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Family Medicine > Case 6: Diabetes > Flashcards

Case 6: Diabetes Flashcards

1
Q

Relevant medical history for a patient w diabetes

A
  • age at onset and characteristics of onset of diabetes
  • previous Tx regimens
  • response to Tx
  • current treatment
  • nutrition hx
  • level of physical activity
  • diabetes education history
  • hyperglycemic and hypoglycemic episodes
  • hypoglycemic awareness
  • microvascular complications: retinopathy, nephropathy, neuropathy (sensory and autonomic)
  • macrovascular complications: cardiovascular
  • psychosocial problems: depression
  • dental disease
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2
Q

T1D pathophysiology

A

Immunologic: pancreas is damaged and beta cells do not produce enough insulin

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3
Q

T2D pathophysiology

A

Body cannot recognize insulin produced by pancreas and use it properly (insulin resistance)

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4
Q

High blood pressure makes ….

A

vascular disease in diabetes much worse (high blood glucose affects blood vessels and organs throughout entire body)

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5
Q

Cardiovascular disease in diabetes

A
  • CAD + CVA
    Most common cause of death in diabetes
  • Dx of diabetes = risk to previous MI
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6
Q

Retinopathy

A

Most common cause of new cases of blindness among adults of working age
- by the time vision is affected, substantial nerve damage may have already occurred

Must go annually to ophtho for dilated exam: detects retinal thickening (due to macular edema0

  • T1D: first annual 5 years post Dx
  • T2D: go right after Dx
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7
Q

Prevention of retionpathy

A

Laser photocoagulation treatment can slow progression of retinopathy and reduce vision loss but does not restore lost vision (do this!)

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8
Q

Fundoscopic features in severe, non proliferative retinopathy

A

1) cotton wool spots (areas of previous infarction)
2) retinal hemorrhages (partial obstruction and infarction)
3) microaneurysms (vascular dilation)

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9
Q

Proliferative retinopathy

A

Hallmark is neovascularization (growth of new vessels that is prompted by retinal vessel occlusion and hypoxia)

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10
Q

Neuropathy

A

Sensory: distal peripheral neuropathy
Autonomic: gastroparesis, sexual dysfunction

Prevalence of neuropathy is defined by loss of ankle jerk reflexes

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11
Q

Most common cause of end stage renal disease

A

Diabetes (nephropathy is very common)

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12
Q

Is hyperthyroidism an end result of diabetes?

A

No

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13
Q

Hyperthyroidism and diabetes

A

The hypermetabolic state can unmask underlying glucose intolerance and adversely affect glucose control and lipid management

**Hypothyroidism can also complicate management of diabetes

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14
Q

Severe T2D can result in…

A

Hyperosmolar hyperglycemia syndrome (more commonly) but also DKA if insulin deficiency is severe enough: pt will produce ketones and develop hyperglycemia (eldelry patient with T2D who becomes acutely ill w pneumonia)

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15
Q

American Diabetes Association recommendations on who to screen for diabetes?

A
  1. Patient > 45 years old
  2. Overweight patient (over BMI 25) < 45 years old with at least one of eleven risk factors

If results are normal: screen every 3 years

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16
Q

11 risk factors of diabetes that ADA recommends screening patients <45 for

A
  1. inactive
  2. race (native american, AA, pacific islander, asian, latino)
  3. First degree relative w diabetes
  4. Previous dx of impaired fasting glucose (>125) or impaired GTT (2 hr > 140 after 75 g load)
  5. HTN (BP 140/90 or higher)
  6. HDL <35 or TGs >250
  7. Hx of gestational diabetes or baby > 9 lbs
  8. PCOS
  9. Hx of cardiovascular disease
  10. HbA1C >/= 5.7
  11. acanthos nigricans (signs of insulin resistance)
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17
Q

USPSTF recommendations for diabetic screening

A

Grade B recommendation: screen for T2D for BP > 135/80

I recommendation if BP <135/80

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18
Q

Diagnostic criteria for diabetes (4) - any of them fulfilled

A
  1. Random glucose > 200 + Sx of hyperglycemia such as polyuria or unexplained weight loss
  2. Fasting glucose > 126
  3. HbA1C > 6.5
  4. OGTT: >140 post 2 hrs of 75 g load

for 2, 3, 4 - must be confirmed on a different day unless patient has unequivocal or unquestionable Sx of hyperglycemia

