Diabetes

Question 1

What is the major cause of death in DKA in children?

Answer 1

Cerebral oedema

Question 2

What must you ask in any child presenting with vague symptoms?

Answer 2

Polyuria, polydipsia, nocturnal enuresis

Question 3

What is T1DM?

Answer 3

Autoimmune destruction of pancreatic ß-cells by anti-GAD and anti-islet cells. Causes hyperglycaemia.

Question 4

How does T2DM present?

Answer 4

Polyuria, polydipsia, fatigue

In obese person

Often in older person

Question 5

How does T1DM present?

Answer 5

Polyuria, polydipsia, fatigue

Weight loss

Often in younger person

Question 6

What is T2DM?

Answer 6

Insulin resistance from chronic hyperglycaemia

Question 7

How do you diagnose diabetes mellitus?

Answer 7

Random glucose > 7mmol

Fasting glucose > 11mmol

Glucose tolerance test > 11mmol

(repeat tests required)

Question 8

What autoantibodies are associated with T1DM?

Answer 8

Anti-GAD

Anti-islet cell

Question 9

What is c-peptide and would it be raised in T1DM and/or T2DM?

Answer 9

Measure of endogenous insulin production

Low in T1DM
Normal/high in T2DM

Question 10

Name a rapid acting insulin.

Answer 10

Novorapid

Question 11

Name a long acting insulin

Answer 11

Lantus

Question 12

What insulin regimen are most T1DM patients on and what does it consist of?

Answer 12

Basal bolus

Long acting basal insulin (lantus)

Short acting insulin (novoarpid) taken before meals

Question 13

What should the HbA1c target be in

1. most diabetics?
2. young diabetics?

Answer 13

1. 53mmol/mol

2. 48mmol/mol

Question 14

What is HbA1c?

Answer 14

Glycalated haemoglobin

Measures average glucose levels in blood in last 6-8 weeks

Question 15

What should diabetic patients blood glucose targets be before meals?

Answer 15

6mM (4-7mM)

Question 16

What is the pathogenesis of T2DM?

Answer 16

Fat and fatty acid produce inflammatory mediators which inhibit insulin receptor substrate 1 which inhibits insulin function resulting in insulin resistance.

The ß-cells compensate for this by over-secreting insulin but these eventually fatigue resulting in ß-cell dysfunction

Question 17

What are the main chronic complications of T2DM?

Answer 17

Macrovascular

• MI
• Stroke

Microvascular

• neuropathy
• retinopathy
• nephropathy

Question 18

What is the stepwise treatment pathway in diabetes mellitus?

Answer 18

1. Lifestyle modification
2. Lifestyle + oral monotherapy
3. Lifestyle + combined therapy
4. Lifestyle + injected therapy

Question 19

What is involved in a diabetic review?

Answer 19

Ask about lifestyle

Visual acuity
Leg/foot exam
Urinalysis
HbA1c
U and Es
Cholesterol
Measure BMI
Blood pressure

Question 20

8 months old boy presents with polyuria, polydipsia and failure to thrive. What is the diagnosis?

Answer 20

Maturity onset diabetes of the young (MODY)

Question 21

Name 2 genes which are mutated in MODY and which MODY types they cause.

Answer 21

Hepatocute nuclear factor
- MODY1/3/5

Glucokinase
- MODY2

Question 22

What is MODY treated with?

Answer 22

Sulphonylureas

Question 23

Patient with BMI 31 presents with polydipsia, polyuria and lethargy. They are autoantibody positive and non-insulin requiring. What is the diagnosis?

Answer 23

Latent onset diabetes of adulthood (LADA)

Question 24

How do you diagnose LADA?

Answer 24

Elevated pancreatic autoantibodies (anti-GAD, anti-islet cell)

Non-insulin requiring at diagnosis

Question 25

What must patients do when administering insulin?

Answer 25

Change injection site Long term use of same injection site causes lipohypertrophy which disrupts insulin absorption

Question 26

What dose of insulin would a 60kg male get for bolus and basal use?

Answer 26

60kg person gets 18 units insulin a day (weight times 0.3) 18 units divided equally between basal and bolus Basal - 9 units Bolus - 9 units (3 units per meal)

Question 27

What is the 1. insulin carbohydrate ratio (ICR) 2. insulin sensitivity factor (ISF)/ correction factor (CF)?

