Term
| pathophysiology of type 1 DM |
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Definition
-autoimmune destruction of beta cells in the pancreas
-inability of pancreas to secrete insulin
-exposure to trigger stimulates destruction of beta cells (immunologically-mediated) |
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Term
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Definition
polyuria, polydipsia
nocturia
fatigue
weight loss |
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Term
| What in-office diagnostics can you use to detect type 1 DM? |
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Definition
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Term
| What value of a random plasma glucose gives you a diagnosis of diabetes? |
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Definition
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Term
| What value of a fasting blood glucose gives you a diagnosis of diabetes? |
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Definition
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Term
| What value of a 2-hr GTT gives you a diagnosis of diabetes? |
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Definition
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Term
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Definition
| when proinsulin is split into insulin and c-peptide |
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Term
| What level of c-peptide suggests type 2 DM? |
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Definition
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Term
| What level of c-peptide suggests type 1 DM? |
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Definition
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Term
| How is HbA1c used with type 1 DM? |
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Definition
| to monitor the progression of the disease (NOT diagnostic) |
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Term
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Definition
basal insulin (pump or long-acting)
pre-meal rapid-acting insulin |
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Term
| How is the pre-meal insulin dose determined in type 1 DM? |
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Definition
| carbohydrate count and adjustment for the pre-meal glucose level |
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Term
| 1 unit of rapid-acting insulin should be given for every ____ grams of carbohydrate to be consumed. |
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Definition
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Term
| What is the correction dose for rapid-acting insulin it type 1 DM? |
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Definition
| 1 unit of insulin per 25-50 mg/dl |
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Term
| What is the goal of treatment for type 1 DM? |
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Definition
HbA1c <7%
pre-meal glucose levels 80-130 mg/dl
(for some, consider HbA1c <8% and pre-meal glucose levels 100-150 mg/dl) |
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Term
| The insulin dose often is adjusted in increments of ____% at a time, and the effects are assessed over about _______ before making any further changes. |
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Definition
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Term
| What do you need to do if a patient presents at your clinic with type 1 DM symptoms? |
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Definition
| send them immediately to hospital |
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Term
| Why is it important for diabetics to moisturize their feet regularly? |
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Definition
| to prevent cracks that could become potential sites of infection |
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Term
| How often should type 1 diabetics monitor their blood sugar? |
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Definition
| at least 4 times a day (before each meal and at bedtime) |
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Term
| What screenings need to be done at diagnosis of type 1 DM and why? |
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Definition
TSH, thyroperoxidase antibodies, thyroglobulin antibodies
celiac disease (tissue transglutaminase or antiendomysial antibodies with serum IgA)
because type 1 DM is an autoimmune disease, pts. are at risk for developing other autoimmune diseases |
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Term
| How often should TSH be checked in a type 1 diabetic if the initial screen is normal? |
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Definition
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Term
| When should a screen for celiac disease be repeated in a type 1 diabetic if the initial screen was normal? |
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Definition
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Term
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Definition
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Term
| What are short-term complications associated with type 1 diabetes? |
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Definition
hypoglycemia
poor wound healing
increased risk of infection |
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Term
| What do you give a conscious patient who is hypoglycemic? |
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Definition
| glucose tablet 15 g po (OTC) |
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Term
| What do you give an unconscious patient who is hypoglycemic? |
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Definition
| glucagon 0.5-1 mg SC or IM |
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Term
| What long-term complications are associated with diabetes? |
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Definition
nephropathy
retinopathy
neuropathy
CAD
PVD
CVD |
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Term
| When should screening for microvascular complications begin in a type 1 diabetic? |
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Definition
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Term
| When should screening for microvascular complications be started in a type 2 diabetic? |
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Definition
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Term
| What annual screening tests should be done to check for nephropathy? |
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Definition
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Term
| Urine microalbumin is abnormal at what value? |
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Definition
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Term
| urine microalbumin of 30-300 |
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Definition
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Term
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Definition
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Term
| What GRF value warrants a referral to a nephrologist? |
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Definition
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Term
| What medications should be avoided with diabetes? |
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Definition
| nephrotoxic agents (aminoglycosides, NSAIDs, IV contrast) |
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Term
| If a nephrotoxic agent must be used, what do you need to monitor regularly? |
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Definition
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Term
| What medications should be used to treat hypertension in the diabetic patient? |
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Definition
| ACE inhibitors or ARBs, then move to diuretic (thiazide if GFR>30, loop if GFR <30) |
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Term
| What exam is needed to screen for retinopathy? |
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Definition
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Term
| What characterizes non-proliferative retinopathy? |
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Definition
-retinal venules dilate, then microaneurysms appear
-hard exudates and flame-shaped hemorrhages
-cotton-wool spots appear |
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Term
| What are cotton-wool spots? |
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Definition
| retinal microinfarctions due to capillary occlusion |
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Term
| What characterizes proliferative retinopathy? |
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Definition
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Term
| What does a patient with proliferative retinopathy need? |
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Definition
