For type 2 DM patients, what are some long-term treatment plans/lifestyle changes that are important for them?
- Adhere to Oral-antidiabetic medication regimes as prescribed
- CVS medications (if applicable) should be taken as well since hypertension/hyperlipidemia are risk factors for Diabetes + can contribute to Peripheral vascular disease
- Lifestyle changes of exercising, less smoking
During a Diabetic foot screening, what important features would you be looking for? (how to test for neuropathy, Peripheral arterial disease?)
- Neuropathy - pertaining to Loss of sensation in feet. Use **monofilament ** and touch patient, see if he is able to detect any sensation
PAD - pertaining to Reduced blood flow in feet, due to atherosclerosis which is worsened by Diabetes (hyperglycemia)
To check for Reduced blood flow, feel for Temperature and pulse. Calculate Ankle-Brachial index.
***
For e.g., Right ABI = (Highest pressure in Right foot)/(Highest pressure out of Both Arms)
What are the main characteristics of Type 1 and Type 2 DM?
- Type 1 DM is an Autoimmune disorder which involves pancreatic Beta cells being destroyed, leading to an absolute loss of insulin. Type 1 DM patients require life-long insulin dependence.
- Type 2 DM is characterised by** Insufficient insulin action due to resistant cells** (Insulin resistance). Chronic type 2 DM patients may eventually require insulin dependence due to Beta cell failure.
What are some common symptoms of Hyperglycemia in Diabetic patients?
- Polyuria (excessive urination), Polydipsia (excessive thirst), Polyphagia (excessive appetite)
- Weakness, fatigue
What are some symptoms of Chronic/a prolonged state of Hyperglycemia?
A prolonged state of Hyperglycemia can cause Microvascular and Macrovascular complications in individuals.
- Microvascular: Retinopathy (Blurry vision), Neuropathy (loss of sensation in Foot), Nephropathy (kidney failure)
- Macrovascular: CVS Disorders (Myocardial infarction), Peripheral Vascular disease, Cerebrovascular disease (stroke)
Additionally, the immune systems of diabetic patients are weakened due to hyperglycemia making them more prone to infections
PVD leads to reduced blood flow, tissue death and eventual Amputation
Which 2 diabetic emergencies can occur due to Chronic hyperglycemia?
- Diabetic Ketoacidosis (common in type 1 DM patients who have an absolute lack of Insulin, causing Body to undergo lipolysis and go into ketosis)
- Hyperosmolar Hyperglycemic State (common in type 2 DM patients)
A person presents to the emergency room with dry mouth, inability to sweat and extreme confusion and dehydration. What is your first course of action?
Patient is suffering from HHS. Similar to DKA treatment, we must administer:
* Insulin IV, IV fluids and electrolytes to replace Fluid loss from polyuria/polydipsia
* IV Dextrose to prevent Hypoglycemia
Type 2 DM patients are most likely to suffer from HHS, as they still possess some level of Insulin that is sufficient to prevent Lipolysis like in DKA.
No Ketones found in Urine tests
What is a healthy/normal Fasting plasma glucose for a person?
- 4.0 - 6.9 mmol/L is below the normal range for a non-DM patient
- Above or equal to 7 = DM
- Below 4 = Hypoglycemia
Above 14/ Above 30 mmol/L = DKA/HHS
What are some risk factors for developing type 2 DM?
- Obesity
- Hypertension
- Genetics
What is the role of Insulin Sulfonylureas (~amides, e.g Tolbutamides)?
Increases Insulin secretion by blocking Katp Channels and stimulating insulin release from Beta cells
AE: Hypoglycemia
Increased risk of CVS related death
What is the role of Biguanides (Metformin)?
**Increases insulin sensitivity ** in cells, improves Insulin resistance.
Adverse effects (AE)/Contraindications:
Nausea, vomiting, decreased Vit B12 absorption
Renal, Liver failure patients should not use
List some actions of Insulin on the body.
(how it affects Fats, Proteins and Glucose)
- Insulin allows cells to take in Glucose for energy (enables Glucose uptake) and encourages storage of glucose as Glycogen
- Prevents breakdown of Fats into fatty acids (Encourages deposition of fat)
- Increases** protein synthesis**
What sort of lab testing can be done to assess DKA?
