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Year 3 Medicine > Diabetes > Flashcards

Diabetes Flashcards

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1
Q

What is Diabetes Insipidus?

A

Reduced ADH secretion/kidney response to ADH causes passage of large volumes of dilute urine

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2
Q

Give 3 symptoms of Diabetes Insipidus

A

Polyuria
Polydipsia
Dehydration

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3
Q

Give 3 causes of Cranial DI

A

Congenital (ADH genetic defects)
Tumour
Trauma

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4
Q

GIve 3 causes of Nephrogenic DI

A

Inherited
Chronic Renal Disease
Drugs (Lithium, Demeclocycline)

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5
Q

What 4 investigations could you do if you suspected DI?

A

Us and Es (?hypernatraemia)
Glucose (rule out DM)
Plasma:Urine Osmolality (rule out primary polydipsia, urine should be no more that twice as conc)
8hr Deprivation Test (<700)

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6
Q

How would you treat Cranial DI?

A

Desmopressin

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7
Q

How would you treat Nephrogenic DI?

A

Treat underlying causes
NSAIDs (Prostaglandins locally inhibit ADH)
Bendroflumethiazide (inducing hypovolaemia may kickstart RAAS)

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8
Q

Describe the pathophysiology of Type 1 DM

A

Onset in childhood
Autoimmune destruction of pancreatic B cells
HLA association

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9
Q

Describe the pathophysiology of Type 2 DM

A

Decreased insulin secretion/increased insulin resistance
Associated with obesity/sedentary lifestyle
No HLA association
There is an autosomal dominant form affecting young people - MODY

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10
Q

Give 4 other causes of DM

A

Steroids
Pancreatitis
Cushings Disease
Glycogen Storage Disease

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11
Q

What is the triad of DM symptoms

A

Polyuria
Polydipsia
Weight Loss

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12
Q

What are the parameters for diagnosing DM in terms of Venous Glucose?

A

Fasting >7mmol/l
Random >11.1mmol/l

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13
Q

What is the parameter for diagnosing DM using the OGTT?

A

> 11.1mmol/l

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14
Q

What is the parameter for diagnosing DM using HbA1c?

A

> 48mmol/l
6.5%

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15
Q

What are the parameters for ‘Pre-Diabetes’?

A

Fasting glucose of 5.5-6.9mmol/l
HbA1c of 42-47mmol/l (6-6.4%)

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16
Q

What is required for a Diabetes diagnosis?

A

Either
Symptoms and ONE positive blood result
Or
Positive bloods on two separate occasions

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17
Q

What advice would you give patients who are diagnosed with Type 1 DM? Give 4 points.

A

Review and research diet
Try to limit other things contributing to CVS risk
Ensure foot care
Avoid binge drinking (delayed hypoglycaemia)

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18
Q

Name one ultrafast, one medium and one long acting insulin

A

Ultrafast - Novorapid
Medium - Isophane Insulin
Long - Insulin Glargine

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19
Q

Name a premixed insulin

A

Novomix (30% short, 70%long)

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20
Q

Describe 2 different regimens to manage T1DM

A

Basal Bolus - rapid acting at meals and two long acting (determir)
BD - Twice Novomix daily

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21
Q

What could you give patients if they struggle with the insulin regime?

A

Insulin Pump

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22
Q

Give three important pieces of advice for T1DM regarding insulin

A

Vary injection site
Change needles
Continue insulin if ill (and replace lost calories with milk)

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23
Q

Describe the 4 step (up) therapy for T2DM

A

1) Lifestyle and Diet
2) Metformin
3) Dual Therapy (Metformin + another)
4) Triple Therapy or Insulin Therapy

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24
Q

What is Metformin’s action?

