a lady with vomiting. a 23-year-old female student presents to her gp 5 days after returning from a...
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A lady with vomiting
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A 23-year-old female student presents to her GP 5 days after returning from a ski holiday. She developed what she thought was a stomach upset while away, but this failed to settle and she now has increasing nausea and recurrent
vomiting.
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Initial management
• Fingerprick blood glucose in GP surgery simply reads "high" on meter.
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How would you manage her?
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How would you manage her?
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Investigations
• She has arrived in the emergency assessment unit and you are the first doctor to see her. You confirm the history as above and a nurse checks a fingerprick blood glucose for you which simply reads “high” on the meter. She looks unwell and is slightly drowsy and breathing rapidly.
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What tests would you arrange and what might you expect to find?
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What tests would you arrange and what might you expect to find?
• ABG
• UE
• Blood glucose
• CXR
• ECG
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Initial treatment I
• Her tests confirm that she is acidotic (pH 7.03) and blood glucose is 46 mM.
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How would you manage her now?
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How would you manage her now?
• Fluids
• Insulin
• Potassium replacement as necessary
• Ng tube
• ?ITU
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Initial treatment II
• After 12 hours of iv insulin and fluids, she looks and feels better. Her acidosis has resolved and her blood glucose has fallen to 8 mM.
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What do you do now?
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Next step
• After 48 hours of intravenous insulin, her urinary ketones have cleared completely and she is eating and drinking.
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monitoring
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Prescribing
• Sometimes when diabetic patients in hospital are unwell or are nil by mouth for medical procedures or operations, they are prescribed 'sliding scale' insulin.
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Change over
• The medical team has decided that the patient is stable enough to be changed over to a sub-cutaneous insulin regime.
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How long before stopping the insulin infusion should the first sub-cutaneous insulin dose be given?
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She asks you about the long-term implications for her health of
developing diabetes.
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Long term complications
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large blood vessels
small blood vessels
TIA
stroke
angina
myocardial infarction
heart failure
peripheral vascular
disease
diabetic retinopathy
diabetic nephropathy
erectile dysfunction
autonomic neuropathy
peripheral neuropathy
Systems affected by diabetes
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retinopathy
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ischaemic heart disease
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Diabetic Nephropathy
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An insidious clinical syndrome characterised by persistent albuminuria, elevated blood
pressure and , if left untreated ,a relentless decline in GFR
What is diabetic nephropathy ?
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20 40 12010060 80
Kidney
function
age
Kidney function and age
100%Diabetic kidney
disease
Detected and treated
trouble
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GOOD NEWS
#1 onset and course of diabetic nephropathy
can be ameliorated to a very significant degree
by interventions
#2 these interventions have their greatest impact
if instituted early on in the course of the condition
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- the condition is important
- there is treatment
- facilities for diagnosis/ treatment exist - there is a recognised early stage
- there is a suitable test
- the test is acceptable to the population
- interveniton is cost effective
#2 Screening
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Lewis, E. J. et al. N Engl J Med 1993;329:1456-1462
ACE inhibitors and diabetic nephropathy
Cumulative incidence in patients with DN
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What is glycosylated haemoglobin
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betaalpha
haemoglobin
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betaalpha
haemoglobin
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betaalpha
haemoglobin
HbA1C
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HbA1CHbA
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HbA1C (%)
Average Blood Sugar (mmol/L)
5 4.5
6 6.7
7 8.3
8 10.0
9 11.6
10 13.3
11 15.0
12 16.7
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DCCTThe Diabetes Control and Complications Trial
1993
Retinopathy in Patients with Type 1 DM Receiving Intensive or Conventional Therapy-
9.1%
7.2%