Diagnosing Diabetes<br />Joseliza de la Cruz, M.D.<br />Tiffany Chu, RN<br />
S.B. 45 y/o F from Sampalok<br />CC: numbness over lower extremities <br />3 days PTC            weakness with easy fatiga...
ROS: <br />(-) cough, colds, fever<br />(-) SOB, orthopnea, PND<br />(+) occ. Palpitations, (-) chest pain<br />(+)polydip...
Ob-Gyne History: G2P2 (2-0-0-2)<br />History of delivering large babies via CS<br />History of elevated BS during pregnanc...
PE: conscious, coherent, ambulatory<br />Ht: 5’3” Wt: 150 lbs BMI: 26.6<br />BP 150/90 HR 92 RR 18 Temp 37C<br />Pink palp...
Neurological exam<br />GCS 15 <br />CN intact <br />(no ptosis, no facial asymmetry, tongue midline)<br />No motor or sens...
Subjective data<br />45 y/o female <br />caterer<br />numbness over lower extremities  “karayomnatumutusok”<br />weakness ...
Objective data<br />BMI: 26.6<br />BP: 150/90 HR92<br />Pink palpebral conjunctivae<br />Clear breath sound<br />Normal ra...
Initial impression: DM2<br />Plans: Stat Hgt – 202Instructed TCB in AM with CBC, U/A, FBS, Bun, Crea, Lipid profile, Na, K...
polydipsia, polyuria, wt loss<br />Hgt: 202<br />
IFG – d/t  increased hepatic glucose uptake<br />Inc Hgt – decreased peripheral usage of glucose  <br />
Complications    <br />Acute <br />DKA and HNS<br />Chronic <br />Vascular, Nonvascular and Others<br />
Table 338-7 Chronic Complications of Diabetes Mellitus<br />Microvascular <br />    Eye disease    <br />        Retinopat...
Mechanisms of Complications<br />Inc intracellular glucose  -&gt; AGEs<br />Sorbitol pathway  <br />                  -  a...
Diabetic Retinopathy<br />Proliferative diabetic retinopathy<br />Hallmark features:<br />Neovascularization near the opti...
DM Nephropathy<br />1st 5 years<br /><ul><li>Glomerularhyperperfusion and renal hypertrophy – Inc GFR
  thickening of the glomerular  BM, glomerular hypertrophy, and mesangial volume expansion occur as the GFR returns to nor...
 steady decline of GFR </li></ul>7-10 years<br /><ul><li>Macroalbuminuria  - BP elevation </li></li></ul><li>Tight glycemi...
Diabetic neuropathy<br />Polyneuropathy<br />Mononeuropathy<br />Autonomic neuropathy<br />Symptoms:<br />Distal symmetric...
Gastrointestinal Dysfunction<br />gastroparesis  - delayed gastric emptying<br />              anorexia, nausea, vomiting,...
Diabetic autonomic neuropathy <br />Cystopathy - inability to sense a full bladder and a failure to void completely<br />T...
Coronary Artery Disease<br />+DM2 – death rate 2x in men and 4x in women<br />Risk factors:<br />Dyslipidemia<br />HPN<br ...
BP goal 125/75                    BP: 150/90</li></ul>3.     PVDs (Foot ulcers)<br />
Alpha-glucosidase inhibitors - inhibitors block polysaccharide and disaccharide breakdown and decrease postprandial hyperg...
D-phenylalinine derivatives - acts directly on the pancreatic β cells to stimulate early insulin secretion<br />	   &gt;Na...
Sulfonylureas -stimulate insulin secretion by interacting with the ATP-sensitive potassium channel on the beta cell <br />...
Choice of Initial Glucose-Lowering Agent <br />mild to moderate hyperglycemia -  FPG &lt; 11.1–13.9 mmol/L (200–250 mg/dL<...