A

Biguanide that increases insulin sensitivity

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25
Give 3 SE of Metformin
Nausea, Abdo Pain, Lactic Acidosis (in renal impairment)
26
Name a DPP4 Inhibitor. What is it's action?
Sitagliptin DPP4 destroys incretins which enhance insulin release
27
Name a Glitazone. What is it's action?
Pioglitazone Increases insulin sensitivity
28
When are Glitazones contraindicated? What are their side effects?
CI - Osteoporosis, CCF SE - Hypoglycaemia, Fractures
29
Name a Sulphonylurea? What is it's action?
Gliclazide Increases insulin secretion by binding to ATP sensitive potassium channels, closing them
30
Name an SGLT2 inhibitor. What is it's action?
Dapaglifozin Blocks glucose reabsorption in the PCT
31
Name a GLP1 analogue. What is it's action?
Exenatide Incretin mimics
32
Name four complications of Diabetes
Vascular disease Nephropathy Retinopathy Neuropathy
33
Give two eye diseases associated with Diabetes
Diabetic Retinopathy Cataracts
34
Describe the pathophysiology of Diabetic Retinopathy
Microvascular occlusion causes retinal ischaemia Leads to AV shunts, Neovascularisation and Oedema
35
Describe 3 characteristic features of Diabetic Retinopathy
Microaneurysms - physical weakening of vascular walls Haemorrhages - when weakened vessels rupture, can be small or large (AKA Flame - track along nerve-fibre bundles in superficial retinal layers) Cotton Wool Spots - Build up of axonal debris
36
How would Diabetic Retinopathy present?
Often gradual painless visual deterioration If haemorrhages - sudden onset of dark, painless floaters which may resolve over several days.
37
Most Diabetic Retinopathies are not treated, however if they are, give 2 treatment options
Laser Treatment - aim is to induce regression of new blood vessels and reduce central macular thickening Intravitreal Steroids
38
Give 4 possible features of foot neuropathy
Reduced sensation in stocking distribution Absent ankle jerks Charcot Joint Claw Toes
39
How would a diabetic ulcer present?
Punched out ulcer in area of thick callus
40
Describe 3 non surgical managements of 'Diabetic Foot'
Regular Chiropody Bisphophonates Antibiotics
41
Hypoglycaemia is classified as <3mmol/l glucose. Majority of times it's a diabetic cause, but using the mnemonic EXPLAIN, state 7 non diabetic causes.
Exogenous Drugs (ACEI, B Blockers) Pituitary Insufficiency Liver Failure Addisons Insulinoma Non pancreatic Neoplasms
42
Give 3 autonomic and 3 neuroglycopenic symptoms of Hypoglycaemia.
Autonomic - Sweating, Anxiety, Hunger Neuroglycopenic - Confusion, Drowsiness, Coma
43
What is Whipple's Triad?
Symptoms + Hypoglycaemia + Resolution as plasma glucose rises
44
Describe the pathophyiology of DKA
Without insulin to drive glucose into the cells, the body is forced into starvation state, using ketones for energy and causing acidosis
45
Name three triggers of DKA
Infection Non Compliance Chemo
46
Name 5 symptoms of DKA
Drowsiness Vomiting Dehydration Abdo Pain Polydipsia
47
Describe 3 diagnostic classifications of DKA
VBG pH<7.3 Glucose>11.1mmol/l Ketonaemia (>3mmol/l) or Ketonuria
48
Describe a four step management plan of DKA
1) IV 0.9% NaCL - 1L over an hour 2) Insulin at 0.1 unit/kg/h 3) Monitor K+ - ?add to next bag of fluid 4) Start 5% Dextrose infusion when CBG<15
49
Give 3 complications of DKA
Cerebral Oedema Hypokalaemia Aspiration Pneumonia
50
What is a Hyperosmolar Hyperglycaemic State?
Seen in unwell patients with T2DM Hx of a weeks dehydration with glucose>30mmol/l NO KETONE METABOLISM
51
How would you manage Hyperosmolar Hyperglycaemic State?
Rehydrate slowly Replace K+ when urine starts to flow Only use insulin if glucose isn't reducing
52
Describe the different between Dry and Wet Gangrene
Dry Gangrene - Black 'mummified' toes that often autoamputate Wet Gangrene - indicates infection
53
Describe four features indicating Necrotising Fasciitis from Diabetic Foot
Spreading Cellulitis Black Spots Dishwater Fluid Appearance Crepitus (tissue paper sound when pressing - gas gangrene)
54
Describe two features you are looking for on an X-Ray of a diabetic foot
Osteomyelitis Gas Gangrene
55
Why is ABPI generally done on right arm?
Steal Syndrome is more common on the left You generally stand to the right of the patient
56
Explain the ABPI value indicating Diabetic Foot