- Bicarbonate levels are usually lowered in patients with DKA.
- Ketone levels in urine and blood tests are also elevated in DKA.
A patient is admitted for DKA and presents to the emergency room with Fruity smelling breath, and laboured breathing. What would be your immediate actions?
- Insulin should be immediately administered intravenously to correct hyperglycemia.
- IV fluids/electrolytes should be administered to replace fluid loss due to polyuria
- Insulin sliding scale, IV dextrose and constant Blood glucose monitoring to ensure patient does not go into hypoglycemia
any underlying infections should also be addressed: antibiotics by IV if
What is the role of Tzds (thiaelelzleodickyds)?
Reduces fatty acid in Blood, is also an Insulin sensitiser like Metformin (a Biguanide).
AE: Hypoglycemia, Patients with HF, Liver failure should not use.
Why is it important to address infections in Diabetic patients especially?
Weakened immune system makes Diabetics more vulnerable to infections, and reduced blood flow to areas of the Body makes recovery harder.
Stress from infections in particular can also Release stress hormones which elevate Glucose levels, worsening their diabetic condition/hyperglycemia.
Where and how should a Subcutaneous injection of insulin be carried out?
- In one of the 4 quadrants of the Abdomen, 1cm above Pubic symphysis and 1cm below the Lowest rib
- Upper thigh
- Lower buttocks
- Lower arm just before elbow
At a 45 degree angle (.)(.)
How should a mixture of 2 different types of insulin (fast-acting and long-acting) be Drawn?
Clear = fast-acting, Cloudy = long-acting
Cloudy - clear - clear - cloudy
- Insert air equal to amount needed into cloudy vial first, then remove syringe
- Insert air equal to amount needed into clear vial, do not remove
- Withdraw required amount of clear vial
- Withdraw required amount of cloudy vial
Withdrawing fluid from the cloudy vial first results in syringe getting dirty, may interfere with reading markings on syringe.
shake cloudy vial and ensure all powder is dissolved
Which of the following is/are not Microvascular complications of DM?
- Diabetic Neuropathy
- Diabetic Nephropathy
- Peripheral vascular disease
- Stroke
Peripheral vascular disease and Stroke (cerebrovascular disease) are both not Microvascular complications of DM.
A patient’s Capillary Blood glucose was tested to be 3.8mmol/L. He is still conscious and able to swallow, but has a fast heartbeat and is shaking anxiously. What are your immediate actions?
Hypoglycemia Protocol: Between 2.8-3.8mmol/L,
* Administer 15g of Fast-acting carbs: Dissolve Dextrose monohydrate 16.5g in <100mls of water. If patient is unable to swallow, to administer intravenously.
* follow up CBG count within 15 minutes, notify Doctor
Below **2.8mmol/L, Administer 30g ** instead
If patient is unconscious, order lots of IV Dextrose and call Doctor. (??? its joever)
Describe the process through which Thyroid hormone is formed.
Hypothalamus -> releases TRH -> Anterior pituitary -> releases TSH -> Thyroid gland -> releases Thyroid hormone
In Hashimoto’s Thyroiditis, an autoimmune disorder common in women aged 40-50, the Thyroid glands are destroyed. Patients suffering from this disease may present with a Goiter, as well as an inability to sweat and cold intolerance. What can their expected T3, T4 and TSH levels be?
What classification of Hypothyroidism (primary, secondary, tertiary) is this?
Symptoms are consistent with Hypothyroidism -> T3, T4 levels are low. TSH levels will be high because Anterior Pituitary is still functioning and produces more TSH to stimulate production of Thyroid hormone (negative feedback mechanism).
Thyroid glands are destroyed -> Primary hypothyroidism
What are some signs of Myxedema? What leads to Myxedema?
Myxedema is a result of longstanding hypothyroidism, and results in:
* Edema
* Hypothermia
* Feeling cold
* Dry/pale skin
'’swelling and thickening of skin’’ occurs.
