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Okay, Today's session is the diabetes station. Okay, so in previous weeks, we've covered a lot of the other medical specialties. This week, we're sort of doing an endocrinology thing. Okay? And we thought, we are doing We do a focus session on diabetes, cause it's such an important condition. Diabetes is one of those conditions. If you have a really, really good on the side of diabetes, you understand our lot of medicine. Okay, there's a lot of medicine in diabetes. Okay, A lot of different specialties relevant to diabetic patients. So today's session, it's gonna be a big right, very white spotting. Okay, courage of many different specialties. But that's just because diabetes it's such a big subject to cover. And and it generally deserved its own a session. So I started with the best case of the way we're gonna cover. Loads of aspects of diabetes can work. I will cover focus history taking for polyuria will cover sort of explaining a diagnosis of diabetes, a two assessments of diabetic ketoacidosis prescribing insulin, adjusting insulin attack two diabetes, um, doing annual review for diabetic patients examining a diabetic patients. Okay, All the different complications, like retinopathy findings Europe of the findings. Um, hyperglycemia. Okay, but it's gonna be a white coverage of very suspects. But our first station is We've been We're in the GP. Okay? We've been asked Teo, take a focus industry from Mr Doubled or a 95 year old male who presents with polyuria. Okay. And then we've been asked to initiate it. Initiate and mind from plan with pertinent investigations. So, as always, we're gonna do some sort of polyuria on spot diagnosis. Eso have ah, think about it and let me know what you guys stick in the chat. So you have a 12 year old boy is dance for a general checkup with the GP. His mother reports that he has been more tired than usual. Upon questioning, he admits to waking up, frequently urinate and has not been sleeping well. He also reports recent increased thirst and weight loss. Yes. Yeah, this is type one diabetes. Very good. So type one diabetes. So we get this guy, we're gonna focus on both types today. But this is classic presentation of type one diabetes mellitus. So yeah, why is it it's a young boy resenting with increased frequency of urination Okay. Polyuria tired. More more than usual. Okay. Fatigue very predominant in the type one. Diabetes on day increased increased this and weight loss. Classic features, particularly type one diabetes compared to type two. Uh, particularly the weight loss. Okay. Very important feature of type one diabetes mellitus. Excellent. 47. Your mail, man with a history of hypertension. Hyperlipidemia presented polyuria polydipsia polyphagia for the past few months. He's noticed some blurry vision and tingling. Tingling in your feet. Yes, I yeah. Type two diabetes mellitus skin. Um, what is Why that Why is this type two diabetes compared to the first one? What indicates that this is more likely to be a type two diabetes picture Age? Age is big thing. Okay, Type two diabetes affects all the patients compared to type one about diabetes risk factors. Okay, that's a big thing. So talk to diabetes. Very strongly associated with the so called sort of metabolic syndrome. Okay. Hypertension and hyperlipidemia. Very strongly associated with type two diabetes mellitus. Okay. What's this stuff about blurry vision and tingling in his feet? What is that? Suggested the diabetic patients rather not put the Indy, you know? Okay, we'll talk about both of these findings in good detail later on. Okay, um, is retinopathy neuropathy? Is that a microvascular complications or a macrovascular complication of diabetes? Yeah. Microvascular complications. Okay, again, we'll talk about diabetes. Complications like drawings. Well, uh, excellent. Still talk about polyuria. So we have a 34 year old woman presents with polyuria. You know, small. It is low. And plasmas banality slightly high. Had a transfer. Little surgery for acromegaly. One month ago. You were now small. It is unchanged. After what deprivation test. What do you think we're getting? Ah, diabetes, insipidus. Which type is it likely to be in this patient? Which type of diabetes insipidus so crazy? Oh, okay. Send or central. Okay, you call it, But this's like the scenario. Cranial diabetes insipidus. Okay, so we're gonna focus particularly mainly on diabetes mellitus today. Okay, But diabetes insipidus is another important sort of differential for polyuria presentations. And we'll talk briefly about that diabetes insipidus, particularly the investigations for it. But what indicates that this is diabetes insipidus? What if you can pick one line 11 line from this spot diagnosis? What indicate indicates this is diabetes, insipidus. Although I'll tell you Get, um, do is I'd say the big thing is the unchanged water declarations