>1.2 Due to calcification of the peripheral arteries increasing the pressure (NOT because they have superior blood flow to PAD)
57
Describe the Doppler Sounds of vessels
Monophasic Biphasic Triphasic Monophasic is diseased, and triphasic is healthy (you can hear the elastic recoil in competent vessels)
58
Using the mnemonic SWOMPD, how would you manage a diabetic foot?
Sepsis Wound Management Offloading (Orthotics) Mechanical (Orthopaedics input) Perfusion (Lifestyle, Meds, Surgical) Diabetic Control
59
What antimicrobials would you use for MILD Diabetic Foot?
Flucloxacillin
60
What antimicrobials would you use for MODERATE Diabetic Foot?
Flucloxacillin, Ciprofloxacin and Metronidazole
61
What antimicrobials would you use for SEVERE Diabetic Foot?
Piperacillin, Tazobactam and Vancomycin
62
What investigation should you do if atypical features for diabetes?
C Peptide
63
Give three scenarios where HbA1c cannot be used
Haemoglobinopathies Children CKD
64
What is impaired glucose tolerance?
OGTT more than 7.8 but less than 11.1
65
Describe T1DM monitoring
HbA1c three monthly Self monitoring QDS Aim for 4-7mmol/l
66
What medication could you add to overweight patient’s T1DM medication?
Metformin
67
Describe the sick day rules for diabetes
Monitor CBG more frequently Have access fo phone Don’t change hypoglycaemic/insulin dose (stop metformin if dehydrated) Can consider corrective dose if rising glucose/insulin - 10-20%
68
What diet measures should you encourage in T2DM
High fibre Low glycaemic index Low fat Target weight loss 5-10%
69
When should you start dual therapy in T2DM?
When HbA1c is 58mmol/l
70
With what oral hypoglycaemic agent are you permitted a higher target HbA1c?
Sulphonylureas (eg Gliclazide) as can cause hypoglycaemia
71
How can the GI side effects of Metformin be minimised?
Titrate up slowly Modified release
72
If Metformin is contraindicated what can be used first line?
Gliptins (DPP4 inhib) Glitazones Gliclazide (Sulphonylureas) Can use Glifozins if CVD profile
73
What should be added to Metformin in patients with significant cardiac history?
Glifozins (SGLT2 inhib)
74
When can GLP1 analogues be trialled?
If failure of triple therapy and insulin Or unsuitable for insulin
75
What are the recommended adjustments during Ramadan for diabetic patients?
High carbohydrate meal before sunrise Splitting oral hypoglycaemic dose so majority is post sunrise Regular monitoring
76
What are the DVLA rules regarding Diabetics
Have to have no hypoglycaemic episodes and have full glycaemic awareness if on insulin HGV drivers must also provide regular glucose monitoring
77
Name three GI neuropathic manifestations of diabetes
Gastroparesis Chronic Diarrhoea GORD
78
Describe diabetic foot screening
Annual screening for pulses and sensation If moderate to high risk of diabetic foot - refer to local diabetes centre
79
How would you manage Hypoglycaemia?
Alert - quick-acting glucose/glucogel, use of hypobox Unconscious - IM glucagon, or if good access 20% glucose
80
At what BGC do you experience neuroglycopenic symptoms?
<2.8
81
What should be done about patients long-term insulin during DKA?
Stop short-acting, continue long-acting
82
When has a DKA resolved?
pH>7.3 Bicarb>15 Ketones<0.6 Can start short-acting once eating and drinking If not resolved in 24h - endocrinologist
83
What is the process behind Hyperosmolar Hyperglycaemic State?
Osmotic Diuresis
84
Why should you give VTE prophylaxis in HHS?
Hyperviscocity can result in MI/Stroke
85
Why is HHS more deadly than DKA?
Happens gradually over a few days therefore electrolyte disturbances are normally more severe
86
Name three criteria to indicate HHS
Marked Hypovolaemia Serum Osmolaltiy > 320 (high osmolality) No ketonaemia
87
When should insulin be administered in HHS?
Only if significant ketones or glucose refractory to fluids Glucose between 10-15 is satisfactory
88
Why should fluid be administered carefully?
Risk of Cerebral Pontine Myelinolysis due to fluid shifts aim to give 3-6L over 12h
89
Describe the water deprivation test for Diabetes Insipidus
Prevent patient from drinking and take hourly osmolalities After deprivation : Cranial and Nephrogenic Insipidus still have low urine osmalality Primary Polydipsia has high (as can concentrate urine) High concentration after desmopressin = cranial

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