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Diabetes Mellitus and Hypoglycemia

Diabetes Mellitus and Hypoglycemia

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Diabetes Mellitus
- Acute complications
o
Hyperglycemia: elevated glucose
\ue000
Leads to polyuria (excess urination), polydipsia (excess thirst), polyphagia (loss of
calories so excess eating)
o
Hypoglycemia: decreased glucose
\ue000
Complication from insulin treatment and oral hypoglycemic agents
\ue000
Occurs during exercise and fasting as well
o
Diabetic Ketoacidosis
\ue000
In absence of insulin, lipolysis stimulated, this provides fatty acids which are converted
to ketone bodies in liver
\ue000
Hyperglycemia and ketone bodies found in type 1 diabetes mostly
\ue000
Can also occur in type 2 during infections and sever trauma, not as common as type 1
\ue000
Get increased respiration, polyuria, nausea and acetone breath, vomiting, abdominal pain
in children
\ue000
Treat with ER and IV fluid therapy and insulin
o
Hyperosmolar Coma
\ue000
Occurs in absence of ketosis in type 2
\ue000
Usually due to decreased fluid intake
\ue000
Higher incidence of coma than ketoacidosis due to more severe hyperglycemia and
dehydration (10 times higher)
Hypoglycemia (Insulin Shock)
-Drug-induced
o
Stimulation of sympathetic nervous system (adregenergic), which can be from too much insulin:
brain and nervous system react.
-Non-drug related:
o
Fasting hypoglycemia
\ue000
Exercise
o
Reactive/Post-prandial
\ue000
Induced by a meal
o
Symptoms are adrenergic in nature, so get shaking, sweating and palpitations
o
All symptoms are related to adrenaline
o
Also see confusion, irritability, headaches, abnormal behaviour, weakness, diplopia
o
Nocturnal hypoglycemia
\ue000
Occurs mostly in insulin-dependent individuals
\ue000
Night sweats, nightmares (symptoms usually due to excess insulin)
-Renal Failure, Insulinoma, GH deficiency
Types of Comas in Diabetes Mellitus
-Hyperglycemic Coma
o
Blood glucose is greater then insulin
o
Symptoms are weak and rapid pulse, skin is dry and warm, intense thirst, acetone breath,
respiration increased, seizures, and altered consciousness
o
Get patient to the ER
-Non Ketotic Hyperglycemia Coma (NKHHC)
o
Symptomatic hyperglycemia, inadequate fluid intake, dehydrated, osmotic diuresis
o
There are CNS alterations, extreme hyperglycemia without marked hyperketonemia and mild
metabolic acidosis
o
Get patient to the ER
-Hypoglycemic Coma
o
Insulin excess gives insulin shock
o
Patients pulse is full and rapid, skin is cold and clammy, intense hunger, decreased respiration,
irritable, confusion, and seizures
o
Treat by giving sugar
Chronic Complications of Diabetes Mellitus Seen On Ophthalmoscopy (if that is even the word, I think its
Fundoscopy, but you get the point)
-Cotton wool patches on the eye =
infarction resulting in nerve cell damage, hemorrhage, can be caused
by hypertensive retinopathy
o
Associated with cataracts and glaucoma
o
See exudates (fat/protein) which accumulate in back of eye
-Damaged Disk = papilledema (acute swelling from excess pressure)
o
Pressure is on CN 2 (optic), this
pushes disk forwards
o

Signs also seen in brain tumor
-Enlarged Cup = glaucoma (decreased vessels around optic disk)
-Papular Eruptive Xanthoma = lipid problem (usually

