Diabetes For Finals - FinalsEazy
Summary
This on-demand teaching session is designed for medical professionals to learn about different types of diabetes and diabetic emergencies. During the session, Maria Myriads from the ski team’s content team will provide attendees with a comprehensive overview of diabetes and its management, from recognizing the symptoms and diagnosing to insulin therapies and lifestyle advice. This engaging session is complete with interactive quizzes and a review of relevant lab tests for atypical presentations of diabetes. Join Maria for a comprehensive and educational approach to diabetes!
Learning objectives
- Understand the definition and physiological control of diabetes.
- Compare and contrast Type 1 and Type 2 diabetes.
- Identify different diagnostic tests to distinguish between Type 1 and Type 2 diabetes.
- Utilize dietary strategies and insulin treatments to effectively manage diabetes.
- Identify and discuss the treatments, possible emergencies, and prognosis of diabetes.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.
um we work on really a free platform. So we work on our social media. If you really enjoy the session, please, please. Tigers in Twitter Instagram Facebook Does those are handles? Place tigers. If you enjoy, the session is gonna be fantastic. Want to do, um and please remove your skis? Yet outlawed are common risk. Is he a gmail dot Come out of your spam a juncture that you can receive Updates from us and slides will be sent All those who feeling the feedback from on metal dressed representative is Mary Myriads part off the leadoff Are content team here in our ski see? And she has a wonderful presentation ready for you guys on, um, diabetes. All the different types of diabetes and diabetic emergencies as well. So I'll pass it over to marry to take it away. Thank you. Event Hi, everyone. My name is Maria A. I'm in fourth year and Cardiff on down part of the ski team. I just hear my slice. No. All righty. So we're talking about diabetes city. Really? We'll be covering type one and type two diabetic emergencies. Your stage of diabetes on a few other types a swell. So let's get started. So we're gonna start with just the basics off physiology. There's simply when we eat carbohydrates. This a say we ate a piece of bread, you get a rise in the blood glucose. Okay, so the locals in the butt increases on. We use this glucose in the cells, break it down to get the energy to study, play whatever the body heals, the blood glucose levels between 4.4 and 6.1. Normally, we have two hormones that kind of regulate this process. We have insulin, which is produced by the beach cells, and I was 100 lbs in the pancreas. When locals increases insulin increases, wells help reduce it down. It does this by allowing the body cells to absorb the glucose in twos as a few. So if we think of glucose as the key on, the cell has a door. So the glip the sorry, the insulin is the key, so the insulin opens the door off the cell to allow the glucose into the cells. It also allows muscle never cells to store it as glycogen, so it's normal than under like hormone, so it helps build bigger molecules, so he uses the glucose about glycogen to sort. Glucagon is a hormone produced by the alpha cells in the aisles of Langerhans in the pancreas is well on increases when the glucose levels in your blood is lower and it works on breaking the glycogen that we stored into glucose to help increase the level, and we're able to use it for as fuel to get energy. It also converts the proteins and fast into glucose as well to help increase the level. And it's known as a catabolite hormone, so it breaks down bigger molecules into smaller ones. On I just remember Catholic starts with a C, so it cuts down molecules into smaller ones. Alibi Anabolic starts with an A, so it's God's so it produces and bigger and military Okay, so what is diabetes? It is simply a problem with the insulin secretion, which what type one is or a problem with how the but the cells, the body cells respond to insulin, which what type two is. Let's start with a question. 53 year old woman has a routine medical review for work. She's asymptomatic, and clinical examination is normal, which results would suggest the diagnosis of impaired fasting glucose. It's married. Just a quick question. Are you able to see the pole? Yes. Okay, cool. Just, uh, if if around 40 50 seconds, I'll just stop the bullet. That's okay. Who? Yeah, yeah. You want me to supper? Would you like to solve it? That's when I just don't think. Thank you All righty. That's correct. So fasting glucose of 6.5 on two occasions. Let's have a look at this. Don't When we're making diagnosis of diabetes, we highly rely on the numbers, and it's a very popular question and exams as well. There is a difference between impaired glucose tolerance and impaired fasting glucose. So impaired fasting glucose is when the fasting glucose is between 6.1. That's a 6.9, and it helps in our diagnosis off prediabetes impaired glucose tolerance. It includes the fasting glucose, but also the two hour glucose tolerance test. When it's between 7.8 and 11.1, so includes both because it reflects how the body is not able to propose is the carbohydrates for