Answer 27

1. units of insulin requires to clear x grams of carbohydrate ICR=1:10, 1unit insulin clears 10g carbohydrate 2. units insulin required to reduce blood glucose by x mM ICF=1:2, 1 unit insulin lowers BG by 2mM

Question 28

What dose should be changed if a patient is reporting hypo/hyperglycaemia?

Answer 28

Dose before the hypo/hyperglycaemia

Question 29

How much should an insulin dose be changed by?

Answer 29

10%

Question 30

What must you check before changing an insulin dose?

Answer 30

``` Renal function Injection site (lipohypertrophy) Lifestyle changes ```

Question 31

What is the major cause of death in DKA in adults?

Answer 31

Hypokalaemia Aspiration pneumonia Co-morbidities

Question 32

What is the pathophysiology of DKA?

Answer 32

Lack on insulin prevents glucose moving into cells starving them of energy which causes them to release stress hormones. Stress hormones produce more glucose and breakdown lipids which forms ketone bodies. Ketone bodies are acidic and cause ketoacidosis.

Question 33

How does DKA present?

Answer 33

Polyuria, dehydration, breathlessness, vomiting, abdominal pain, sweet breath

Question 34

What blood tests would you order in suspected DKA? What results would confirm your suspicion?

Answer 34

Urine ketones >3mM Blood glucose > 11mM Bicarbonate <15mM

Question 35

What ketone is used to measure 1. blood ketones 2. urine ketones?

Answer 35

1. ß-hydroxybutarate | 2. acetoacetate

Question 36

Outline management of DKA.

Answer 36

*replace losses* IV fluid IV insulin Potassium ECG monitoring for hyperkalaemia

Question 37

Name 8 symptoms of hypoglycaemia.

Answer 37

``` Tremor Sweating Anxiety Irritability Tachycardia Headache Hunger Blurred vision ```

Question 38

What can cause hypoglycaemia?

Answer 38

Missed meals Exercise Alcohol (increases insulin activity) Over treatment

Question 39

How do you manage hypoglycaemia in a 1. conscious patient 2. unconscious patient

Answer 39

Conscious - 15-20g rapidly absorbed glucose - recheck BG (if abnormal repear step 1) - 15g simple carbohydrate Unconcsious - 1mg subcutaneous glucagon

Question 40

What is hyperglycaemic hyperosmolar syndrome?

Answer 40

Hyperglycaemia causes hyperosmolality without ketoacidosis

Question 41

What is the name given to hyperglycaemia causing hyperosmolality without ketoacidosis?

Answer 41

Hyperoglycaemic hyperosmolar syndrome (HHS)

Question 42

How does hyperglycaemic hyperosmolar syndrome (HHS) present clinically?

Answer 42

Confusion, dehydration and blurred vision over days to weeks

Question 43

What blood tests would you order in suspected hyperoglycaemia hyperosmolar syndrome (HHS)? What results would confirm your suspected diagnosis?

Answer 43

Blood glucose - very high (>30mM) Ketones - none U&Es - hyperosmolar

Question 44

How do you calculate osmolality? What is a normal result?

Answer 44

2([Na]+[K]) + [urea] + [glucose] 285-295

Question 45

Outline management of hyperoglycaemic hyperosmolar syndrome (HHS).

Answer 45

Normalise osmolality with - IV fluid - IV sodium (give insulin if ketones or blood glucose not falling in response to fluids)

Question 46

What are the classes of lactic acidosis? What causes each?

Answer 46

Type A - hypoxia Type B - other (DKA, meformin, liver diseas etc.)

Question 47

How does lactic acidosis present?

Answer 47

Hyperveiltation | Confusion (coma)

Question 48

What is the initial management of lactic acidosis?

Answer 48

IV fluid

Question 49

What is charcot foot?

Answer 49

Arthopathy characterised by degeneration of weight bearing foot joints assoaciated with diabetes

Question 50

What are the different classes of neuropathy in diabates?

Answer 50

Peripheral (distal symmetric aesthesia, proprioception loss) Focal (one/group of dysfunctional nerve(s) Proximal (proximal lower limb pain progressing to weakness) Autonomic (increased sympathetic nervous action eg gastroparesis)