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Diagnosing diabetes

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Diagnosing diabetes

  1. 1. Diagnosing Diabetes<br />Joseliza de la Cruz, M.D.<br />Tiffany Chu, RN<br />
  2. 2. S.B. 45 y/o F from Sampalok<br />CC: numbness over lower extremities <br />3 days PTC weakness with easy fatigability<br /> no chest pain, epigastric pain or <br /> back pain<br /> self medicated with Paracetamol and <br /> No consult done <br />1 day PTC weakness persisted <br /> numbness over lower extremities “karayomnatumutusok”<br /> no blurring of vision<br /> Consult<br />
  3. 3. ROS: <br />(-) cough, colds, fever<br />(-) SOB, orthopnea, PND<br />(+) occ. Palpitations, (-) chest pain<br />(+)polydipsia (10-12 glass of water and soda)<br />(-) epigastric pain, vomiting, change in appetite<br />(-) lbm, constipation<br />(+) polyuria (8x/day) , (-) dysuria, oliguria<br />(+) wt loss <br />PMH: TB 1999 treated for 6 months with no ff up<br />(-) asthma, HPN, Diabetes or kidney dse<br />(-) cancer <br />
  4. 4. Ob-Gyne History: G2P2 (2-0-0-2)<br />History of delivering large babies via CS<br />History of elevated BS during pregnancy<br />FH: diabetes – father and 2 siblings<br />HPN – mother <br />(-) CA, Kidney dse, Asthma<br />PSH: non-smoker, non-alcoholic<br />Works as a Caterer <br />
  5. 5. PE: conscious, coherent, ambulatory<br />Ht: 5’3” Wt: 150 lbs BMI: 26.6<br />BP 150/90 HR 92 RR 18 Temp 37C<br />Pink palpebral conjunctivae, anictericsclerae<br />Supple neck, no palpable lymph nodes, neck veins not distended<br />Symmetrical chest expansion, no retractions, clear breath sounds<br />Adynamicprecordium, normal rate, regular rhythm, no murmurs<br />Flabby abdomen with midincisional scar in the hypogastric area, NABS, soft nontender<br />Pulses full and equal, no edema<br />
  6. 6. Neurological exam<br />GCS 15 <br />CN intact <br />(no ptosis, no facial asymmetry, tongue midline)<br />No motor or sensory deficits<br />No babinski<br />
  7. 7. Subjective data<br />45 y/o female <br />caterer<br />numbness over lower extremities “karayomnatumutusok”<br />weakness with easy fatigability<br />polydipsia, polyuria, wt loss <br />no chest pain, blurring of vision<br />Strong family history of diabetes<br />History of delivering large babies<br />
  8. 8. Objective data<br />BMI: 26.6<br />BP: 150/90 HR92<br />Pink palpebral conjunctivae<br />Clear breath sound<br />Normal rate regular rhythm<br />No edema<br />Essentially normal neuro exam<br />
  9. 9. Initial impression: DM2<br />Plans: Stat Hgt – 202Instructed TCB in AM with CBC, U/A, FBS, Bun, Crea, Lipid profile, Na, KEKGOphthalmology referral if labs suggestive of DM<br />Rx: Paracetamol 500mg/tab prn for pain/ numbness <br />
  10. 10.
  11. 11.
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  13. 13. polydipsia, polyuria, wt loss<br />Hgt: 202<br />
  14. 14. IFG – d/t increased hepatic glucose uptake<br />Inc Hgt – decreased peripheral usage of glucose <br />
  15. 15. Complications <br />Acute <br />DKA and HNS<br />Chronic <br />Vascular, Nonvascular and Others<br />
  16. 16. Table 338-7 Chronic Complications of Diabetes Mellitus<br />Microvascular <br />  Eye disease    <br /> Retinopathy (nonproliferative/proliferative)  <br />   Macular edema  <br /> Neuropathy    <br /> Sensory and motor (mono- and polyneuropathy)   <br />  Autonomic  <br /> Nephropathy<br />Macrovascular <br />  Coronary artery disease  <br /> Peripheral arterial disease  <br />Cerebrovascular disease<br />Other  <br /> Gastrointestinal (gastroparesis, diarrhea)  <br /> Genitourinary (uropathy/sexual dysfunction) <br />  Dermatologic <br />  Infectious <br />   Cataracts and  Glaucoma  <br /> Periodontal disease<br />
  17. 17. Mechanisms of Complications<br />Inc intracellular glucose -&gt; AGEs<br />Sorbitol pathway <br /> - aldosereductase<br /> - redox potential <br />DAG - PKC <br /> - alters endothelial cells and neuronal structures <br />Hexosamine pathway<br /> -F6P in glycosylation and proteoglycan production<br /> - altering gene expression of TGF or PAI-1<br />Growth factors <br /> VEGF-A - diabetic proliferative retinopathy <br /> TGF - diabetic nephropathy <br /> - (+) BM production of collagen and fibronectin by mesangial cells<br /> Hyperglycemia leads to increased production of reactive oxygen species or superoxide in the mitochondria.<br />
  18. 18.
