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Endocrine > Diabetes Mellitus > Flashcards

Diabetes Mellitus Flashcards

1
Q

What is required to diagnose Type 1 DM?

A

Unequivocal hyperglycaemia with acute metabolic decompensation OR

Repeated measurements that are abnormal OR 1 abnormal measurement + symptoms

  • fasting blood glucose > 7.0 mmol/L
  • casual glucose >11mmol/ L
  • 2 hour post challenge glucose >11mmol/ L
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2
Q

What is required to diagnose impaired fasting glucose?

A

Fasting glucose 6.1 – 6.9 mmol/L AND

2 hour post challenge glucose <7.8mmo//L

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3
Q

What is required to diagnose impaired glucose tolerance?

A

Fasting glucose 6.1 – 6.9 mmol/L AND

2 hour post challenge glucose 7.8- 11.0 mmo//L

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4
Q

A symptomatic patient has a RPG >11.1 OR FPG>7.7. What is the conclusion?

A

DM

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5
Q

A symptomatic patient has a RPG<7.7 OR FPG<6. What is the conclusion?

A

Not DM

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6
Q

A symptomatic patient has a RPG 7.7-11.1. What is the conclusion?

A

do the LEGIT test of FPG

  • If FPG is btwn 7.7-11.1 = do OGTT
  • If FPG > 11.1 = DM
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7
Q

A symptomatic patient has a FPG 6-7. What is the conclusion?

A

do OGTT to confirm

- If 7.7 11.1 = DM

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8
Q

[Hx taking in a diabetics patient] What is the relevant history (exclude PMH, drug hx, social hx, fam hx) to take?

A

1) Duration of DM
2) Type 1/ 2 DM

3) Diagnosis
- What were the presenting symptoms at that time?
- When was it diagnosed?
- How was diagnosis made: if he remembered fasting/ drinking any sweet drinks

4) Control
- Home capillary glucose monitoring?
- Last HbA1c?
- Symptoms of hyperglycemia: polyuria, polydipsia, nocturia, LOW?
- Regular follow up?

5) Compliance / Current Management
- Follow-up: where, who, frequency
- What drugs are you taking?
- Do you take your drugs regularly?
- Compliance to medications and follow-up 🡪 if not, why?
- Regular foot and eye screening
- What is your diet like? Do you exercise?

6) Complications * ask about pre-existing complications + screen for them

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9
Q

[Hx taking in a diabetics patient] What are the relevant complications of diabetes to screen for in the history?

  • emergencies
  • microvascular
  • macrovascular
A

Emergencies

  • DKA: Polyuria, polydipsia, LOW, abdominal pain, N&V
  • HHS: Polyuria, polydipsia, LOW, confusion, LOC
  • Hypoglycemia: giddiness, drowsiness, tremulousness, LOC, seizure

Microvascular

  • Diabetic retinopathy: blurring of vision, laser treatment
  • Peripheral neuropathy: glove and stocking distribution (tends to be length dependent)
  • Autonomic neuropathy: ARU, gastroparesis, early satiety, imbalance, postural hypotension
  • Nephropathy: proteinuria, oliguria, anasarca (pedal edema, SOB)

Macrovascular

  • IHD: exertional dyspnoea, chest pain, effort tolerance, signs of ACS
  • CVD: (increased risk of stroke/ TIA!): weakness/numbness, blurring of vision, facial droop, instability, confusion, inability to express self; transient episodes?
  • PAD (peripheral arterial dz): ulcers, claudication, infections
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10
Q

[Hx taking in a diabetics patient] What is the relevant past medical hx to ask?

A

Metabolic syndrome: obesity, dyslipidaemia, HTN

Women: any history of gestational diabetes, polycystic ovarian syndrome (PCOS)

DM type 1: history of associated autoimmune disorders e.g. Graves’ disease, vitiligo

Causes of 2o diabetes: Cushing’s syndrome, Acromegaly, PCOS

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11
Q

[Hx taking in a diabetics patient] What is the relevant drug hx to ask?

A
  • Drug allergies
  • Current medications
  • TCM/over the counter drugs?
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12
Q

[Hx taking in a diabetics patient] What is the relevant social hx to ask?

