Type 2 Diabetes Mellitus

Question 1

what is the name given to the combination of severe bone and soft tissue infection in patients with diabetes?

Answer 1

fetid foot

Question 2

what is fetid foot?

Answer 2

extensive, chronic soft tissue and bone infection causing a foul exudate

Question 3

what is the management of fetid foot?

Answer 3

extensive surgical debridement and/or amputation

Question 4

what is type 2 diabetes mellitus?

Answer 4

pancreatic beta cells production of insulin becomes insufficient due to insulin resistance

Question 5

how do you diagnose type 2 diabetes mellitus?

Answer 5

• random blood glucose = 11.1 mmol/l
• fasting plasma glucose = 7 mmol/l
• 2 hour glucose tolerance = 11.1 mmol/l
• HbA1C = 48 mmol/mol (6.5%)
  symptomatic + 1 of the above OR asymptomatic + 2 results on different days

Question 6

what are the complications of T2DM?

Answer 6

• gastroparesis
• autonomic neuropathy
• peripheral arterial disease
• diabetic foot infections
• sexual dysfunction
• cardiac complications

Question 7

what causes gastroparesis?

Answer 7

nerve damage to the autonomic nervous system, specifically the vagus nerve which is responsible for controlling the gastric muscles

Question 8

what does damage to the vagus nerve lead to?

Answer 8

• delayed gastric emptying
• offensive egg smelling burps due to baterial overgrowth
• early satiety
• abnormal stomach wall movements
• morning nausea

Question 9

what is the management of gastroparesis?

Answer 9

• motility agents - metoclopramide or domperidone
• tight glycaemic control
• antibiotics - erythromycin
• botox injections (to relax the gastric outflow obstruction)
• gastric pacemakers = last resort

Question 10

what is postural hypotension caused by in T2DM?

Answer 10

autonomic nervous system damage

Question 11

what is postural or orthostatic hypotension?

Answer 11

fall in systolic blood pressure by 20mmHg or more after changing posture, typically from lying to standing

Question 12

what are the clinical features of an autonomic neuropathy?

Answer 12

• drop in blood pressure on movement - dizziness, falls and LOC
• sitting or standing slowly may help with light headedness
• exacerbated by dehydration (can occur in hyperglycaemia with consequent polyuria)

Question 13

what is the management of autonomic neuropathy?

Answer 13

• increased dietary salt
• use of salt retaining hormones - i.e. fludorcortisone or midodrine
• raising the head of the bed to retrain the body’s baroreceptors
• wearing elasticated stockings to overcome venous pooling in the peripheries

Question 14

what is the known macrovascular complication of T2DM?

Answer 14

peripheral arterial disease

Question 15

how does peripheral arterial disease present?

Answer 15

• foot discolouration
• gangrene
• intermittent claudication
• rest pain
• night pain
• absent peripheral pulses (confirmed on doppler)

Question 16

what is the management for a diabetic foot infection?

Answer 16

• good glycaemic and blood pressure control
• smoking cessation
• improving the circulation (potentially with angioplasty or bypass surgery)
• debridement of the wound
• use of larvae therapy (maggots)
• antibiotics

Question 17

what is a complication of diabetic foot infection?

Answer 17

osteomyelitis

Question 18

how is osteomyelitis diagnosed?

Answer 18

MRI

Question 19

what are the common causative organisms in diabetic foot infections?

gram +ve organisms

Answer 19

• staph aurea
• enterococcus

Question 20

what are the common causative organisms in diabetic foot infections?

gram -ve organisms

Answer 20

• pseudomonas aeruginosa
• escherichia coli
• klebsiella species
• proteus species
• anaerobes

Question 21

what are the causes for sexual dysfunction in T2DM?

Answer 21

• poor glycaemic control
• neuropathy
• microvascular complications
• obesity
• hypertension
• depression
• medication side effects
• alcohol
• cannabis
• hypogonadism

Question 22

what investigations should be carried out in a T2Dm patient with sexual dysfunction?

Answer 22

• 9am testosterone blood test
• gonadotrophin levels

Question 23

what is the pathophysiology of cardiac complications in T2DM?

Answer 23

• hyperglycaemia + free fatty acids -> change in blood vessel -> cardiovascular disease
• lining of the blood vessels may become thicker -> impaired blood flow

Question 24

what is the conservative management of T2DM?

Answer 24

• diet advice
• encouraging regular physical activity
• smoking cessation
• measure HbA1c levels at 3-6 month intervals

Question 25

what is the medical management of T2DM?

Answer 25

• metformin
• pioglitazine
• DPP-4 inhibitors
• sulphonylureas
• SGLT-2 inhibitors

single therapy -> dual therapy -> triple therapy

Question 26

what is the recommended insulin therapy?

Answer 26

basal insulin therapy with isophane (NPH) insulin e.g. insulatard

Question 27

what is the typical pattern of sensory loss in T2DM?

Answer 27

glove and stocking sensory loss

Question 28

what should T2DM target blood pressure be?

Answer 28

140/90mmHg

Question 29

what is the first-line management of peripheral diabetic neuropathy?

Answer 29

tricyclic anti-depressants (e.g. amitriptyline)