eating. Also, for pre diabetes? We check. We can check the hate to be won't see you, which would be 42 to 47 on If the patient is them platted. It's one result is okay if patient is asymptomatic, so he's coming with no symptoms. We need to do two tests on different days to confirm the diagnosis. For diabetes. It's a bit higher numbers so running, but because of equal to or greater than 11.1 at the same with the G t. T. So the oral glucose tolerance test after two hours the fasting blood glucose would be equal to or greater than seven on hate to be on C equal to agree to them. 48. These numbers just we need to kind of learn it to, um, enter that. It's an easy question to get right in the exam. Just make sure that we know oh to intrude. It's weather saying, period. Nothing new clothes or close shoulders. Frank. You're getting a 23. A woman who was that with with type one diabetes, Miles A. Since chatter level be before meals excluding first thing in the morning. So it's just before the meals knocked on, waking up in the morning right? That was a close school, so it's actually 4 to 7, but 4 to 6. Pretty close. So Type one diabetes type one diabetes Autoimmune condition. It's, um, basically, your immune system is attacking and destroying the pancreatic beaches cells, and therefore you're not able to secrete insulin. It's mainly a genetic, so a patient type one diabetes usually does have a first degree relative with type one diabetes as well. On if they have the HLA d r three antigen or hatred lady are for antigen. They're more likely to get Type one diabetes, but also, environmental triggers can play a role. So especially viruses. So I saw a patient, actually who had absent Barr virus, which triggered, and the presentation of Type one diabetes, which was actually in DKA. So she presented as a, um, emergency. Usually type one diabetes is in younger patients on. That's very important when thinking about a diagnosis, whether type one or type two, because usually Type two are usually in older patients. The clinical features are polio area polyps yet, and weight loss classic three. Why do they present with this polyuria if we think about it so you get increased glucose in the in the blood. And what does glucose usually do? They absorb water, they just act tract the water to it, Okay to help with the homeostasis. So then water in the cells, if this still on, go into the blood vessels. And when there's more water in the blood vessels, more water is being filtered out in the kidney, and therefore the patient's pee more and when when they pee more, your Cozaar hydrated even more so you feel first, see, so you get pull it up so you want to drink more and more it loss, but also when you can't access the glucose inside the cells and the glucose can enter the cells, you look for other sources used for energy. So you start burning off fact and using five after your energy, and therefore you lose weight and Children as well. You can get a nocturnal enuresis, which is like bedwetting. But yeah can present in diabetic ketoacidosis. Measure the key toes and to ensure that they're not in DKA, and you need to act quickly. The diagnosis is mainly clinical, clinical diagnosis and type one diabetes. But better the gluco was Yeah, I could mention before to just confirm our noses, and it's similar numbers. You also do a urine if you suspect type one diabetes, but it's a presentation. So, for example, um, someone who's older, so 50 years old, I d. They're not losing as much weight on, but there's a slow progression off their hyperglycemia. But you still think this is type one diabetes. You can do further investigations, which we're going to talk about in the next light. Management for type of diabetes is mainly lifestyle as well as insulin, so the dieticians have a great role. Um, in managing Type one diabetes, they do a lot of education with the patients, especially the Children, teaching them how to count their carbohydrates. What they're supposed to even have to calculate that with the insulin they're having. Uh, there are different types of instant again. We're going to talk about this in a few slides on, But it's very important with Type one diabetes to monitor the butt because regularly so patients would be expected to do like a finger prick to, um, see your blood glucose level 45 times a day, usually four times for, uh, those five times for Children on Uh, they can go to the GP and check their hate. Be able on C 3 to 6 months. So three monthly if they're still at the start and still a bit unstable to see how they can manage with the incident. Once they're stable, it becomes six months Onda when measuring at home. That was the question that we just had on waking up the targets all 5 to 7. But before meals at other times, it's 4 to 7, 5 to 7 at the start when you're when you're waking up, because you need to make sure that you're not having too much insulin at night before you sleep. You know, like been a time with high wakeup with hypoglycemia with low, um, blood glucose. So that's why the participate higher at five. So what are the other of situations that we can do if it's an atypical presentation? So these investigations are not we don't do this regularly is just if we suspect