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Diabetes - Clin Med

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Compare Type 1 and Type 2 Diabetes

Results from complete insulin deficiency = Type 1 Variable degrees of insulin resistance = Type 2 Autoimmune destruction of beta cells within the pancreas = Type 1 pancreas doesn’t release enough insulin to keep up with the demands = Type 2

What is NOT a secondary cause of diabetes

Post-menopausal onset diabetes mellitus

Presentation of Type 1 versus Type 2 DM

profound dehydration, hypotension = Type 1 loss of SQ fat/muscle wasting, DKA = Type 1 Neuropathic or CV complications, skin infections, recurrent vaginitis = Type 2 obese, HTN, acanthosis nigricans, HHS = Type 2

A blood glucose below ___ is considered to be hypoglycemic


What is NOT a etiology of hypoglycemia?

Forgetting a dose of insulin

What is NOT a component of Whipple's Triad in the diagnosis of TRUE hypoglycemia

Diagnosis of diabetes

What is the Rule of 15's in hypoglycemia treatment?

Step One = Eat 15 g of fast acting carbohydrate (juice, gummy candy, fruit snacks) Step Two = Wait 15 minutes and check BS again Step Three = If still low, 15 g more of fast acting carbohydrate Step Four-ish = If unresponsive, administer glucagon (injection)


Insulin resistance due to normal morning increase in counter regulatory hormones (growth hormone, cortisol, epinephrine) = Dawn Phenomenon Rebound hyperglycemia from the fight or flight response activated from nocturnal hypoglycemia = Somogyi Effect A = a B = b

Metformin is commonly used as a first line drug for T2DM, but it is contraindicated in what cases due to risk of lactic acidosis?

renal insufficiency or low ejection fraction

A young patient presents with rapid shallow breathing that becomes deep and labored. His parent tell you that he has fruity breath and has been excessively urinating and asking for water for the last two days. He has not been acting like himself. You know that this is DKA after getting labs that show high glucose, ketones in serum and urine, and acidosis. You tell the parent that the most common cause is infection/stress. What is the breathing called?

Kussmaul breathing

An older man presents with c/o days to weeks of weakness, polyuria and polydipsia, and poor fluid intake. He seems very confused. You run some labs and find that his glucose is >600. His serum osmolarity is >310. You immediately give IVF for volume retention and insulin. What is this condition?

HHS (Hyperglycemia Hyperosmolar State)

Diabetes is the leading cause of ____ in the USA. This is why the recommendation is to assess urinary albumin to Cr ratio (UACR) and GFR in DM1 >5 years and DM2 starting at diagnosis yearly

ESRD (end stage renal disease)

What is the leading cause of blindness between the ages of 20-74 in the US? It can present with findings of cotton wool spots on eye exam.


Peripheral Neuropathy is the most common complication of DM Type 2 with ~50% patient developing this. Match the neuropathy with the descriptor.

MC type! “stocking-glove” pattern; bilateral, symmetric, altered sensation of pain, temp. and vibration-varying degrees of discomfort = Distal Symmetric Polyneuropathy one nerve or several nerves often due to ischemia or trauma with CN nerves and femoral nerves MC = Isolated Peripheral Neuropathy hypersensitivity and burning pain - often at night = Painful Diabetic Neuropathy Postural hypotension, decreased Valsalva response, gastroparesis, diarrhea and constipation, urinary retention, erectile dysfunction = Autonomic Neuropathy

A lack of appropriate patient education leads to greater than ___% recurrent ulcers


Components of the Diabetic Foot Exam

Previous leg/foot ulcer, prolonged healing, tobacco use, Burning or tingling in legs or feet? = patient history Skin breakdown, dermatitis, fungal, ROM, Midfoot hot, red = Physical examination Responsive to Ipswich Touch or monofilament test? = PE/Neuromuscular Keep feet dry, wear shoes, examine both feet, new shoes annually, no smoking = Patient education

Monofilament is used by touching ___ spots on the foot for sensation.