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19
Q

Optimal range for glucose in diabetics

  • fasting blood glucose
  • post prandial glucose
A

Fasting BG: 80-120

PP glucose: <180 (1-2 hrs after meal)

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20
Q

LEARN model for two way dialogue to help pt understand their chronic disease

A
  • Listen w empathy
  • Explain your perception and strategy
  • Acknowledge differences/similarities b/w your approach and patients approach
  • Recommend treatment
  • Negottiate agreement
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21
Q

Diabetics should have a foot exam…

A

Every year

22
Q

2 risk factors for foot ulceration and subsequent amputation

A
  • impaired sensation (distal symmetric polyneuropathy)

- impaired perfusion (peripheral vascular disease)

23
Q

Foot exam should include testing for loss of protective sensation with following

A

1) Sensory testing w 10 g monofilament + any one of the following:
- vibration using 128 Hz tuning fork
- pinprick sensation
- ankle reflexes (Achilles, not patellar)

2) Assessment of pedal pulses: DP/PT
3) Inspection for skin change such as hair loss, temperature changes for signs of vascular insufficiency

24
Q

Strongest risk factor for delayed ulcer healing and amputation in diabetes patients

A

Peripheral vascular disease

25
Q

Hyperosmolar hyperglycemic state

A

Increases with increasing age and serum osmalility

  • plasm glucose level > 600
  • no metabolic acidosis or ketones

Characterized by severe fluid deficit (9L)
Precipitants: pneumonia, UTI, decreased fluid, stroke, MI< pulm embolism
Tx: fluid replacement

26
Q

Diabetic ketoacidosis

A

If <65: mortality is 2%, whereas if 65, mortality is 22%

  • metabolic gap acidosis + ketones
  • lower plasma glucose level: ~250
27
Q

Follow up diabetes studies (6)

A
  1. HbA1C
    a) if stable < 7: 2x/year
    b) if not meeting goal: 4x/year
  2. BMP to screen for nephropathy annually (and if on metformin: metabolic acidosis)
    - use creatine to calculate GFR to stage chronic kidney dz
  3. Spot urine albumin to creatinine ratio to screen for microalbuminuria annually
  4. Serum B12 levels
  5. TSH if not performed in last year and one of following…
    - Type 1 Diabetes
    - new Dx of dyslipidemia
    - women over 50
  6. Fasting lipid profile
    - at time of Dx and
    - annually
28
Q

HbA1C

A

Glycosylated hemoglobin: represents plasma glucose concentrations over 4-12 week period of time
- only need to add fingerstick glucose if pt acutely endorses Sx of hyper or hypoglycemia @ time of visit

29
Q

Metformin can cause (2)

A
  • metabolic acidosis

- B12 deficiency

30
Q

B12 can be low due to (2)

A
  • metformin

- nutritional deficiency leading to B12 def (contributing to peripheral neuropathy rather than diabetes)

31
Q

Management of ASCVD risk factors (to avoid CV and cerebrovascular pathology) includes (5)

A
  • smoking cessation
  • hypertension
  • dyslipidemia
  • life style modification: diet and exercise
  • glycemic control
    +/- aspirin
32
Q

Smoking in diabetics

A

Advice all patients to QUIT, not just cut back

*smoking is most important modifiable cause of premature death

33
Q

Hypertension in diabetics

A

Keep BP < 140/90
If above and > 18: initiate pharm Tx
- non blacks: ACEI, ARB, TZ, or CCB
- blacks: TZ, CCB

34
Q

Is screening asx diabetics for coronary heart disease recommended when baseline EKG is normal?