have someone said Okay, so diabetes insipidus, uh, what's the problem? And diabetes and sit. That's what's which. Hormone is not working to its normal function. Yeah, 88. Okay, so anti diuretic coma on so incredible diabetes insipidus. What's happening is there's a lack of production of a th Okay, you're not reabsorbing what? To properly and from your two bills. Okay, so that's even to, uh, polyuria. Okay. Specifically, you're getting production are very diluted urine. Okay, So urine, which has a very low osmolality. Okay, so your nose multi is low. So again, diluted urine. Very suggestive. Diabetes. Insipidus urine osmolality unchanged afterwards. Deprivation test. So we'll talk. About what? The deprivation test later on. But what if the urine osmolality increase after water deprivations? Asked what would that indicate if the urine osmolality increased after water deprivation test? Yeah, well, we can end it indicate it basically indicates that it's not diabetes and syphilis. Okay, if the urine osmolality is increasing after a Walter deprivation test, that basically rules out diabetes insipidus okay, and it could have someone said it could suggest that it's something like primary polydipsia. Okay, where the patients was drank a lot of water. But the other key thing is that the because your nose multi is unchanged after water deprivation test. It's pathological. Again, it suggests diabetes insipidus on the history of transplant surgery for acromegaly one month ago. What is that? What is that indicating here? Walker that indicate? Yeah, damage to the pituitary gland. Okay, so, cranial diabetes is it? This is characterized by a lack of production of a th. Okay. And remember, 80 eight's produced produced from the posterior pituitary. Done. So a patient had a transformational reception for acromegaly. So central complication off surgery is damage to the pituitary gland. Onda. Back of lead to cranial diabetes. Consider this. Okay, school next one, we have a 45 year old woman who presents again with polyuria. Your nose multi is low again. And plasma was gravity is slightly high. Past medical is you have bipolar disorder. You know, those modalities unchanged after the desmopressin administration tests. But I think about this one. Okay. Yeah. Good. So this is still diabetes insipidus. Okay, but this is actually nephrogenic diabetes insipidus. Okay, So there's two types of diabetes. Insipidus. That's cranial diabetes insipidus. And there's an after cardiogenic with cranial diabetes. Insipidus. There's a lot of production of a th the nephrogenic diabetes insipidus. Basically the problems in the kidneys. Okay, the kidneys are responding to the 80 hitch, and that's leading to a lack of water re absorption from the TV tubules. Okay, abscesses be different. So with nephrogenic d I kidneys are not responding to the ADH. Okay, so you're getting the same features? Um, mostly relevance of the past. Medical history of bipolar disorder. Yeah, lithium toxicity. Good. So lithium very strongly associated with causing nephrogenic d I on and last the last time. What about the DESMOPRESSIN administration test? What does that indicate? Yes, I will talk about it. We'll talk about desmopressin administrations. That's a bit okay, but the thing is that the desmopressin is basically 88. Okay? It's a synthetic form of a th. Um So if the urine osmolality increased after doesn't president administration tests that suggests it actually, cranial diabetes insipidus. Because your problem cranial diabetes insipidus is that there's a lack of 88. So when you give desmopressin, your you're replacing the function so it should increase your nose morality. But with nephrogenic d I? Because the kidneys other problem is not going to respond to the desmopressin. So the urine osmolality will remain unchanged. Okay, so Desmopressin administration test is how you differentiate cranial die from nephrogenic be I, uh, last one seven year old boys brought to the emergency departments by his mother for two days of abdominal pain and vomiting has increased thirst, urination, nocturia and weight loss. Onda his respirations deep at 40 minutes. Permit cap refill. Time is prolonged, but he has dry music memories. What do you think? Yeah, yeah, mostly the lot of you're getting. So this is DKA. Okay. This classic picture of diabetic ketoacidosis for a very important acute complication of diabetes. So again, why DKA in particular? So, young child, likely type one diabetic. Okay. History of abdominal pain. Vomiting. Okay. Very diabetic ketoacidosis patients classic symptoms of severe generalized abdominal pain, vomiting, increased thirst, urination, nocturia weight loss, or features off diabetes in general. Okay, but it's much more exaggerated in DKA respirations. Deep at 40 minutes, 45 minutes. What is What's that called in be care? Deep breath creations. Yeah, cause cause my breathing very gets cap refill prolongs