PANCE Endocrine Flashcards
What are the parameters for impaired glucose tolerance
Fasting glucose should be between 110 and 126mg/dL or a 2 hr postprandial glucose between 140 and 200mg/dL
This is a 1% to 5% annual increase in risk for developing type 2 diabetes.
When does overt IDDM appear?
When 90% of B-cells are destroyed.
Name the 3 risk factors for DM2
obesity-greatest risk factor
genetics
age-insulin production decreases with age
Pathophys of obesities role in DM2
Obesity is associated with increased plasma levels of free fatty acids, which make muslces more insulin resistant, reducing glucose uptake. Therefore, obesity exacerbates insulin resistance.
In the liver, free fatty acids increase the production of glucose. In DM2 pts the pancrease does not secret enough insulin so this results in hyperglycemia. B-cells become desensitized to glucose=decreased insulin secretion.
What is the characteristic lipid profile with DM2
Hypertriglyceridemia with HDL depletion and LDL levels increased.
What is the dawn phenomenon and the Somogyi effect?
Both cause morning hyperglycemia.
Dawn phenomenon is probably related to the increase in growth hormone.
The Somogyi effect is a rebound effect to nocturnal hypoglycemia which activates a response leading to morning hyperglycemia.
If morning hyperlycemia is present, check BG at 3am, if the BG is elevated then the pt has dawn phenomenon and before bed basal insulin shouls be increased. If levels are low, that is Somogyi, and and the pts evening insulin should be decreased to avoid nocturnal hypoglycemia.
When do you check the pts HbA1c?
With elevated HbA1c, when do you recheck?
When should you screen for microalbuminuria?
When should you check BUN and creatinine levles?
When should pt visit Ophthymologist?
When should you check cholesterol?
When should you check for DM neuropathy?
Screen all adults over the age 45yrs evry 3 yrs. Every 3mos. Every year for diabtic pts. Every year. Every year. Every year. Every 6 months.
What are the parameters for random gulcose check?(2hr post prandial check)
<200mg/dL
Which DM type exhibits a stronger genetic disposition?
DM2 has a 90% concordance rate between identical twins.
What is the typical presentation for type 1 and type 2
Type 1= DKA
Type 2= 3 poly’s, fatigue, wt loss, blurred vision, candidal vaginitis.
Patients who have not had medical attention will present with?
impotence, peripheral neuropathy, proteinuria, retinopathy.
How much insulin does a DM 1 require?
0.5-1.0 unit/kg per day
Whats the pathophys of neuropathy?
microscopic vasculitis leading to axonal ishemia
How to dose the insulin for a pt new to insulin.
Take the total number of units of regular insulin that the pt requires in 1 day.
Take 2/3 of this and give it at per breakfast, and 1/3 pre dinner (70%NPH, 30% regular)
Know the onset and duration of Lispro(humalog) Regular insulin(Novolin) NPH (intermediate) Levemir
Lispro= 15min and 4hr
Regular insulin= 30-60min and 4-6hrs
NPH= 2-4hrs and 10-16hrs
Levemir= duration 24hrs(low insidence of hypoglycemia)
Know the mixes
Humalog (NPH/Lispro) 75/25 or 50/50
Humulin (NPH/reg) 70/30
Both onset 30-60min with duration up to 20hrs
Know the insulin sliding scale
Blood glucose insulin dose
150-200 2units
200-250 4units
250-300 6units
300-350 8units
350-400 10units
Most common cause of death in diabetic pts?
CAD
Diabeteic nephropathy types
Nodular Glomular sclerosis
Diffuse glomular sclerosis
Nodular glomerular sclerosis (Kimmelstiel-Wilson syndrome) Hyaline deposites in 1 area of the glomerulus (pathognomonnic for DM)
Diffuse glomular sclerosis-global hyaline deposits (also occurs in HTN)
In a pt with DM, persitent…….. with……….will lead to decrease in ……..and eventurally lead to ESRD.
