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Diabetic KetoacidosisDIABETES MELLITUS -Is a group of metabolic diseases in which there are high blood sugar levels over a prolonged period,Diabetes is due to either the pancreas not producing enough insulin or the cells of the body not responding properly to the insulin produced. -Types of diabetes mellitus : *Type 1 DM (IDDM-insulin dependent) -usually juvenile onset but may accur at any age -causes of IDDM : .insulin deficiency due to selective destruction of insulin secreting pancreatic beta cells -Pt always need insulin and prone to ketoacidosis and wight loss -it is associated with other autoimmune diseases (HLA-B8/HLA-B15/HLA-DR3/HLA-DR4) *Type 2 DM (NIDDM-non-insulin dependent) -usually maturity onset (males > females) & most are over 40yrs / Strong family history of diabetes -causes of NIDDM : .decreased insulin secretion .increased insulin resistance -it is associated with obesity and lack of exercise and calorie excess
+Type 1DM ____________________________ Type 2DM .younger Pt .older Pt .HLA-D3 & D4 linked .no HLA assoc. .autoimmune beta cell destru. .Insulin resis. ,beta cell dysf. .polydipsia,polyuria,weight loss,ketoacidosis. .often asymptomatic,present with micro- or macrovascular complications. -Symptoms of hyperglycaemia : .polyuria .polydipsia .unexplained weight loss .visual blurring .genital thrush .lethargy .random glucose of >200mg/dl .acute metabolic decompensation,resulting in coma (ketoacidosis for IDDM,hyperosmolar coma for NIDDM) - Complications of DM : .Background retinopathy .Cataracts .Mononeuritis multiplex .impotence .6th cranial nerve palsy .Albuminuria .Painful neuropathy .DKA +Other causes of DM : .drug induced “steroids,thiazides” .pancreatic “pancreatitis;surgery where pancreas is removed;trauma;cystic fibrosis;pancreatic cancer” .endocrine “cushing`s disease;acromegaly;phaeochromocytoma;hyperthyroidism” .others “Acanthosis nigricans;glycogen storage diseases” +Other categories of DM : .impaired glucose tolerance IGT (fasting plazma glucose <7mmol/L & OGTT 2h glucose >7.8mmol/L) .impaired fasting glucose IFG (fasting plazma glucose >6.1mmol/L) +Causes of insulin resistance IR (is a physiological condition in which cells fail to respond to the normal actions of the hormone insulin) : .obesity .werner`s syndrome .pregnancy .polycystic ovarian sundrome .acromegaly .metabolic syndrome .cystic fibrosis .TB drugs .cushing`s
**Diabetic nephropathy (or diabetic kidney disease) is a progressive kidney disease caused by damage to the capillaries in the kidneys glomeruli. -Symptoms can take 5 to 10 years to appear after the kidney damage begins,include : .severe tiredness .headaches .general feeling of illness .nausea, vomiting .lack of appetite .itchy skin .leg swelling -Causes : .Poor control of blood glucose .High blood pressure .Type 1 diabetes mellitus (before age 20) .History of cigarette smoking .A family history of kidney problems -Diagnosis : .urinary albumin excretion <30 mg/24h; -Treatment : .ACE inhibitor medications (for hypertension)
Diabetic Ketoacidosis -Is a result of severe insulin insufficiency.It is assciated with hyperkalemia.It occur in type 1 diabetics may be the presenting manifestation,May occur in type II diabetes (insulin independent) but very rare. -May be precipitated by infection,surgery,MI,wrong insulin dose. -The diagnosis requires ketosis and acidosis (pH<7.3) / The diagnosis can be made by finding elevated blood glucose,incresed serum levels of acetoacetate,acetone,and hydroxybuyrate,metabolic acidosis,and increased anion gap. (Total body potassium is high is false) -Signs & Symptoms : .polyuria .hypervetilation .polydispia .ketotic breath .lethargy .dehydration .anorexia .vomiting,abdominal pain,com -Investigations: .lab glucose,blood cultures .urine tests “ketones” -Comlications : .cerebral edema .aspiration pneumonia .hypokalaemia .hypomagnesaemia .hypophosphataemia .hypoglycaemia .hyponatrimia .thromboembolism .hyperosmolar non-ketotic coma .Increased anion gap .Pseudohyponatremia .Paco2 decreased .PH decreased .leukocytosis -Treatment : .Give K .Monitor intake – output .Correct acidosis when pH is less than 7.1 .Monitoring ketones in the blood is more important than in urine .Heparin may be used prophylactically
+Anti-glutamic acid decarboxylase (GAD) antibodies (Anti-GAD antibodies are usually positive in DM type1) +Diabetes may be secondary to : .Pheochromocytoma .Glucagonoma .Cushing's syndrome .Thiazide therapy .Acromegaly .Pancreatic carcinoma + hypoglycemic agents : .Glibenclamide .Chlorpropamide .Gliclazide .Ghlorpromazine .Glipizide + There is an association between the use of biguanide oral hypoglycemia agent metformin (Glucophage) and the development of (Lactic acidosis)