A
  • Occupation, shift work
  • Caregiver
  • Smoking
  • Alcohol
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13
Q

[Hx taking in a diabetics patient] What is the relevant fam hx to ask?

A
  • DM
  • HTN, HLD, CVS disease, Stroke, CKD
  • Other autoimmune - condition
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14
Q

[PE taking in a diabetics patient] What would you look out for on general inspection of a patient with diabetes?

A

Parameters: HR, BP (postural hypotension in autonomic neuropathy)

Age, BMI: clues of T1/T2

Evidence of dehydration (osmotic diuresis, DKA)

Signs of secondary diabetes

  • Abnormal endocrine facies (eg. Cushing’s syndrome, acromegaly)
  • Pigmentation (eg haemochromatosis – bronze diabetes)

Signs of autoimmune disease (eg. Vitiligo, Graves)

Signs of DKA

  • Patient may be comatose/delirious due to dehydration, acidosis, plasma hyperosmolality
  • Kussmaul’s breathing (deep laboured breathing seen in DKA)
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15
Q

[PE taking in a diabetics patient] What would you look out for on inspection of a diabetic patient’s legs?

A

Hairless and atrophied skin (small-vessel vascular disease and resultant ischaemia)

Superficial skin infections

  • Boils
  • Cellulitis
  • Fungal infections

Diabetic dermopathy: Small rounded plaques with raised borders lying in a linear fashion over shins

Necrobiosis lipoidica diabeticorum

  • Yellowish brown plaques usually found over shins; surrounded by red active margin
  • Plaques may ulcerate

Charcot’s joints

  • Grossly deformed disorganised joints
  • Due to loss of proprioception or pain or both 🡪 causing recurrent & unnoticed injury

Ulcers (toes or pressure areas of feet due to ischaemia + peripheral neuropathy)

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16
Q

[PE taking in a diabetics patient] What would you palpate on palpation of a diabetic patient legs?

A

Palpate injection sites for:

  • Fat atrophy
  • Fat hypertrophy

Check for peripheral vascular disease

  • Feel for peripheral pulses
  • Temperature of feet
  • Capillary return

Neurological examination

  • Assess formally for peripheral neuropathy including dorsal column loss (diabetic pseudotabes) – will cause loss of proprioception, light touch, pain
  • DM causes predominantly sensory loss
  • Because Diabetic Neuropathy is length dependent and sensory axons are longer than motor
  • Motor function generally maintained

Tap reflexes – reduced/ absent

17
Q

[PE taking in a diabetics patient] What would examine for in a diabetic patient’s upper limbs?

A

Signs of Hyperlipidaemia: xanthelasma

  • Nails: signs of Candida infection
  • Acanthosis Nigricans (axilla; related to severe insulin resistance)
  • Blood pressure lying and standing (diabetic autonomic neuropathy causes postural hypotension)
18
Q

[PE taking in a diabetics patient] What would examine for in a diabetic patient’s eyes?

A

Signs of Hyperlipidaemia: xanthelasma

Test visual acuity (retinal disease, glaucoma, cataract)

Fundoscopy

1) Rubeosis (new blood vessel formation over iris 🡪 cause glaucoma)
2) Cataracts
3) Non-proliferative retinal changes: Micro-aneurysms, Dot /blot haemorrhages, Cotton wool spots, Hard exudates
4) Proliferative changes (in response to ischaemia in retina): New vessel formation, Vitreal haemorrhage, Scar formation, Retinal detachment, Laser scars (small brown or yellow spots)

Cranial Nerves

  • Diabetic CN 3 palsy from ischaemia which spares pupil
  • Other CNs may be affected by CVA
  • Rhinocerebral mucormycosis: periorbital, perinasal swelling and CN palsies
19
Q

[PE taking in a diabetics patient] What would examine for in a diabetic patient’s ears?

A

Malignant otitis externa usually due to Pseudomonas aeruginosa

20
Q

[PE taking in a diabetics patient] What would examine for in a diabetic patient’s mouth?

A

Evidence of Candida infection

21
Q

[PE taking in a diabetics patient] What would examine for in a diabetic patient’s neck and shoulders?