and 80 for presentation on that's 20 bodies. So there are four older antibodies that we can test for, and I would sell antibodies go stomach acid decarboxylase antibodies incident on the bodies and the insulin associated two or 20 bodies, and the most common true that that we test for is the islet cells, antibodies and the lieutenant. Absolutely horrible. It acceptable because they're the moves like the two be associated with type one diabetes. We can also measure the C peptide level seepa tight as a molecule that is produced when the pancreas is producing. Incidence is produced with it, so within type one diabetes, if you measure that, it's going to be lower and then the normal level. Insulin therapy. So we said, there are different types of insulin. You get rapid acting, short acting, intermediate acting long, acting on mixed in some combinations, the most common ones that patients use already rapid acting insulin on the long acting insulin, the ones in pink on. They are used in a region called basal bolus, so he take a base off the incident that stays with you the whole day. So the long acting incident the Humira, your Lantus that stays for 24 hours. But with each of the meals, you take a rapid acting insulin that helps with the quick peek off Locos that happened once we eat breakfast, lunch or dinner. There are other regimes as well that are used regimens that are used. Um, there's the 1 to 3 injections, whether the patient basically particular one injection two or three injections off, like the mixed incident or intermediate and shorts. So different combinations on that's done with a specialist but not very common on for your Children are not able. Teo have injections yet. We use a pump so continuous subcutaneous insulin, and it's very cool. So if you're in placement once and you see a patient, have a look a day pump and that their phone fee have graphs off the measurement beforehand, it's very, very cool technology. But that's off. The basal bolus has given us injection subcutaneous injections, Um, and it's administered to the interior electoral aspect of the thigh, buttocks or the abdomen. Most people do it in the abdomen. I need to ensure to tell the patients to rotate the site of injection so they don't get like the hypertrophy, where the fat cells basically increase in size and just want to play more. And they would get a bit of a lump on their on their abdomen, which is not very nice out on the table here for you, with all the different types on the time of onset, the peak time of when it's highest on how long it stays for. You don't need to learn this off my heart and just having awareness of the rapid acting and the long acting mainly, and knowing that the long acting stays for 24 hours like the whole day. About 24 hours on the rapid acting starts really quickly. So then in 10 to 20 minutes, it starts working for whatever meal the patients have. Next question, I 56 year old male patient comes from his annual diabetic review. His type two diabetes is currently died controlled his blood test row HB a one c 0 51 million mole. Um oh, what takes me one c target? Uh, you comes, you know, from the ball. Yeah, aiming for very nice. So I've ever read up there 48. Okay, let's talk a bit about type two diabetes. So back to diabetes is more of an insulin resistance. Eso the cells are not able to respond to the insulin being produced by the pancreas on overtime. That pancreas basically produce more more more insulin to get the glucose into the cells that it gets tired and goes into failure. It's highly related to obesity on bullet. The family history is well, because usually there's someone else in the family called the House. I peed Type two diabetes on Also family Origins from countries that have a high prevalence of Type two diabetes, such as the Middle East Ages. Oh, clinical features. Again, you got polyuria, polydipsia and fatigue. So they did come really tired. Really easily. Diagnosis again. Same numbers it has for a random blood glucose or local cell told incest fast and cosmic glucose or his video and see on if the patient is no, it's not showing symptoms, and it's actually a coincidental finding you need to make sure to repeat on a different day management again. Lifestyle soul. You start by asking them to kind of men their diet and work with them on doing that and maybe increase exercise. Lose weight if they are obese on D. If that doesn't work, you start on a single therapy, which is usually metformin, that we start with. If again they come for review and they're hate to be one C is greater than 58. Then you start another drug so you could go on Google Third be, if again on the next review and HBOC still richer than 58 triple therapy If breaks it down to 50. To get on the next review, you can start incident therapy and Andi again. We used HB a one C to monitor how the how the public ALS were in the past about 33 months is they are on the lifestyle, um, modifications on metformin, then your head to be one C target is 48 like, uh, prediabetes. Uh, but if they are on a drug that can cause hypoglycemia that can basically cause the glucose to come too low Such a self in your ears on insulin, then your target is 53. I didn't just more numbers to remember