Hypoglycemia -This is the commonest endocrine emergency -brain damage & death can occur in severe prolonged cases -Symptoms : .sweating .drowsiness .seizures .coma .tremor .palpitation -Causes : .Insulinoma .Hypoadrenalism .Paracetamol overdose .Alcohol .Postprandial .Hepatic failure .Glibenclamide therapy .Addison's disease *Fasting hypoglycaemia -Causes (EXPLAIN) .Exogenous drugs .Pituitary insufficiency .Liver failure (enzyme defects) .Addison`s disease .Islet cel tumours (insulinoma,hodgkin`s disease) .Non-pancreatic neoplasms .hyperinsulinism (can occur secondary to insulinoma) *Post-prandial hypoglycaemia -may occur after gastric surgery and in tyoe 2 diabetes Insulinoma -Pancreatic B-cell tumor and associated with MEN-1,can cause hypoglycemia-benign tumors / it presents as fasting hypoglycaemia with wipple`s traid -Clinical findings : .include symptoms of subcute or chronic hypoglycemia .blurred vision .headache .feeling of detachment .slurred speech .weakness .symptoms occur in the early morning or late afternoon or after fasting or exercise -Diagnosis : .This is made by finding a serum insulin level of 8 mg/mL or more in the presence of blood glucose values <40 mg/dL .CT scan,U/S and arteriography may also be useful in detecting the tumors -Treatment : .surgical excision
Glucagonoma -Glucagonoma are rare tumor of the alpha cells of the pancreas -DM is present in 80-90% of cases of glucagonoma (not responding to insulin)
**Thyroid Function Test (TFTs) -Hypothyroidism (inc. TSH – dec. T4.T3) -Hyperthyroidism (dec. TSH –inc. T4.T3) -Subclinical hypothyroidism (inc. TSH –normal T4.T3) -Subclinical hyperthyroidism (dec.TSH –normal T4.T3) +The most sensitive indicator of primary hypothyroidism is TSH (thyroid-stimulating hormone)
**Hyperthyroidism (Thyrotoxicosis) -Can result from excess production of TSH “rare” or abnormal thyroid stimulators.Amiodarone can induce thyrotoxicosis -Weight loss despite inreased appetite -heat intolerance,sweating,diarrhoe,tremor,irritability,emotional lability,itch,oligomenorrhoe-may cause infertility Graves` disease -M.C.C of hyperthyroidism in Pt under age 50yrs / TSH is low -This is autoimmune disease caused by stimulatory TSH-receptor antibodies.It is associated with other autoimmune disease (vitiligo,type 1 DM,addison`s disease) *Toxic adenoma -Can result from a hyperfunctioning adenoma (toxic) *Toxic multinodular goitre -Is non-autoimmune disease of the elderly associated commonly woth arrhythmia and congestive heart failure (CHF) and sometimes the simple goiter *Ectopic thyroid tissue -Metastatic follicular thyroid cancer (choriocarcinoma or struma ovarii) -About Grave's disease (thyrotoxicosis) : .inc. pulse .tremor .palmar erythema .hair thinning .lid lag .lid retraction .goitre .eye disease (may be the 1st sign of G.d - exophthalmus) .pretibial myxoedema .oedematous swellins .above lateral malleoli .thyroid acropachy (clubbing,painful finger and toe swelling) .dec. TSH / T4-T3 inc. .mild normocytic anaemia .leucopenia,Ca inc.,LFT inc. .myopathy may occur .atrial fibrillation .oligomenorrhea .tachycardia .excessive warm sweating .nervousness -Treatment of thyrotoxicosis : .Neomercazole .Radioactive iodine .Surgery .Propranolol inderal .Carbimazole .Potassium perchlorate .Propranolol +Cyclophosphamide is NOT -Diff. Diagnosis : .acromegaly .neurosis,anxiety .pheochromocytoma .cardiac disease .ophthalmoplegia and exophtha;mus -Complications : .heart failure (thyrotoxic cardiomyopathy) .angina .osteoporosis .ophthalmopathy .gynaecomastia .thyroid storm
Thyroid Storm -Is a rare but severe and potentially life-threatening complication of hyperthyroidism (overactivity of the thyroid gland) -It is characterized by : .high fever (often above 40°C/104°F) .fast and often irregular heart beat (tachycardia) .vomiting, diarrhea and agitation .heart failure may occur, and myocardial infarction is encountered .jaundice,dehydration,hyotension .death may occur despite treatment .high T3.T4 .coma -It is precipitated by stress,surgery or trauma
**Hypothyroidism (myxoedema) -Primary hyoithyroidism can occur secondary to chroinic thyroiditis (Hashimoto disease);this is the M.C.C of goitrus hypothyroidism -Symptoms & Signs : .tiredness .cerebral ataxia .dry skin and hair .weight gain .non-pitting oedema .constipation .carpal tunnel syndrome .poor congition .menorrhagia .hoarse voice .peripheral neuropathy .bradycardia,hyponatremia & anemia .myalgia,dementia .in the newborn sings include cretinism .toad-like face.appetite decreases and weight increases .pleural effusion .lethargy .deafness .depression .periorbital puffiness .Pericardial effusion .dislike of cold -Diagnosis : .in primary (inc.TSH – dec. T4) .in secondary (dec. or normal TSH – dec.T4) -Causes : .primary hypothyroidism (lymphocytic infiltration of the thyroid) .hashimoto`s thyroiditis .iodine deficiency .secondary hypothyroidism (from hypopituitarism ) is very rare -Associations : .turner`s syndrome .down`s syndrome .cystic fibrosis .primary biliry cirrhosis Date: 2016-04-22; view: 521
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