Introduction To Diabetes

Question 1

What is diabetes?

Answer 1

Metabolic disorder characterised by chronic hyperglycaemia due to defects in insulin secretion and/or action

Question 2

How do you diagnose diabetes?

Answer 2

Fasting plasma glucose of 7mmol/mol or more
2hrs after Oral Glucose Tolerance test over 11.1mmol/mol

Random plasma glucose > 11.1mmol/mol

Should have accompanying symptoms to diagnose

Question 3

What causes T1DM?

Answer 3

Autoimmune or idiopathic destruction of pancreatic B cells leading to an absolute deficiency in insulin

Question 4

What causes T2DM?

Answer 4

Decreased sensitivity to insulin occurs, more insulin needs to be made which can also lead to impaired insulin secretion over time

Question 5

What blood test can be used to diagnose T2DM?

Answer 5

HbA1c > 48mmol
Repeated 1 month later to confirm if no other signs and symtoms

Question 6

What are some other forms of diabetes (not T1DM or T2DM)?

Answer 6

Secondary diabetes:
-Cushings
-acromegaly
-Phaeochromocytoma
-thyrotoxicosis

Syndromic:
-Huntington’s chorea
-turners
-klinefelters

Infections:
-CMV
-congenial rubella

Drug induced:
-steroids
-thyroxine
-thiazides

Question 7

What is the typical presentation of a patient with T1DM?

Answer 7

Young
Acute presentation
HYPERGLYCAEMIA
Polyuria
Polydipsia
Weight loss

Diabetic Keto-Acidosis presentation

Question 8

What is the diagnostic criteria for diabetic ketoacidosis?

Answer 8

Hyperglycaemia > 11.1mmol
Ketosis >3mmol
Acidosis pH < 7.3

Question 9

Why does the patient typically have high serum K+ when in DKA?

Answer 9

Patient is insulin deficient
Insulin needed to internalise K+ into cells

Question 10

How does a patient with Type 2 diabetes typically present?

Answer 10

Older
Insidious symptoms of hyperglycaemia and diabetes complications

Question 11

What are the 2 categories of complications of diabetes?

Answer 11

Microvascular
Macrovascular

Question 12

What are some microvascular complications of diabetes?

Answer 12

Diabetic neuropathy
Diabetic nephropathy
Diabetic retinopathy
Erectile dysfunction

Question 13

What are some macroscopic complications of diabetes?

Answer 13

Coronary heart disease (MI)
Stroke
Peripheral ischaemia (foot ulcers)
Hypertension

Question 14

What are the 3 classifications of diabetic retinopathy?

Answer 14

R1 = Background retinopathy
R2 = Pre-proliferative
R3 = Proliferative

Question 15

What does M1 refer to with diabetic retinopathy?

Answer 15

Maculopathy

Question 16

What does O mean in reference to diabetic retinopathy?

Answer 16

Other non diabetic lesion

Question 17

What does P mean in terms of diabetic retinopathy?

Answer 17

Previous laser therapy/photocoagulation

Question 18

What does U mean in terms of diabetic retinopathy?

Answer 18

Unclassified often due to cataract

Question 19

What are the characteristic appearances of R1 (Background Retinopathy)?

Answer 19

Microaneurysms, dot haemorrhages, cotton wool spots and hard exudates

Question 20

What are the characteristic appearances of R2 pre-proliferative diabetic retinopathy?

Answer 20

Multiple blots, IntraRetinal Microvascular abnormalities , venous beading

Question 21

What are the characterstic appearances of Proliferative R3 diabetic retinopathy?

Answer 21

Neo vascularisation of Disc (NVD)
Neo vascularisation Elsewhere (NVE)
Retinal detachment
Vitreous haemorrhage

Question 22

When is a patient with diabetic retinopathy referred IMMEDIATELY to ophthalmology?

Answer 22

Rubeosis iridis/neovascular glaucoma
Vitreous haemorrhage
Retinal detachment

Question 23

When does a patient need an urgent referral for ophthalmology? 2weeks or less

Answer 23

R3

Question 24

When does a patient need a routine referral for ophthalmology? 13 weeks or less

Answer 24

R2 or M1 changes

Question 25

What is the medical treatment for diabetic retinopathy?