a feature off dehydration. Okay. As well as the dry mucous membranes. Okay, so that's a quick rundown of some key differentials of polyuria. Okay, we're gonna talk through all these conditions and a lot more detail that it's a quick side on polyuria history taking. Okay, I'm not gonna go through this. This is I leave it to you guys have a go through, but generally asking about the timeline. Okay. When the policy you started and you want to ask about general features of diabetes, Okay. Like polyuria polydipsia, dehydration, symptoms, polyphagia symptoms. Okay, to have a read when you get the slights. And remember, asked about risk factors for metabolic syndrome, thinking about type two diabetes as well. Um, again, I'm not going to go through this in too much. Okay? I'm kind of hoping you guys have some basic knowledge about diabetes, but in terms of the key differences between type one diabetes, type two diabetes, uh, this slide, basically some rises. This sort of keep oint to think about. Okay. Again. Type one diabetes and type two diabetes General common features is polyuria polydipsia polyphagia okay because of the high levels of glucose type one diabetes, because there's an absolute insulin deficiency. Okay, where cells are being destroyed, DKA is often the first president sensation. Okay, what you're getting because daycare is happening because of an absolute instant efficiency, so be here's a common is usually is often a first presentation, particularly young people, whereas in type two diabetes, because there's usually some instant function remaining. Ah, the risk of DKA is a lot lower in type two diabetes. Okay, because the key thing is that even if you have a little bit of insulin, because insulin, a little bit of insulin is enough to and switch off ketogenesis on stop DKA. Okay, so usually it's a lot rarer in type two diabetics. Competitive one diabetics type one diabetes. Usually it's childhood onset. Type two diabetes happens in a bit older age on steps we lost much more prominent Type one diabetes compared to type two diabetes again Type one diabetes Diabetics doesn't absolute insulin deficiency, so patients are insulin dependent from onset. Okay, they need insulin for the rest of their life. Where is the type two diabetes? Because there's still some incident function remaining. It's not. You don't necessarily stop with insulin, okay? You can manage things with other thing with conservative measures are medications initially, but eventually, patients might eventually become insulin dependence. If they're lysine, it control is very poor. And we both type one diabetes and type two diabetes. They both cannot have a risk off microvascular complications and microvascular complications. Okay, so microvascular complications. We've talked to some of them. So writing up with the neuropathy now from to be okay, microvascular complications. Can you guys list me some microvascular complications? If anyone, if any of the coast and removed the annotations as well be good? Yeah. I was asking about the microvascular complications. Macrovascular complications, not micro. Yeah. Stroke. Okay, So cerebral vascular disease, coronary artery disease on peripheral vascular disease. Okay, we're gonna talk about micro vascular complications because we've we've talked about, you know, things like, uh, coronary artery disease, stroke and other sessions. Again, we'll talk about the peripheral arterial disease during the vascular station in a couple of weeks. Okay, So today, we'll primarily focused on the microvascular complications because that's very community relevant for diabetes patients. Cool. Presenting the history so as usual. This is a general approach for presenting histories. Okay, This is where we like to teach history. Taking at all so easy. Okay. Always follow patient details. What is that? Keeping scenting complaints. Okay, so today I talked to Mr Double Book. It's doubled or 95 year old male presented with features of polyuria. Okay, uh, talk about the history. Presenting complaints. Okay, So stuff you picked up from the sort of open questions you got and focus questions you ask. Okay, Timeline off the POLYURIA. Okay, well, a vin negative. So we talked about this in detail and other sessions, and relevant negatives were talking about, um, peaches that help rule out of the differentials. Okay. Or red flag, peaches that you want to mention. Okay, um, rather than past medical history, social history, dive, drug history. So And if I'm in a type two diabetic patient, you want to mention things like hypertension, high lipids, high cholesterol. Okay, idea that would be relevance to They're presenting complaint. Okay. Remember, it's not about giving the entire history, okay? It's about picking out the most important details on presenting that to the examiner mentioned what the patient's ideas, concerns and expectations are. Talk about what your top different