what is critical about a DM physical exam?
look at their feet
they may not look at their feet
what kind of pain do DM pts feel with ulceration?
none
what is the primary goal of working with DM pts and peripheral neuropathy?
prevention of ulcers, infections/early txment
patient education
examination of feet regularly
proper foot wear
what 6 things are involved in the foot exam?
- inspect the skin (temp, infections, ulcers, nails)
- foot architecture
- palpate PT and DP pulses
- check ankle reflexes
- check fine touch
- check vibration sense
what are txment choices for peripheral neuropathy?
1st line Tricyclics (amitriptyline, nortriptyline)-start low, go slow, PM dosing b/c sedation-25mg
gabapentin-neurontin
pregabalin-lyrica
duloxetine-cymbalta
which type of neuropathy is hard to treat?
autonomic neuropathy
what are common autonomic complaints?
gastroparesis constipation neurogenic bladder (lacks full sensation or motor capacity to go) erectile dysfunction orthostatic hypotension resting tachycardia
what is orthostatic hypotension?
bodies ability to adjust constriction of blood vessels when going from sitting to standing position
when would you be suspicious of resting tachycardia?
pt who is resting and has a high-normal heart rate
what is cardiac denervation?
inability to feel chest pain or palpitations
what is esophageal dysfunction?
bolus is not moved through the esophagus correctly
what is symmetrical anhidrosis?
inability to sweat (causes inability to disapate heat)
what is gustatory sweating?
sweating while you eat
what is a pupillary autonomic neuropathy?
decreased diameter of dark adapted pupil
argyll-robertson type pupil
what is the most common cause of death in the US and the most common cause of death in ppl with DM?
cardiovascular dz
why are small, dense LDL’s the bad ones?
they combine with the macrophages and become foam cells
what is a stimulus for atherogenesis?
inflammation
what is the trifecta of DM CV dz?
atherosclerosis PLUS no ability to feel CP
RED FLAG?
Type 2 DM
active
“feeling wierd”?
what happens with a plaque ruptures?
platelet plug forms
blockage
BOOM
heart attach
what are the 5 steps to manage cardiac risks of a cardiac pts?
- ASA QD
- control BP
- control lipids
- weight reduction
- STOP SMOKING
what is the most common cause of renal failure in the US?
diabetic nephropathy
what are the two key ways to prevent nephropathy?
- glycemic control
2. BP control
what is considered normal albuminuria?
<30mcg/mg
what is considered microalbuminuria?
30-300mcg/mg
what is considered macroalbuminuria?
> 300mcg/mg
what is a screening test for nephropathy?
morning spot urine
what lab values are dx of nephropathy?
2-3 elevated readings over 2-3 months
what is a late finding of renal dz (40% of kidney damage)?
elevated creatinine
what are management options for DM nephropathy?
ACE inhibitors (normotensive w/microalbuminuria)
low protein diet (in macroalbuminuria)
aggressive BP management in HTN pts
what is the most common cause of DKA?
infection
what is the most important electrolyte abn of DKA?
hypokalemia
why does ETOH become a problem with diabetes?
missing insulin mixing drinks (high sugar)
what should you consider when you have a pt in DKA?
psychiatric concerns (less common,but should be considered)
what are dx lab features of DKA?
high blood glucose low pH high ketonuria low bicarb (getting bound while trying to compensate) dehydration (high BUN and creatinine) hypokalemia (total body stores) high anion gap
how do you correct serum sodium?
serum value + 1.6 (glucose-100)
why is someone in DKA hypokalemic?
K+ is switching places with H+ to try to compensate for the acidosis
then you pee out a lot of potassium
what are the 3 types of ketone bodies?
- acetone
- acetoacetate
- beta hydroxybuterate
which ketone bodies to test strips detect?
acetone
acetoacetate
why should you not check serial ketones?
the ketones will move backwards in the enzymatic process and it will look like they are getting worse
why do you have to be careful when treating DKA and the glucose gets down to 250?
too low too quickly causes major fluid shifts and can cause cerebral edema and death
what are clinical features of hyperosmolar hyperglycemic state (HHS)?
hyperglycemic
dehydration
hx of type 2 diabetes
what are lab features of HHS?
marked hyperglycemia high serum osmolaltiy high dehydration no acidosis no ketosis AMS (common in elderly pts) \+/- K level (massive diuresis)
what is the definition of hypoglycemia?
BS <60 mg/dl
what are neuroglycopenic sxs?
nonsense
acting silly
unable to concentrate
what is autonomic hyperactivity?
sweaty
clammy
impending doom