A

NO

- this approach fails to identify which pts will have silent ischemia on screening tests

35
Q

Use ______ to prevent dyslipidemia in diabetics

A

STATINs for LDLc 70-189

  • moderate for diabetics 40-75
  • high for diabetics 40-75 w >7.5% est 10 yr ASCVD risk
  • If <40 and >75 – consider on case by case basis
36
Q

Patients > 21 years old with or without diabetes who ahve LDL > ____ should be on statin

A

190

37
Q

Target diabetics specifically with aspirin (75-162)?

Most common prescribed dose is 81 for aspirin

A

No- consider aspirin therapy just as we would in patient w/o diabetes because meta analysis only showed it reduced risk of MI in men

38
Q

ADA (4) recommendations regarding aspirin use

A
  1. Use aspirin as secondary prevention in diabetes pt with history of CVD
  2. Consider aspirin as primary prevention strategy in diabetics w increased CV risk (10 year risk > 10%) - this group typically includes men > 50 and women > 60 who have at least one additional RF
    - family Hx of CVD
    - HTN
    - smoking
    - dyslipidemia
    - albuminuria
  3. In patient in above age group with multiple RFs but estimated 10 year risk 5-10% also consider adding aspirin
  4. Do not use aspirin for CVD preventions with low CVD risk (10 yr risk is <5%) such as men < 50 and women <60 with no additional risk factors bc adverse effects of bleeding is worse than benefits
39
Q

USPSTF (2) recommendations regarding aspirin use

A
  1. Use aspirin for men 45 to 79 when reducing MI benefit is > than harm due to GI hemorrhage
  2. Use aspirin for women 55 to 79 when reducing ischemic stroke is > than harm due to GI hemorrhage
40
Q

If CVD patient has documented aspirin allergy…

A

Give clopidogrel 75 mg

41
Q

ADA/EASD consensus algorithm for management of T2D

A

FIRST TIER (well validated studies)
Step 1: Diagnosis
- HbA1C > 6.5%: lifestyle change + metformin
Step 2: Assessment - if HbA1C > 8
- continue lifestyle + metformin
- add sulfonylurea, glimepiride, or basal insulin on intermediate acting insulin (NPH)
Step 3: Reassessment - if HbA1C still > 8
- continue lifestlye + metformin
- add basal insulin or if already added, intensify insulin regimen
- discontinue sulfonylurea to avoid hypoglycemia

SECOND TIER (less well validated studies) 
Step 4: Explore other treatment options
- rapid acting insulin with meals
- Thiazolidenideiones 
- Meglitinides
- GLP 1 analogs
- DPP 4
- amylin analog
- alpha glucosidase inhibitors
42
Q

Thiazolidinediones

A
  • good for those who cannot tolerate GI side effects of metformin or who have hypoglycemia on other agents
  • risks: heart failure, edema, bone fractures
43
Q

Vaccines for patients with diabetes (3)

A
  • influenza annually
  • Hep B
  • Pneumonia if pt > 2 yrs. Revaccinate at 65 if vaccine was first received over 5 years ago
44
Q

Who gets Hep B

A
  • diabetics
  • HIV
  • immunocompromised
  • liver disease
45
Q

Who gets early pneumonia vaccine

A
  • diabetics
  • nephrotic syndrome
  • chronic renal disease
  • immunocompromised
46
Q

Familismo

A

Family is viewed as primary source of support

- ask patient if he or she wants to include family members in decision making

47
Q

Respeto/Simpatia (respect)

A

Special respect shown to elders and authority figures

  • Hispanics avoid disagreement - prefer communication based on politeness and respect (Simpatia)
  • may agree to plan they do not want
48
Q

Personalismo

A
  • Value friendly relationship over formal one

- always address with Mr. or Mrs. or Ms. (not first name)

49
Q

Fatalismo

A

Holding belief that control over one’s diabetes is external to self, thinking nothing can be done to improve diabetes or health “it’s all out of my hands”
- address this by mantra, Help yourself and god will help you”

50
Q

Body image

A

Patients may not accept the idea that thinner is healthier - approach diet from perspective of balance

51
Q

Effects of hispanic culture on communication

A
  • familismo
  • respeto/simpatia
  • personalismo
  • fatalismo
  • faith/religion
  • body image
  • language barriers
  • health literacy
  • complementary or alternative health practices

Family Medicine (10 decks)

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