A

Examine carotid arteries for evidence of vascular disease

Scleroedema diabeticorum: diffuse cutaneous infiltration causing bilateral thickening (+ reddening) of skin of upper back and shoulders

Acanthosis nigricans a/w insulin resistance

  • Dark patches of skin, may have odour
  • Found in skin folds: posterior and lateral folds of the neck, the armpits, groin, navel, forehead etc
  • a/w hyperinsulinemia 2’ to IR

Goitre due to grave’s (a/w T1DM)

22
Q

[PE taking in a diabetics patient] What would examine for in a diabetic patient’s abdomen?

A

Palpate for hepatomegaly (fatty infiltration, or due to haemochromatosis)

Lipodystrophy – excessive loss of fat and inability to produce it properly

23
Q

What are the investigations to be performed in a diabetic patient?

A

Rule out secondary Causes

  • 24-hour urine cortisol / Dexamethasone suppression test: for Cushing’s
  • IGF1 levels: for acromegaly

Confirming Diagnosis

  • Fasting glucose
  • OGTT

To assess control: HbA1c

Complications

  • Urine Albumin/Cr ratio (or UPCr) 🡪 positive indicates diabetic nephropathy. Since albumin and Cr fluctuates based on hydration, by taking Cr into consideration 🡪 negatives fluid status
  • UECr / Rena panel: assess for CKD
  • Fundoscopy
  • Nerve testing / Diabetic Foot Screen
  • Ankle- brachial index (ABI): simple, noninvasive, widely used test that detects peripheral arterial disease (PAD)
  • ECG +/- Trops if symptomatic
  • Lipids, BP
24
Q

What can cause falsely low HbA1c?

A

Increased RBC turnover, Hypersplenism, Blood loss, Anaemia, Blood transfusion

25
Q

What can cause falsely high HbA1c?

A

Asplenia, Polycythaemia

26
Q

What are the causes of persistent morning hyperglycaemia?

A

Dawn Phenomenon (more recognised)

  • Causes Hyperglycaemia upon waking
  • Due to surge of Cortisol & Glucagon in the morning
  • Need to INCREASE dose of BASAL insulin

Somogyi Effect (less recognised)

  • Rebound hyperglycemia in response to hypoglycaemia during the night
  • Need to DECREASE dose of BASAL insulin
27
Q

A diabetic patient has good FPG and HbA1c. What does that mean?

A

Good control

Beware of hypoglycemia

28
Q

Who, how and how often is DM screened?

A

How? FPG

Who do we screen?

  • Adults of ANY AGE who have one or more risk factors for diabetes. Risk factors: Obesity, FHx of T2DM, GDM, HTN, HLD, PCOS, PMHx of CV Dz
  • > 40YO for those w/o risk factors

How often do we screen? Every 3 years for those w/ normal glucose tolerances, and every year for IGT and IFG

29
Q

What are the targets of control in patient with diabetes?

A

HbA1c Targets: target is patient dependent!

  • For most patients <7%, depending on patient factors
  • For frail & elderly patients / Hx of CV disease: 7-8 %

LDL targets

  • In patients with DM w/o established stage 3 CKD or worse <2.6
  • In patients with DM + established stage 3 CKD or worse <2.1

TG targets

  • High risk of pancreatitis if TG is >10
  • Aim to bring down TG to below <4.5

BP Targets
- If proteinuria = 130/80; if no proteinuria = 140/90

BMI – 18-23

Diet: low fat, low fried food, low salt, low carbs, complex carbs eg: brown rice

Exercise: 150min aerobic exercise / week for weight neutral; 300min for weight loss

Others: Smoking cessation, reduce drinking

30
Q

What is the management for patients with HbA1c <7%

A
  • Medical nutrition therapy, exercise, patient education

- Metformin monotherapy is an option

31
Q

What is the management for patients with HbA1c 7-9%

A

Monotherapy: 1st line metformin

Alternative therapy: Sulfonylurea Dipeptyl peptisase 4 inhibitors/ Thiazolidinedione Dual therapy may be appropriate for some patients

32
Q

What is the management for patients with HbA1c >9%

A

Metformin PLUS 2nd agent from the outset

Alternative: start insulin therapy

Endocrine (18 decks)

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