for diabetes. We also make sure Teo wanted her. Their BP often expression. Six year old man comes for review in the diabetic clinic. He was diagnosed with type two diabetes eight years ago. He works as a teacher, is a nonsmoker, and his BM iced 30. He couldn't have metformin do two gastrointestinal side effects, But it's on Glipizide, another of a statin. He was successfully treated for bladder counts or four years ago. His animal bloods are as follows here in the table. What is the best next step in management? Okay, so most people got the right answer. We'll talk about why it's not an empire. I get his own, um, in the next few slides. Okay. So like we said earlier, this justice diagrams gonna try and simplify things you start with metformin. Usually is the first drug. If metformin is no tolerated or contra indicated, then you would start in one of the other ones. You're options are self in urea, DPP, four inhibitors and tile. Is it in a non needs constant eight on CGI l t two inhibitors. If that doesn't work, then you were at another one as well as a third therapy. Um, Andi, if the third if if they're on three tablets on still the, um they're hit me one c, still high about 58 and under. B. M. I. C is about 35. Then they are. They fit the criteria to start incretins the GOP one minute if they don't actually fit this criteria, then they would be started on insulin. Here's a table off a summary with all the drugs. Um, I wouldn't go. I'm not gonna go through exactly everything here. But it's important. Teo, know the side effects off these drugs here in the last column of highlighted, the ones that I thought come a lot in questions. So the ones in pink and metformin, one big side effect is lactic acidosis. It doesn't actually have another in real life, but it's very faint is very popular when it comes to exam questions. Self in here is so cause hypoglycemia because it increases the release of insulin, increase the secretion of insulin s o. There's this, um, risk of hypoglycemia. Just like how If you're having just normal incident exogenous insulin, um, again, they also, uh, can cause weight gain. So if someone with a high be my preferred, you don't want to give themselves in your ears by a glitch is on here. Um, a contraindicate indicated with bladder cancer, so I can increase in the risk with blood counts. Um, so since the patient in the crash and had breath, bladder counts are previously, then you want to avoid that, Ideally. Okay, question five. It 15 year old girl presents with confusion and business. She's in pain, and it's holding her abdomen. She wasn't rabid. Other his bones, the headaches since she was 13 years old, Her blood percent ceiling on her ass to set up on insulin computer. You know, for the patient according to my sidelines, what is the correct rate of insulin you should prescribe? So I think my my Internet plate of it. Can you guys see this? Lights? Yeah, we can. Really? No, I think the introduced keeps cutting off a bit, but hopefully is going to better now. Great. Because you're on one units. Um, I think this is the most important number kind of to remember when it comes to Well, we're going to talk about now. DKA so very important. Remember the insulin dose? Because I think this is just the number to remember for the management here because it's it's asked a lot in exams. Okay, So diabetic a chest CT acidosis. Someone with diet with type one diabetes, um, is at risk off getting this cold on what triggers it usually is an infection or dehydration or fasting for a long time or like we talked about, it can be the first presentation triggered by one of the previous one that we just said. Clinical presentations, usually abdominal pain, vomiting, dehydration and smell of acetone like fruity smell. They say I haven't really smother um hyperventilation. So what? They call cause no respiration. So they're just breathing really hard. They can even try some things. Um, signs of respiratory distress. So, like intercostal recessions. And they can be a bit drowsy or they can present in high. Probably make sure because of how they didn't dehydrated, they are died. One's very important. So that would be above three minimum per liter. The ritual hyperglycemia above 11 on the patrol acidosis. So basically what the name says diabetic, increased glucose, Keto increased keystones acidosis. You get acidosis and you can see that when you do a, um uh, an ABG you would an arterial blood gas. You can see the bicarbonate on the pH of the blood management. This is an emergency. So any emergency just starts with a B C d. Checking their airway, their breathing, their circulation there GCS are they Do they have any other trauma any anything happening on after that? You thought your diabetic justices treatment, which includes fluids, insulin, glucose on Botox? Assume so. The afternoon I use is, I think so. You start one liter of saline over an hour, and then you give your insulin at fixing of 0.1 unit again, that's that's the number to remember. It's usually a short acting, insulin like Act Rapid, and then you check their monitor, their blood glucose. And if it if it's go wing, um, it's becoming to law. You wanna add dextrose to your next fluent, um, and infusion because