease (Low serum cortisol)
What are the clinical manifestations of increased prolactin hormone?
Amenorrhea, decreased libido, infertility, galactorrhea, gynecomastia
What are the clinical manifestations of decreased prolactin hormone?
Deficient lactation
T/F: Vestibular, Auditory, and photoreceptors are derived from the same ciliated progenitors
True
What is the inheritance of usher’s syndrome?
Autosomal recessive
What is the triad of usher’s syndrome?
Hearing loss, RP, and metal disability
Patients with usher’s syndrome will have reduced ERG or EOG?
ERG
What is refsum’s disease?
Disease associated with hereditary retinal degeneration. Findings include autosomal recessive RP and increased serum phytanic acid.
What systemic disease associated with hereditary retinal degeneration has symptoms of RP and fat intolerance?
Hereditary Abetaproteinemia
What systemic disease associated with hereditary retinal degeneration has symptoms of RP before the age of 20 and cardiac conduction abnormality?
Kearn’s Sayre syndrome
What disorder producing pseudo-retinitis pigmentosa is associated with hyper ornithemia and increased ornithine levels?
Gyrate atrophy
What disorder producing pseudo-retinitis pigmentosa is associated with choroidal atrophy with macular sparing?
Choroidemia
Which disease is associated with keratitis and hearing loss?
Cogan’s syndrome
In Cogan’s syndrome, which becomes involved first, the cornea or the ear?
Either can become involved first.
What is the treatment of Cogan’s?
Systemic steroids
Which are the two most significant disorders that cause hearing loss/deafness
Usher’s syndrome and Cogan’s.
What is barrett’s esophagitis?
Precancerous metaplasia of the stomach mucosa associated with GERD.
What is the concern regarding anti-acids with GERD patients?
Anti-acids can cause a rebound acid reflux
What is the gram negative organism that is present in the acidic conditions of the stomach that can contribute to symptoms of GERD?
Helicobacter Pylori
What are the signs and symptoms of H. Pylori?
Dyspepsia (indigestion), Gastritis (inflammation of the gastric mucosa), Peptic ulcer disease (erosion of GI mucosa in the stomach)
What are five causes of gastritis?
H. pylori, alcohol, stress, autoimmune, and NSAIDs
What are the 3 tests based on endoscopic biopsy that are used to diagnose H. Pylori?
Biopsy urease test
Histology
Culture
What are 3 non-invasive tests used to diagnose H. Pylori?
Serology, C urea breath test, stool antigen test.
What is the algorithm for treating H. Pylori?
1) Test for pylori
2) If positive, treat with omeprazole, clarithromycin, and metronidazole (7-14 days).
3) If still positive, treat with omeprazole, clarithromycin, and amoxicillin (7-14 days).
4) If still positive, go to 3rd line of treatment (not important).
5) If still positive, refer to specialist.
What is the cause of persistent pancreatitis?
Fibrosis and ductal strictures (narrowing). Typically caused by chronic alcoholism or can be idiopathic.
What are the signs and symptoms of chronic pancreatitis?
recurrent attacks of pain
What are some complications of chronic pancreatitis?
Mal-absorption and glucose intolerance (DM)
What is the treatment of chronic pancreatitis?
Supportive, analgesics, diet modifications, and enzyme supplements.
Ocular complications of pancreatitis include ischemic retinopathy that looks very similar to what retinal pathology?
Purtscher’s retinopathy (CWS, NFL hemorrhages, diffuse retinal edema, nonperfusion on FANG and ICG)
T/F: ischemia can occur in pancreatitis?
true
Which organs are involved in gastroenteritis?
Stomach and small intestine
Gastroenteritis is typically caused by infection, but what infectious agent also ties gastroenteritis with reactive arthritis?
Bacteria! Specifically clostridium, salmonella, Shigella, Campylobacter, and E Coli
Gardner syndrome is characterized by which findings?
Intestinal polyposis, Soft tissue tumors, benign osseous (bone) growths, RPE hypertrophy