LDL)
o
If eruption, must act quickly
o
May be secondary to diabetes, liver problems, and may be hormone related
Other Conditions related to Diabetes Mellitus
-Skin tags = evident in the years before type 2 is diagnosed. Normal finding, but seems to be a link
between skin tags and blood sugar, especially over the age of 35
-Ulcers
o
Venous/Stasis Ulcer
\ue000
Medial and lateral aspect of malleoli
\ue000
Superficial ulcer, some pain
\ue000
Warm to touch due to stasis, venous blood stays in the area
\ue000
Heels are purple due to blood leaking into tissue
\ue000
Minimal pulse and sensation
\ue000
Can have atrophy blanche = scarring and healing from venous stasis related to previous
ulceration
o
Arterial Ulcer
\ue000
Dorsum of foot and tips of toes and over tibia
\ue000
Absent foot pulse
\ue000
Deep ulcer and painful
o
Neuropathic Ulcers
\ue000
Develop at pressure sites, and bottom of foot
\ue000
Decreased sensation of big toe, of foot, and joint position sense
\ue000
Will lose sense of fine touch
\ue000
Achilles reflex will be diminished
\ue000
Pulses are reduced, don\u2019t feel pain
Chronic Complications of Diabetes Mellitus
o
Microvascular Disease
\ue000
Retinopathy, Nephropathy
o
Macrovascular Disease
\ue000
Atherosclerosis
o
Insulin Resistance Syndrome (Syndrome X)
\ue000
Obese or sedentary people with type 2 or family history of type 2 diabetes
\ue000
Hypertension, hyperinsulinemia, dyslipidemia, hyper or normoglycemia
\ue000
Progress to coronary artery disease/stroke
- Clinical manifestations are diabetic nephropathy, ocular disease, peripheral neuropathy, infections,
gallstones, xanthomas, impotence and foot ulcers
o
Hyperglycemia
\ue000
With excess glucose, it can bind more to cells not requiring insulin like nerves, lens of
eye, kidney and blood vessels leading to many problems
o
Protein Glycosylation
\ue000
Glucose binds to proteins in proportion to hyperglycemia which can lead to cross linking
with blood vessel walls and this can lead to hypertension because of decreased elasticity
o
Sorbitol Accumulation
\ue000
Accumulation of sorbitol (made from glucose) occurs because of prolonged high glucose
levels, this leads to influx of water and swelling and cell damage
o
Lipid Glycosylation
\ue000
Glycosylated LDL\u2019s don\u2019t bind to LDL receptor in liver and so LDL is now available for
depositing in arterial wall, so increased TG levels and this contributes to hypertension
Lab Tests
-Glucose Tolerance Test
o
Looks at how well the body can produce insulin in response to a challenge with lots of sugar.
o
Good test for people with hypoglycemic symptoms
-Skin Prick Test
o
Need to know when person ate, so not exact, and on glucose tolerance curve diabetes type 2
would be represented by staying high for a longer period of time on the curve
-Glycosylated Hemoglobin
o
Estimates plasma glucose for past 3 months
o
97-98% of hemoglobin in adults is HbA
o
Normal glycosylation of blood is 4-5.9% in diabetes can se 13-20% HbA1C
-Urinary Ketones and Urinary Glucose
o
Ketonuria = can occur in starvation states, high protein diets, and alcoholism
o
Gluosuria = not well controlled DM, disease of renal tubules (seen in gestational diabetes)

Diabetes Mellitus
- Increased glucose metabolism
- Hyperglycemia in fasting state
- Caused by defective or deficient insulin secretion and/or insulin receptor defects (type II)

Classification of Diabetes
-Type I (insulin dependent DM)
o
Not producing any insulin, islet cells of pancreas are destroyed
o
Produce ketones
o
Seen usually in younger onset (juvenile diabetes)
o
Have HLA islet cell antibody
-Type II (Non-insulin dependent DM)
o
No ketosis, Have some insulin, More mature onset
o
No islet cell antibodies
o
Decreased sensitivity of beta cells to glucose and eventual loss of beta cells
\ue000
Type A = have defect in insulin receptor
\ue000
Type B = have Ab to insulin receptor
-Type III (Gestational DM)
o
History of DM in family, previous infant of more then 9 lbs, unexplained still births, previous
miscarriages
o
Mother has anti-insulin hormone, secreted by placenta (human chorionic somatomammotropin).
More glucose is available to the baby so it grows larger

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