HTN with proteinuria lead to a decrease in GFR
Ocular problems in DM pts?
cataracts, retinopathy, glaucoma
what is the pathophys of retinopathy
edema of the macula is th eleading cause. Htn +fluid retention exaerbate this issue.
What do you see on fundoscopic evaluation with DM pt
Exudates, hemorrages, cotton wool spots, microaneurysms, venuos dilation
Define proliferative retinopathy
the 2 serious complications
Can lead to what.
new vessel formation (neovascularization) and scarring. 2 serious complications are vitreal hemorrhage and retinal detachment. Can lead to blindness
Diabetic neuropathy is usually………..
with a ………………..pattern
loss of senation leads to ………….
What is charcots joints?
distal symmetric nuropathy
stocking/glove pattern
loss of sensation leads to ulcer formation and ischemia of pressure point areas.
Charcots jt=Neuropathic arthropathy refers to progressive degeneration of a weight bearing joint, a process marked by bony destruction
Diabetic 3rd nerve palsy
eye pain, diplopia, ptosis, inability to adduct the eye, PUPILS ARE SPARED.
Mononeuropathies? 3
Ulnar neuropathy,
Diabetis lumbrosacral plexopathy=chronic pain in thigh with atrophy and weakness.
Diabetic truncal neuropathy=pain in a intercostal nerve
Autonomic neuropathy. 5 things
Impotence (most common presentation) Neurogenic bladder-retention, incontinence Gastroparesis-chronic n/v Constipation and diarrhea postural hypotension.
Infections of ischemic foot ulcers can lead to
Osteomylitis=inflammation of the bone and bone marrow. abscess in bone look like ghost bone on x-ray
3 key features of DKA
Hyperglycemia (serum glucose >250mh/dL)
Metabolic acidosis
Ketonuria (this and Met Acid are required for diagnosis of DKA)
Clinical factors for DKA
Kussmaul breathing. Abdominal pain. fruity breath 3 poly's altered mental status
Ddx DKA
hypoglycemia Etoh ketoacidosis sepsis intoxication hyperosmolar hyperglycemic nonketotic syndrome (HHNS)-mostly in elderly with co-morbidities
If pt is in DKA what do you need to assess before giving insulin?
be sure the pt is not hypokalemic
Treatment of DKA?
Whats the 1st thing you give when dx is established?
insulin, fluids, potassium
FLUIDS.
Complications of treatment of DKA?
Cerebral edema if glucose levels decrease too rapidly.
Hyperchloremic nongap acidosis-due to rapid infusion of a large amount of saline.
When giving fluids when should you star glucose?
add 5% glucose once the blood glucose reaches 250mg/dL to prevent hypoglycemia.
When do you give potassium?
Initiate within 1-2 hrs of starting insulin.
Ensure adequate renal function
Which hormone suppresses insulin?
Cortisol and exercise
Signs of underlying diabetes
. SIGNS OF UNDERLYING DIABETES:
a) Cranial nerve palsies (CN3 with pupillary reflex spared) b) Stocking/glove distal neuropathy c) Acanthosis nigricans d) Vitiligo(patches of unpigmented skin) e) Dupuytren’s contracture f) Autonomic neuropathy (tachy, orthostatic hypotn) g) ↑ UTIs, skin infections, atrophy
What is “honeymoon” period?
“Honeymoon Phase” = recovery of beta-cell fxn in newly-diagnosed Type I diabetic
Name the 3 tetst to diagnose DM
NOT A1c
FBG, RBG, OGTT all on 2 separate days.
Metformin action?
A.A
Decreases hepatic glucose production,
decrease intestinal absorption
increase peripheral glucose uptake
improves insulin sensitivity.
Black box warning for lactic acidosis.(rare)
A.A-diarrhea, flatulence, n/v, asthenia (weakness)
Levemir starting dose?
.75units/kg
daily or BID