there are extremely dehydrated so you don't you don't just give them one way to know you. You give them you can. He can actually need a resuscitation off like six liters and depending how hydrated they are. So there's calculations and on D. These companies are done over the computer, and they calculate how dehydrated they are. And based on that, you can calculate your fluids after Locos. You wanna monitor their potassium check? Um, if they need extra potassium. If it's between 3.5 to 5.5, you add four to minimal of potassium to the second bag of fluids that usually second bags over two hours, so increased the amount you increase the duration off. How long you're giving the foods for, especially for Children. It's very important not to high trade them to quit because they're a risk off cerebral edema. So you don't want that to happen, so you get them to feel it's a bit slower. If the potassium is 5.5, there's no need for replacement. If it's less than 3.5, then you talk to your senior to come on. Do have a look at the patient, but usually there would be a senior from the start anyway, because it's an emergency. You want to check for infection. I might be what triggered it. So you want to make sure to check that and treat it. If there is anyone to take their fluid balance and to make sure that you're giving them the exact right amount of fluids, he tones, you want to try it to see that it's coming down, and that's when you kind of can rest and think, Okay, it's okay now. The next emergency is the high personal or heartburn like seeming state. This one is more, uh, with your diabetes type two. So your D k is really more of your diabetes Type one emergency on hey, chest is more of your type. You just like to emergency. It has similar triggers, so infection can cause it, Um, usually a new T. I. Actually, many specific medications can triggers as well. Substance issues poor that better control on if they are quite a lot of times. Well, considerate clinical features are similar to DEA, so you eat. You feel tired to get polyuria. Polydipsia can feel nausea and vomiting, but DKA it's more or severe on a quicker onset. Hate hs is more of a slower progression. They can feel a bit drowsy. Uh, they can present with actually emergency such a stroke as well, or an M. I was of the hyper viscosity because when they are dehydrated and all the waters being lost, when when they go to the toilet because of polyuria, your blood becomes more concentrated on. You're more likely to form a clot. And if it's left too long and it's not recognized, it can cause a stroke or a m. I, um, again, also, you would get because they are dehydrated. Get cardiovascular symptoms. So hypertension and tachycardia to try and kind of increase. Um, your BP diagnosis severe hyperglycemia. So it's be a lot higher your glucose levels that DKA so be more than 30 usually hyper a smaller state so more than 3rd, 320 and also allows he is measured by two times your sodium plus glucose quest urea volume depletion. So like said that they were dehydrated, extremely dehydrated on because they are the controlled hypertension they control. Also, a presentation of achy I so high urea Andi high creatinine on all this happening without significant ketoacidosis. And that's how you're making sure that that's hate hs and it's no DKA. So you don't get acidosis with it. Management. Again, you're doing your A B C D. But he had There's a massive, um, stress on fluids, fluids, fluids, fluids. They did get loads of fluids. Insulin, is it? Maybe they might know actually need insulin, and you give them BTU prophylaxis because of the extreme high purpose called standing hydration. Okay, lets compare them so we were able to different between both of them. DEA is an absolute insulin deficiency. So type one diabetes, your know, secretive, any incident. That's why you need incident from the start. Insulin therapy Hatred. Yes, you might actually be releasing still a bit of insulin because the main problem actually started with increased resistance in the cells rather than a problem in the pancreas of the spot. For DEA, insulin is the most during the management. Haiti chest for the woods is the most. You start with fluids both ways, but fluids is stressed on more in Haiti. HS diagnosis for DKA, your pH is important, he tones important blood glucose and your bicarbonate for Haiti. Hs your serum osmolality your B and so your your glucose keytones a patiently check if there's, um, if they're higher, the hat can happen occasionally, but no much at all. DEA. And that's where we, um, need to focus in the question. It's a shorter history, so it's hours usually that it just happens quickly. Hey, teacher, a second takes days to actually develop. Okay on. I just drew this diagram here to kind of help explain why we get, um, acidosis in DKA. So, like we said, we're not able to use the insulin into Sorry, no able to the glucose into ourselves. So we start breaking down the fat cells, um, producing fee fatty acids. And these free fatty acids are what are converted to ketone bodies and deliver, and that causes increased Kato homes, which causes the acid in your and hate HS. It's a relative, um, incident efficiency. So we we don't reach the stage that we