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Term
| What happens if hard exudates cover all or part of the macula densa? |
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Definition
| pt. will have central vision impairment |
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Term
| How do you differentiate cotton-wool spots from hard exudates? |
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Definition
| cotton-wool spots have non-distinct borders |
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Term
| Where is the neovascularization associated with proliferative retinopathy typically seen? |
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Definition
| on the optic disc or along the main vascular arcades |
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Term
| What are the macrovascular complications associated with diabetes? |
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Definition
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Term
| What are the macrovascular complications associated with diabetes? |
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Definition
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Term
| When should you treat blood pressure in a diabetic? |
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Definition
| if consistently above 90th percentile for age and sex |
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Term
| What should you do as a preventive measure in patients at risk for developing macrovascular complications? |
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Definition
| start them on ASA at age 40 or if they have additional risk factors (HTN, FHx, smoking, dyslipidemia, albuminuria) |
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Term
| What is the characteristic pattern of peripheral neuropathy? |
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Definition
| glove and stocking pattern |
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Term
| What medications can be used for the treatment of neuropathy? |
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Definition
duloxetine (Cymbalta)
pregabalin (Lyrica)
gabapentin (Neurontin)
TCAs (amitriptyline, nortriptyline) |
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Term
| What 2 medications are approved by the FDA for treatment of neuropathy? |
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Definition
duloxetine (Cymbalta)
pregabalin (Lyrica) |
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Term
| What 2 medications are not approved by the FDA for treatment of neuropathy but are widely used and fairly effective? |
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Definition
gabapentin (Neurontin)
TCAs (amitriptyline, nortriptyline) |
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Term
| What is the SNRI used for treatment of neuropathy? |
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Definition
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Term
| Which of the drugs used for the treatment of neuropathy are more expensive? |
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Definition
duloxetine (Cymbalta)
pregabalin (Lyrica) |
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Term
| What is the acute, life-threatening complication of severe uncontrolled diabetes that typically occurs only in type 1 diabetics? |
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Definition
| diabetic ketoacidosis (DKA) |
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Term
| DKA is a consequence of ________ _________. |
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Definition
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Term
| What may be the presenting symptom of type 1 DM? |
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Definition
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Term
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Definition
poor compliance
insulin infusion catheter blockage
stress
infection/illness (MI) |
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Term
| In DKA, insulin deficiency triggers counterregulatory hormones which leads to... |
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Definition
gluconeogenesis/glycogenolysis (hyperglycemia)
lipolysis (increased free fatty acids) |
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Term
| In DKA, liver metabolism of fatty acids leads to formation of _________ and __________. |
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Definition
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Term
| Acidosis triggers exchange of intracellular _________ for extracellular ______. |
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Definition
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Term
| In DKA, high serum osmolality drives water from intracellular to extracellular space, which leads to... |
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Definition
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Term
| What all is lost in the urine with DKA? |
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Definition
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Term
| How does a patient in DKA present? |
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Definition
polydipsia, polyuria
Kussmaul breathing
fruity breath odor
dehydration
n/v
altered level of consciousness |
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Term
| What do you need to look for in a patient presenting with DKA? |
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Definition
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Term
| What labs need to be done in a patient presenting with DKA? |
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Definition
plasma glucose and serum electrolytes every hour until stable, then every 6 hours
BUN initially
ABG initially, followed with bicarb/ABG/serum pH as necessary
CBC initially |
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Term
| What blood glucose level would you expect in a patient with DKA? |
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Definition
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Term
| What blood pH would you expect in a patient with DKA? |
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Definition
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Term
| What bicarb level would you expect in a patient with DKA? |
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Definition
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Term
| What serum ketone level would you expect in a patient with DKA? |
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Definition
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Term
| What can the BUN tell you about a patient in DKA? |
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Definition
hydration status
higher the BUN, greater the dehydration |
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Term
| Why are electrolyte assays so important with a patient in DKA? |
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Definition
| hypo or hyperkalemia can cause arrhythmias |
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Term
| What imaging should be done for a patient with DKA? |
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Definition
CXR for pneumonia
MRI for cerebral edema (if altered level of consciousness)
EKG/cardiac monitor |
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Term
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Definition
-admit to ICU
-IV fluids (use NS until BG <180, then can switch to 5-10% dextrose with 1/2 NS)
-correct electrolytes (potassium)
-start insulin (0.1 U/kg/hr)
-treat infection |
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Term
| Why should you correct potassium before starting insulin when treating DKA? |
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Definition
| insulin causes potassium to shift back into the cells, so it can plummet if not corrected |
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Term
| When should the initial dose of 0.1 U/kg/hr of insulin be reduced and stopped in a patient with DKA? |
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Definition
reduce after BG drops below 180 mg/dl
stop when ketoacidotic state resolves |
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Term
| What is the most common cause of mortality in patients with DKA? |
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Definition
|
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Term
| What complications are associated with DKA? |
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Definition
-cerebral edema
-severe hypokalemia
-adult respiratory distress syndrome (ARDS)
-concurrent illness (pneumonia, acute MI) |
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Term
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Definition
-teach self-management
-ketone testing strips (urine)
-stress management
-treat illnesses early |
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