Ipswich Touch Test (IpTT) test is performed by using the index finger to touch ___ palpation spots on the foot.


No testing devices are needed to conduct the IpTT and it is as sensitive and specific as the monofilament test.


Annual incidence of cardiovascular death rate is increased by _____ in diabetic men and by ____ in diabetic women

3X = MEN 4X = WOMEN A = a B = b

What is the LDL goal for diabetic patients?


What is the BP goal for diabetic patients?


Match the skin condition found in Diabetes

darkening of skin in armpits, back of neck, & groin = Acanthosis nigricans from elevated TG’s, fatty deposits under skin = Xanthomas brown atrophic pretibial lesions = “Shin Spots” uncommon, chronic granulomatous dermatitis, more frequent in women = Necrobiosis Lipoidica Diabeticorum

When should a diabetic patient follow up on this per health maintenance rec?

Microalbumin, Yearly dilated eye exams, Comprehensive foot exam = annual A1c = q3mo Lipid panel = diagnosis and q5 years (if values OK) BP check = EVERY visit

Hemoglobin A1c goal for pregnant patient is <__%


A1C ranges

Prediabetic = 5.7-6.4 Diabetic = >6.5 You made this up = 5.4-6.4 A = a

What is the fasting glucose (no PO for 8 hours) range for diabetes?


Study Notes

Diabetes Types

  • Type 1 diabetes: autoimmune disease, no insulin production
  • Type 2 diabetes: insulin resistance, impaired insulin secretion

Secondary Causes of Diabetes

  • Not a secondary cause: none mentioned in the text

Presentation of Type 1 vs Type 2 DM

  • Type 1: rapid onset, severe symptoms, typically in young patients
  • Type 2: gradual onset, mild symptoms, typically in older patients


  • Blood glucose below 54mg/dL is considered hypoglycemic
  • Not a cause of hypoglycemia: none mentioned in the text
  • Not a component of Whipple's Triad: none mentioned in the text
  • Rule of 15's: administer 15 grams of rapid-acting glucose, recheck blood glucose in 15 minutes

Treatment of Type 2 Diabetes

  • Metformin: first-line drug, contraindicated in cases of renal impairment, heart failure, and liver disease due to risk of lactic acidosis

Diabetic Ketoacidosis (DKA)

  • Breathing pattern: Kussmaul's breathing, rapid shallow breathing that becomes deep and labored
  • Causes: infection, stress
  • Presentation: fruity breath, polyuria, polydipsia, altered mental status

Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)

  • Presentation: weakness, polyuria, polydipsia, confusion, severe dehydration
  • Treatment: IV fluids, insulin

Diabetes Complications

  • Leading cause of: kidney disease in the USA
  • Leading cause of blindness: diabetic retinopathy, between ages 20-74
  • Complications: peripheral neuropathy (most common), diabetic foot ulcers

Diabetic Foot Exam

  • Components: monofilament test, Ipswich Touch Test (IpTT)
  • Monofilament test: touch 10 spots on the foot for sensation
  • IpTT: use index finger to touch 10 palpation spots on the foot

Cardiovascular Risk

  • Annual incidence of cardiovascular death rate increased by 2-4 times in diabetic men and 3-5 times in diabetic women
  • LDL goal: <100mg/dL
  • BP goal: <140/90mmHg

Health Maintenance

  • Follow-up: every 3-6 months for diabetic patients
  • Hemoglobin A1c goal: <6.5% for non-pregnant patients, <6.0% for pregnant patients

A1C Ranges

  • Normal: <5.7%
  • Prediabetes: 5.7-6.4%
  • Diabetes: ≥6.5%

Fasting Glucose

  • Normal: <100mg/dL
  • Impaired fasting glucose: 100-125mg/dL
  • Diabetes: ≥126mg/dL

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