need to break down our fat. So usually if we're if we're in a fasting state or we're know having enough glucose, you start breaking down your proteins on. Do you get, um, you know, acids on this promotes like, glad flu genesis, a sort of Lupron gluconeogenesis on glycogen license. So you bring down your glycogen and you try to build your glucose to increase it. You don't get to burn your, um, fast cells and therefore you don't get ketone bodies. Our third emergency is hypoglycemia, so that can be caused by decreased and take. So they're in a fasting. See them? They're not eating and chemicals by drugs that are we using that are used thing to manage your diabetes so so often yours and insulin, like we said or it can be a tumor like insulin alone and and still in normal, where you're producing extra insulin or things like adrenal and efficiency, That and, um can affect your, uh, glucose levels clinical features. Um, is what you would expect. So you don't have enough loose. You're really tired. You're sweating your you're you're you might feel quite weak, confused. And if it's left for too long and it's quite severe you can go into a coma on previously is when there was no recognized as much it could. It could even cause that the diagnosis is, uh, glucose less than four millimoles so that the action, um, I use is four to floor to the floor. So if you're for you, you go hypoglycemia, and you must be five to drive. So that's how I remember that it's a little less than four treatment. You want glucose replacement, so you want to just add you're not. You wanna increase their glucose level, and the treatment is based on their conscious that also, if they're awake, you give them or a glucose gel or it's sugary drink. If they're unconscious, then you wanna establish an IV access and give them IV Dextral Street If you're in the hospital, if you're outside the house when you're not able to take on you and then you can give them Lupron bone in, I am injection for next question. It turned a six year old patient presents to the UPS Clinic after having been recently diagnosed with gestational diabetes. She's 26 weeks pregnant on her most recent scan showed an estimated fetal weight off 905 g. She's taking metformin three times a day, and it's having no issues with it. Her fasting blood glucose was last measured four weeks ago, showing 6.3 and millimoles fasting blood level was level extract at the clinic and show 7.1. What change if it'll would, you need to the management of this patient. Mm. Okay, so we're we're back on track with this one. So the answer. Actually, we continue the metformin and we add insulin. Let's talk about gestational diabetes. So just a little diabetes is insulin resistant. That's induced by the multiple extreme off pregnancy risk factors. Forget to station. Diabetes are a B. M. I off over 13. A previous macrosomia baby s, so it large baby this way. More than 4.5 kg. It previous just stational diabetes in in the previous pregnancy. For our first degree relative with diabetes or a family order, origin is well with high prevalence of diabetes. It's important to remember the risk factors for gestation diabetes and because based on that, uh, the, uh, investigations change complications with gestation diabetes include congenital malformations, macrosomia baby or problems within actually delivering the baby. Um, so it's important to kind of deal with this quickly on ensured that it's monitored throughout the pregnancy. So if the patient had gestation diabetes previously, then you want to give them on oral glucose tolerance test as soon as possible after booking, booking the first appointments, usually before the 10 week before 10 weeks, because they need to do blood tests and things like that. So you need to enter that once they had the first appointment that you need to check their G t e t ST. If that's normal at the time, you want to repeat it again at 24 to 28 weeks. If they have any of the other risk factors, then you test. Um, and you had no DVT and or glucose tolerance test 24 or 28 to 28 weeks. You don't you don't need to, um, act as quickly for diagnosing it. You do. If you want a fasting blood glucose off equal or greater than 65.6 on OGTT threshold off methadone or equal to 7.8. How I remember that is just 5678 on. It's just kinda logical that your lower numbers will be with fasting glucose. So I know that 56 or 5.6 is the fasting glucose is 787.8 is your or glucose orders test? I hope that's helpful because we have so many numbers to remember treatment. If fasting glucose is less than seven, then you try, Oh, first with altering their diet and exercise, and then you you see them again after a week or two. If still, um, that's not sufficient on their numbers are still above the threshold. Then you want to add metformin. If again you see them and that's still working out. Then that's when you add insulin and you, but you don't stop the metformin. You keep them in Foreman, But you start adding the incident next to it, and the incident I use is short acting. You don't use the long acting here because it has. It can complicate the pregnancy and the birth. So we only use short acting gestation, diabetes, a fasting glucose level from the start, from when