  19. 19. Diabetic Retinopathy<br />Proliferative diabetic retinopathy<br />Hallmark features:<br />Neovascularization near the optic nerve and/or macula and rupture easily<br />+/- vitreous hemorrhage, fibrosis, and retinal detachment<br />Nonproliferative diabetic retinopathy <br /> late in the first decade or early in the second decade of the disease<br /> Features: <br />Retinal vascular microaneurysms<br />Blot hemorrhages<br />Cotton wool spots <br />Mild nonproliferative retinopathy <br /> 1. changes in venous vessel caliber<br /> 2. intraretinalmicrovascular abnormalities<br /> 3. numerous microaneurysms and hemorrhages<br />Pathophysiologic mechanisms : d/t retinal ischemia<br /> 1. loss of retinal pericytes<br /> 2. increased retinal vascular permeability<br /> 3. alterations in retinal blood flow,<br /> 4. abnormal retinal microvasculature<br />
  20. 20. DM Nephropathy<br />1st 5 years<br /><ul><li>Glomerularhyperperfusion and renal hypertrophy – Inc GFR
  21. 21. thickening of the glomerular BM, glomerular hypertrophy, and mesangial volume expansion occur as the GFR returns to normal</li></ul> 5–10 years<br /><ul><li>Microalbuminuria is defined as 30–300 mg/d in a 24-h collection or 30–300 mg/mg creatinine in a spot collection
  22. 22. steady decline of GFR </li></ul>7-10 years<br /><ul><li>Macroalbuminuria - BP elevation </li></li></ul><li>Tight glycemic control <br />BP control – ACE/ARBs<br />RDA of 0.8g/kg of protein per day<br />wt: 68kilos<br /> protein requirement: 55 g/day<br />
  23. 23. Diabetic neuropathy<br />Polyneuropathy<br />Mononeuropathy<br />Autonomic neuropathy<br />Symptoms:<br />Distal symmetrical pain<br />Ascending discomfort and numbness from LE<br />UE involvement only after LE involvement is sever <br />Treatment:<br />Tight glycemic control<br />Foot care<br />Antidepressants - tricyclic antidepressants such as amitriptyline, desipramine, nortriptyline, imipramine<br /> SSRI – duloxetine<br /> Anticonvulsants - gabapentin, pregabalin, carbamazepine, lamotrigine<br />
  24. 24. Gastrointestinal Dysfunction<br />gastroparesis - delayed gastric emptying<br /> anorexia, nausea, vomiting, early satiety, and abdominal bloating<br />constipation or diarrhea - altered small- and large-bowel motility <br />How to document? Nuclear medicine scintigraphy after ingestion of a radiolabeled meal<br />1. Smaller, more frequent meals that are easier to digest (liquid) and low in fat and fiber<br />2. Metoclopramide 5–10 mg <br />Domperidone 10–20 mg before each meal<br />3. Noninfectious diabetic diarrhea - loperamide and may respond to octreotide (50–75 g three times daily, SC<br />
  25. 25. Diabetic autonomic neuropathy <br />Cystopathy - inability to sense a full bladder and a failure to void completely<br />Treatment:<br /> timed voiding <br /> self-catheterization<br /> Rx: bethanechol<br />2. ED and retrograde ejaculation - one of the earliest signs of diabetic neuropathy <br />Rx: -PDE5: sildenafil<br />
  26. 26. Coronary Artery Disease<br />+DM2 – death rate 2x in men and 4x in women<br />Risk factors:<br />Dyslipidemia<br />HPN<br /><ul><li>ACE, ARB, CCA, CAAn, VD
  27. 27. BP goal 125/75 BP: 150/90</li></ul>3. PVDs (Foot ulcers)<br />
  28. 28.
  29. 29. Alpha-glucosidase inhibitors - inhibitors block polysaccharide and disaccharide breakdown and decrease postprandial hyperglycemia when administered with food<br /> &gt; Acarbose<br /> &gt; Miglitol<br />Biguanides<br />Decreases liver production of glucose<br />Decreases intestinal absorption of glucose<br />Improves cell sensitivity to insulin<br /> &gt; Metformin<br />Combinations<br />Glucovance (Glyburide and Metformin)<br />Avandamet (Avandia and Metformin)<br />
  30. 30. D-phenylalinine derivatives - acts directly on the pancreatic β cells to stimulate early insulin secretion<br /> &gt;Nateglinide (Starlix)<br />Thiazolidinediones - increase insulin sensitivity in muscle, adipose tissue, and liver specifically bind to the PPAR- (peroxisomeproliferator-activated receptor-) nuclear receptor<br /> &gt;Pioglitazone (Actos)<br /> &gt;Rosiglitazone (Avandia)<br />CI: CHF and Liver dse<br />
  31. 31. Sulfonylureas -stimulate insulin secretion by interacting with the ATP-sensitive potassium channel on the beta cell <br /> - ideal for recently dx<br />SE: hypoglycemia<br /> weight gain<br /> increases CV risks<br />
  32. 32. Choice of Initial Glucose-Lowering Agent <br />mild to moderate hyperglycemia - FPG &lt; 11.1–13.9 mmol/L (200–250 mg/dL<br />severe hyperglycemia - FPG &gt; 13.9 mmol/L (250 mg/dL)<br />Can insulin be used as initial therapy in individuals with severe hyperglycemia ?<br />
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  36. 36. Thank you for your kind attention. <br />

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