Endocrinology - Diabetes Flashcards

Question

Discuss the pathophysiology of diabetic ketoacidosis

Answer 1

Severe Insulin Deficiency - stress increase insulin demand that is not matched by pancreas - decrease peripheral glucose utilization and uptake, leading to hyperglycemia - K shift out of cell leading to hyperkalemia with low body store of K Severe Cell Starvation - liver produce and release glucose -> hyperglycemia - adipose tissue release free fatty acids which are converted to ketones by liver - peripheral muscle decrease glucose utilization leading to weakness Ketone Bodies - cause metabolic acidosis, which can be compensated by breathing Hyperglycemia and Ketone Bodies - cause osmotic diuresis - dehydration - electrolyte depletion - hyperosmolality (hyponatremia and cerebral dehydration)

Answer 2

``` Presentation - sleepiness, LOC - blurry vision - N/V - polyuria, polydipsia - Kaussmaul breathing - hypovolemic - fruity ketone breath Investigation - CBC, electrolytes, creatinine BUN - blood glucose - serum osmolality - serum ketone - VBG - urine analysis - ECG Diagnosis (all of the following) - metabolic acidosis with increased anion gap - serum and urine ketone bodies - hyperglycemia ```

Answer 3

Q2-4H electrolytes, anion gap, glucose, creatinine, plasma osmolality, LOC IV Fluids for decreased Effective Circulating Volume - Severe shock give NS 1-2L/h until hypotension correction and then switch to NS 500mL/hr for 4hr then 250mL/hr for 4 hr - mild to moderate start at 500mL - Once euvolemic - Na is normal/high or rate of plasma osmolality fall is <3 switch to 0.45NS - Na is low or rate of plasma osmolality fall >=3 then continue with 0.9%NS - Once plasma glucose reaches 14 add D5W to IV fluids to maintain glucose 12-14 Serum K - <3.3 then give 40mmol/L KCl and no insulin until K >=3.3 - >=3.3 and less 5-5.5 then 10-40KCl Acisosi - if K <3.3 correct hypokalemia before insulin - if K >=3.3 administer IV short acting insulin 0.1unit/kg/h - adjust rate of insulin based on anion gap resolution - if pH <7.0 then NaHCO3 1 amp/h until pH >=7

Answer 4

- screen every 3 years for those over 40 - If screen positive for diabetes must do confirmatory test unless symptomatic (polydipsia, polyphagia, polyuria, weight loss, blurry vision) FPG <5.6 or A1c <5.5% - normal rescreen in 3 years FPG 5.6-6.6 and/or AIc 5.5-5.9% - no risk factors then rescreen more often - risk factors then go to 75g OGTT FPG 6.1-6.9 and/or A1c 6.0-6.4% - go to 75g OGTT - fasting <6.1 and 2h <7.8 - if A1c <6% then rescreen more often - if A1c 6-6.4% then prediabetes - fasting <6.1 and 2h 7.8-11 then impaired glucose tolerance and prediabetes - fasting 6.1-6.9 and 2h <7.8 then impaired fasting glucose and prediabetes - fasting 6.1-6.9 and 2h 7.8-11 then prediabetes - fasting >7 or 2h >11.1 then diabetes FPG >7.0 and/pr A1c >6.5% then diabetes

Answer 5

``` Fasting Blood Glucose - 4-7 2hr Post Prandial - 5-10 or 5-8 if not achieving A1c target - HbA1c <7.0% done every 3 months Blood Pressure - <130/80 Lipids - LDL <=2 or >=50% reduction - apoB <0.8 or non-HDL <=2.6 - done yearly Chronic Kidney Disease - Normal ACR <2.0 - normal eGFR >60 - type 1 screen at 5 year and then yearly - type 2 at diagnosis then yearly Retinopathy - type 1 5 years after diagnosis then yearly - type 2 at diagnosis then 1-2 years Neuropathy - screen with 10g monofilament (until bends) at 1st, 3rd, and 5th metarsal head and base of great toe - type 1 at 5 years then yearly - type 2 yearly Waist Circumference/BMI - Maintain WC <102cm in males and <88cm in females - BMI between 18.5-24.9 Lifestyle Modification - 150minutes/week of aerobic exercises ```

Answer 6

- make timely increase in dose or add drug from different class in order to reach A1C target in 3-6 months - if A1c is <1.5 above target of 7% then begin with lifestyle for three months before switching to metformin - if A1c is >1.5 above target of 7 begin metformin right away and possibly other drug

Answer 7

``` Suboptimal control with oral agents Marked Hyperglycemia at Presentation - A1c >9% - require basal-bolus regimen Stress on Body - infection - pregnancy ```

Answer 8

- First degree relative with type 2 diabetes - history of prediabetes - history of gestational diabetes - metabolic syndrome - PCOS - aconthosis nigricans - OSA - glucorticoids - atypical antipsychotics - retroviral therapy

Answer 9

``` Increase A1c - B12 or iron deficiency - chronic renal failure - hyperbilirubinemia - EtOH or opioids Decrease A1c - use of EPO, iron or B12 - reticulocystosis - ASA - Vitamin C or E - hemoglobinopathies - Splenomegaly - rheumatoid ```

Answer 10

- can be combined with oral agent Basal (glargine or detemir) - start at 10 units or 0.2units/kg at bedtime - check fasting glucose daily and increase by 2 units every 3 days until in in fasting range - if FBG >10 then can increase by 4 units every 3 days Second Injection - If A1c >=7% after 2-3 months then add bolus (lispart or aspart) at pre-lunch, -dinner, -bed - if pre-lunch high then do at breakfast, etc - if after 2 months A1c still out of range then check 2h post-prandial

Answer 11

``` ACEI or ARB - clincal macrovascular disease - age >55 - age <55 and microvascular disease Statin - clinical macrovascular disease - age >=40 - age <40 and diabetes duration >15yr, microvascular complication or cardiovascular risk factor Low Dose ASA - for those with cardiovascular disease ```

Answer 12

Causes - Sepsis - Stroke - Mi, CHF - Renal failure Pathophysiology - partial or relative insulin deficiency decrease glucose utilization in muscle, fat, liver leading to hyperglycemia and liver glucose production - small amount of insulin prevents ketosis - Have more severe dehydration to DA due to gradual onset and increased duration of metabolic decompensation

Answer 13

- hyperglycemia (44-133), hyperosmolality, dehydration without ketosis - More common in T2DM Presentation - Polyuria, polydipsia leading to weakness - decreased fluid intake - decreased LOC Investigation - Increase BG - Hyponatremia in mild dehydration (every 10 increase in BG have 3 decrease in Na) - Hypernatremic in severe - Increase osmolality Management - Rehydration - 500mL/h x4h then 250mL/h for 4h then 0.45% NS when euvolemic unless corrected Na is low or rate of osmolality fall is >=3 - Switch to D5W when BG at 14 - K replacement - K <3.3mmol then give 40mEq/L and hold insulin until K>3.3 - K 3.3-5 then start insulin with 10-40 of K - K >5 then recheck in 2hrs - Insulin - Monitor plasma osmolality

Endocrinology - Diabetes Flashcards

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