she had the test was above or equal to seven. Then you'd start her on insulin street. Okay, if the situation comes on, um, metformin is not doing an effect or the on the mother is doesn't want to take insulin. She doesn't want the injections. She doesn't like them. Then you can give her the glip living acclimated, and that's itself in urea on do. It's the one that the special on that it's allowed to use in just a shin diabetes if the mother declines to use insulin. Okay, Other types of diabetes. So we have the mature onset diabetes off young. This is an auto is normal dominant inheritance, and these conditions are quite rare. You don't see them often, although I actually soul, um, a baby that had moody. And you're how they find out about moody. Usually, and it can be actually antenatal. The So when before the baby is born or after on it's highly asleep with renal cysts. So when they do this camp, they can see Reno cysts on. That's when they kind of clicks in with the family history as well. If someone has diabetes and you want to test him for a movie, it presents as a type two diabetes. But in younger people, the first line treatment itself in your ears, that's all we really need to know. Um, it it doesn't come a lot on exam spikes. It's worth knowing about it. The latent autoimmune diabetes of adulthood. This is known as the 1.5 diabetes, so it's cyclen diabetes in adults. So it's you see, these are the opposites to what else we were used to. And it's characterized by positive antibody. Oh, two antibodies. Three. Human involves metformin and insulin to achieve the optimal lysine of control. Other causes of babies or hyperglycemia drugs such as corticosteroids, your pancreatic insufficiency. So uh, things that can affect your pancreas. So cystic fibrosis or I I run over the wood in Tallassee mia. Endocrine disorders can do that as well. On genetically chromosomally syndromes can increase your risk of getting diabetes on you need till diabetes is something that happens. Um, sometimes it's It can be transient or can stay become chronic on. It's usually due to defective B cell function from birth. Okay, so diabetes is a, um, chronic condition. If it's not well monitored, complications can occur on. That's why we try to, um, on an urgent 12, to try and prevent these complications occurring. So we divide these into three macrovascular complications. Microvascular complications on a mix of both your microvessel complications, things like and my cardio infarction. Am I ischemic stroke or pre for peripheral art? Artery disease. Microvascular is your original plan. You're up early. Nephropathy on the one that's a nix of both is diabetic foot microvascular complications. So if we start with neuropathy, so a effects your nerve, your nerve microvasculature. So the vessels that supply the nerve gets affected and diabetes on early stage. You start by getting systemic sensory pulling uropathy, so it's not as a loving stocking and stocking distribution, so they would lose sensation in their in their hands and their feet. So, like the gloves in the stocking, we get about numbness and tingling and it's usually, uh, be treated with treatments that treats neuropathic pain, soul, duloxetine, amitriptyline and gabapentin. Late stage and uropathy would be autonomic neuropathy so it would can cause a postural hypertension and gastroparesis, um, and that can be treated by a copper might increase the the gastric movements. Or it can cause a ritual every child dysfunction as well. Um, Uropathy will be talked about more in the future sessions, so keep up to date is just a quick few. They're from pathy. Stage one is usually asymptomatic where you get hyper filtration in the woman's capsule. Symptoms usually appear about speech. Three. When the G F R is less than 16 on, it presents as protein urea. It's very important. What if we, uh, if we're, uh, managing diabetes to measure in the Indy Diabetic Review, The albumin creatinine ratio and 80 all 3 to 30 is called micro albumin urea, and it's one of the earliest signs of nephropathy. So that's when we can recognize it and start acting by giving a send him a trice to vasodilator the fair and arterials on prevent further damage. Rational would be, um, you get to stages, you get pre proliferative. And that's when when you when you do an autonomous hope, a test, you see things like aneurysms. Hemorrhage is onda hot extra date. And there's the proliferative stage, which is, um, a liter stage, which you don't really want to get into this what you try to control again. Diabetes is when you start seeing abnormal blood vessels starting to grow in the retina. Diabetic foot. Um, it's a mix of both because the purple arterials get affected, but also the nerves get affected. So you you get things like arterial ulcers. Um, on, uh, science off prefer arterial disease. So you get your six peas your painful personally called, uh, diminished pulses. All these all these sick, all these things on you get ulcers that are post boat on deep with the necrotic base. Then your pathic part is usually happens in pressure areas. So you lose sensation in your feet and you don't realize basically, if you've entered your feet and again they are punched out with reduced