Answer 25

Improve glycaemic control BP control Lipid control Antiplatelet Smoking cessation

Question 26

What is the surgical management of diabetic retinopathy?

Answer 26

Laser therapy Vitrectomy Intravitreal VEGF

Question 27

How do you define Diabetic nephropathy?

Answer 27

Urine dipstick: +proteinuria + Albumin concentration > 300mg/L

Question 28

What is the most common cause of CKD in the UK?

Answer 28

Diabetic nephropathy

Question 29

What is the pathophysiology of diabetic nephropathy?

Answer 29

Hyperfiltration

Question 30

How does Hyperfiltration negatively impact the kidneys?

Answer 30

Lots of glucose reabsorbed with Na+ through SGLT2 Low Na+ in filtrate RAAS activates initially leading to increased GFR You get early stage tubular hypertrophy and hyperplasia Later on get accumulation of matrix and diffuse Glomerulosclerosis , which can then form in nodules Tubular interstitial changes occur due to loss of nephron

Question 31

What is the name of the nodules that can form in diabetic nephropathy?

Answer 31

Kimmelsteil-Wilson nodules

Question 32

How do you manage Diabetic nephropathy?

Answer 32

Improve glycaemic control BP control (ACEi or ARBs bp 130/80) Lipid control Diet lower in protein (<0.8g/kg) Manage anemia hyperphosphatemia, Hyperkalaemia or Vit D deficiency

Question 33

When may a patient with diabetic nephropathy need a nephrology referral?

Answer 33

Family History of PKD CKD 4 or 5 Rapidly declining GFR Systemic disease like lupus Haematuria

Question 34

What is diabetic neuropathy? What part of nerve is affected?

Answer 34

Where you got focal demyelination and distal axonal loss with attempts at nerve regeneration Vasa nevorum

Question 35

What are the 4 types of diabetic neuropathies?

Answer 35

Sensory motor neuropathy Autonomic neuropathy Proixmal motor neuropathy Mononeuropathy

Question 36

What is diabetic sensory motor neuropathy?

Answer 36

Starts distal moves proximal (diabetic feet and sensation loss spreads proximal)

Question 37

What are some examples of diabetic autonomic neuropathy?

Answer 37

Erectile dysfunction Gastroparesis Postural hypotension

Question 38

What is an example of diabetic proximal motor neuropathy?

Answer 38

Diabetic amyotrophy (pain in quadriceps)

Question 39

What nerve is often affected by diabetic mononeuropathy?

Answer 39

Cranial nerve III

Question 40

How do you treat diabetic neuropathy?

Answer 40

NSSRIs like duoloxetine, gabapentin Smoking cessation Antiplatelets BP control

Question 41

When performing a diabetic foot exam what are you looking for?

Answer 41

Skin changes Ulcers Hair loss Pallor

Question 42

How do you assess the neurovascular status of a diabetic foot?

Answer 42

Vascular: -cap. Refil -dorsalis pedis -posterior tibial Neuro is touch

Question 43

How do you assess the different aspects of touch in a diabetic foot exam?

Answer 43

Cotton wool = crude touch Sharp point = pain Monofilament = fine touch Tuning fork = vibration at 1 MTP Proprioception

Question 44

If a patient within diabetic foot cant feel the vibration of the tuning fork at their 1MTP joint what should you do?

Answer 44

Move to medial malleouls If cant feel move tibial tuberosity If cant feel do move to ASIS

Question 45

What is the first sensation to typically be lost with diabetic feet?

Answer 45

Vibration

Question 46

What are some features of neuropathic feet?

Answer 46

Warm Dry skin Palpable pulses Not normally painful Callused

Question 47

What are some features of Ischaemic feet?

Answer 47

Cold Atrophic No pulse Painful Claudication/rest pain Skin blanching on elevation

Question 48

What is the classification system for diabetic feet?

Answer 48

Wangers classification (G1-G5)

Question 49

How does charcots foot present?

Answer 49

Warm hot swollen MTPJs Painful foot Rocker bottom deformity

Question 50

What is the pathophysiology of charcots foot?

Answer 50

Increased blood flow to the foot due to loss of sympathetic nerve loss This leads to increased osteoclast activity and increased bone turnover which can lead to bony deformity

Question 51

What is the management of charcots foot?

Answer 51

Immobilise and don’t weight bare for 2-3months until inflammation resolves