ITM The Middle Aged Patient

Question 1

What is the difference between T1 and T2 diabetes

Answer 1

T1: body cannot produce any insulin due to a genetic predisposition to autoimmune pancreatic B cell destruction
T2: there is not enough insulin due to impaired B cell function

Question 2

Define insulin resistance

Answer 2

The organs and tissues of the body lose their sensitivity to the action of insulin

Question 3

What is insulin resistance triggered by

Answer 3

Chronically: overweight / obesity and physical inactivity
Acutely: infection / trauma / injury / pregnancy

Question 4

What is the diagnostic criteria for T2 diabetes

Answer 4

Fasting glucose >7 mmol/l
Blood glucose of >11.1 mmol/l after a 2 hour oral glucose tolerance test
HbA1c level >48 mmol/mol

Question 5

What are the microvascular complications of DM

Answer 5

Eyes
Kidneys
Peripheral nervous system

Question 6

What are the macrovascular complications of DM

Answer 6

Stroke and MI

Question 7

What is metabolic syndrome

Answer 7

A cluster of risk factors for cardiovascular disease and T2 DM

Question 8

What are the risk factors for metabolic syndrome

Answer 8

Central obesity (88cm female, 104cm men)
Triglycerides >1.7mmol/l (usual is 1 mmol /l)
HDL cholesterol <1 mmol/l males, <1.3mmol/l female
Blood pressure >130/85 mmHg
Fasting glucose >5.6mmol/l
Presence of ectopic fat (liver, pancreas, skeletal muscle)

Question 9

What causes insulin resistance

Answer 9

High dietary fat availability
Adiposity - ectopic fat accumulation
Physical inactivity (2-3 days of bed rest can cause insulin resistance)

Question 10

What are the 2 components of pre diabetes

Answer 10

Impaired fasting glucose (IFG) and / or impaired glucose tolerance (IGT) markedly increase the risk of developing T2D

If not reversed the rate of conversion to T2D is 5-10% per annum
Healthy HbA1c is <38mmol/mol; T2D >48 mmol/mol

Question 11

What are impaired fasting glucose and impaired glucose tolerance

Answer 11

IFG = fasting glucose >5.6mmol/l - <7mmol/l (when the liver is less sensitive to insulin it pumps out more glucose)

IGT= blood glucose of >7.8mmol/l - <11.1mmol/l after a 2 hour oral glucose tolerance test

Question 12

Define pain

Answer 12

A highly unpleasant physical sensation caused by illness or injury

An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage

Question 13

Define acute abdominal pain

Answer 13

Previously undiagnosed abdominal pain that arises suddenly and is of less than 7 days and usually less than 48h duration

Question 14

3 classifications of abdominal pain

Answer 14

Visceral: crampy, achy, diffuse, poorly localised

Somatic: sharp, cutting, stabbing, well localised

Referred: distant from site of generation, symptoms but no signs

Question 15

Surface anatomy of the foregut, midgut and hindgut

Answer 15

Epigastric region: foregut
Periumbilical region: midgut
Pelvic region: hindgut

Question 16

Does psoriasis increase cardiovascular risk

Answer 16

Slight increased risk due to inflammation inside the body which can eventually affect the heart and blood vessels

Question 17

Post operative causes of abdominal pain

Answer 17

Intra-abdominal bleeding or collection, anastomotic leak / dehiscence
Abdominal compartment syndrome

Question 18

Pulmonary causes of abdominal pain

Answer 18

Lobar pneumonia
Pleurisy (inflammation of pleura between lungs and ribs)
Pulmonary embolism

Question 19

Cardiac causes of abdominal pain

Answer 19

Acute MI
Congestive cardiac failure
Myocarditis

Question 20

Metabolic / endocrine causes of abdominal pain

Answer 20

Porphyria
Diabetic keotacidosis 
Lead poisoning 
Hypercalcemia 
Adrenal insufficiency

Question 21

Vascular causes of abdominal pain

Answer 21

Henoch-schonlein purpura
Systemic lupus
Polyarteritis nodosa
Familial Mediterranean fever

Question 22

When is the location and severity of abdominal pain altered

Answer 22

Pregnancy
The older adult
Immunocompromised patients
Altered anatomy eg malrotation, sinus inversus

Question 23

What is methotrexate and how is it prescribed

Answer 23

Methotrexate is a drug used for immunocompromised patient eg with rheumatoid arthritis. It is prescribed weekly as it is seen to be less hepatotoxic when given weekly

Question 24

When are beta blockers contraindicated

Answer 24

In patients with asthma or COPD due to their increased probability of causing bronchospasm

Question 25

What is the caution with ACE inhibitors

Answer 25

Start with a low dose and adjust according to response. Hyperkalaemia and other side effects of ACE inhibitors are more common in those with impaired renal function and the dose may need to be reduced

Question 26

Risk of ACE inhibitors and pregnancy

Answer 26

ACE inhibitors should be avoided in pregnancy unless essential May adversely affect fetal and neonatal blood pressure control and renal function; skull defects and oligohydraminos have also been reported

Question 27

Different routes of administering drugs

Answer 27

``` Po: oral Im: intramuscular Iv: intravenous Sc: subcutaneous Neb: nebuliser Sl: sublingual (under tongue) ih: inhalation ```

Question 28

Why does psoriasis increase cardiovascular risk

Answer 28

Because if there is long term inflammation is can eventually harm the heart and blood vessels

Question 29

When can preventative metformin be given

Answer 29

If the patient is unable / unwilling to change their lifestyle factors

Question 30

What is acute pancreatitis

Answer 30

A condition in which the pancreas becomes inflamed over a short period of time Usually heals within a week

Question 31

What investigations would you run if acute pancreatitis is suspected

Answer 31

Blood tests to measure 2 digestive enzymes: amylase and lipase. If the levels are high then acute pancreatitis is likely

Question 32

Underlying causes of acute pancreatitis

Answer 32

``` Drinking Steroid treatment (psoriasis) Gall stones Metabolic disorders Infections ```

Question 33

How is acute pancreatitis treated

Answer 33

Monitored in hospital for signs of serious problems and given fluids and oxygen

Question 34

What does high gamma glutamyl transpeptidase indicate

Answer 34

Liver disease or damage to the bile ducts can be caused by drinking

Question 35

Risk factors for developing T2 DM

Answer 35

``` Obesity Age >40 PCOS Black / south Asian ethnicity Family history of DM Gestational DM Physical inactivity Dyslipidaemia ```

Question 36

Complications of DM

Answer 36

Micro vascular and macro vascular complications Diabetic ketoacidosis Acute hypoglycaemia Hyperosmolar hyperglycaemic state

Question 37

What is the molecular target for metformin

Answer 37

AMP kinase

Question 38

What is the mode of action of a sodium glucose transport inhibitor

Answer 38

In a healthy person, glucose is filtered at the renal glomeruli and reabsorbed in the PCT via sodium glucose transporters in the luminal membrane of the tubular cells of the PCT SGLT 2i block glucose reabsorption leading to glucosuria And the loss of glucose in the urine leads to lowered blood glucose