sensation. You get thick cholecystitis. You can get close to's where the book basically just become like this, um, permanently and you get deformed. He's such a strong quits. Foot, um, search an image and have a look what it looks like. Onda with diabetic foot. It's important to, um, do a blood glucose checks, of course, on 12 micro biology and X rays to check for osteomyelitis because these ulcers can get infected and can actually invade into the bowling on, but would be a big complication. Question seven. We're nearly. They're 65 year old women who has died. Two diabetes king for Lord, Her annual review. Her blood glucose levels are under control with metformin therapy. The last HBA one C was 53 checking her BP. The reading was 1 55/90. So 24 hour BP monitor was requested and reported her average BP being one for 4/89. What is the next step in her management? Yeah, No. All righty. It is starting these inhibitor. So BP is one of things that we monitor regularly. Like we said, with type of the diabetes, your BP target is less than 1 35/85 for type two diabetes. You split them. If the patient's age is less than eight years or above eight years. So if they're under 80 years your clinical readings that you would do in the in the hospital or the um at the GP, it would be less than 1 40/19 if they're doing an unbelievably BP monitor or homeless pressure. Monta. Then, um, it's 1 35/85 so it's just five less, Um, if they're above 80 it's 1 50/94. Clinic um, reading onda for, um, believe your home wondering. It's 1 45 85. Your first monitor this these inhibitors or on detention two receptor antagonists being your first line. Four patients who are on African Caribbeans, a Arby's are more preferred as first line, so important to remember that as well. So they have an annual review on the patients that have diabetes on. It's important to check um, how they're going with their diet to be advice, how they're how they're going with their carb, counting on managing this along with your medications and check how their physical activity is going. Want to check their hate beyond see more regularly at three or six months, depending on how stable they are with the management, with your target being less than 40 each. Like we said or 53 if they are on medications that can cause hypoglycemia. You want to manage your door? Their BP See their urine for, um, and glyco. You're glad? Glad? Because urea Oh, are keep bones a seizure. And you need those medications as well Confected their electrolytes and their lipids, Um, ensure that they don't eat extra, um, medications to monitor that to To managed out such a statins. You do a foot assessment yearly and a retinal screening as well, because they can progress quite quickly. And you need to make sure that intervening the right time risk prevention. Um, so you want to prevent them from having cardiovascular disease? So you control the blood. Pachter consider statin, like we said on very important smoking cessation as well. Okay, let's do a bit off school diagnosis. And that's what we're gonna end with or you this year in a little bit. Okay, so if you wanna, uh, answering the chopped, then so 77 year old Oh, no. Sorry. There we go. 77 year old lady presents with a one week history off polydipsia polio. Really? Lethargy on examination, she looks dehydrated. Drugs being confused and brush your glucose of 36 increased urea and creatinine. Nice hate hs good. Next one 25 year old man coming with confusion, abdominal pain and vomiting. He has lost 7 kg over three months. ABG shows metabolic acidosis with posture. A stretcher conversation on increased annoying up urine. Dipstick shows Kiddos. Yeah. DKA. Nice. 65 year old man is known to have type two diabetes presents with driving us and sweating. You discover from his wife that he had his morning insulin despite refusing to eat breakfast. Good hypoglycemia. A 27 year old lady. You present her GP at 25 weeks gestation following referred from her mid wife. She'd be find the following BP 1 29 for it and I found it high 2 25.5. Fasting plasma. That was 6.8. Yeah, you got this? Nice. Well, the guys that's safe for me. Um I didn't want to keep you too long, but if you'd like me to repeat any any poss I don't mind over was helpful. Cool. Thank you for our feedback Link has been put in the chat. Um, that's the feedback link. The recording and the slight are already up on the recording will be up. I think by tomorrow, and, uh, slides will be up. Mirena slighter. I know. I put them. Um well, we'll put it up by tomorrow. Next day. Knishes joining us from just getting off the tube in London Dedication, but join us for initial session on endocrine Crinology next Thursday in just two days. It's a really, really good session, and he covers all that, all the different conditions. And you need to know if I do chronology. It's a It's a very, very succinct, yet detailed, uh, so it's gonna be a session. Next biggest neurology is also join us for both the sessions on Tuesday and Thursday. Neurology. Um, I don't even have the life stream. Sorry. Oh, yeah, I will. Um, if you guys have any other questions, please put it in a chat and let us know what what else we can do. Let me help me, right? Yeah. Fantastic stuff. Memory