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what percentage of the united states has diabetes?
10.5%
what percentage of diabetics in the united states didn’t know they had diabetes?
21.4%
what percentage of diabetics in the united states are over 65?
36.8%
what is the normal process of glucose control?
when blood sugar is low, glucagon is released from pancreatic alpha cells & triggers liver to release stored glycogen into glucose
glucose is transported to target cells
when blood sugar is high, insulin is released from pancreatic beta cels & drives glucose into the cells, therefore lowering blood sugar
what is the pathophysiology of type 1 diabetes?
autoimmune process caused by genetic & environmental factors that causes a lack of insulin production
what is the pathophysiology of type 2 diabetes?
insulin resistance, defects at cell membrane, & beta cell failure cause insulin production to decrease
what are the clinical manifestations of diabetes? (include specific ones for type 1 & 2)
polyuria, polydipsia, polyphagia, fatigue
type 1 - weight loss
type 2 - poor wound healing, cardiovascular disease, renal insufficiency, recurring infection
how is diabetes diagnosed?
ha1c (average BG over 6 to 8 weeks) - greater than 6.5
fasting plasma glucose (BG after no caloric intake for 8 hours) - greater than 126
2 hour postprandial glucose - greater than 200
random plasma glucose - greater than 200
**can be elevated with recent carb restrictions, illness, medications, & bed rest
what are some rapid-acting insulins?
humalog, lispro, novolog, & aspart
what is the onset, peak, & duration of rapid-acting insulins?
onset - 10 to 30 min
peak - 30 to 90 min
duration - 3 to 5 hr
what are some short-acting insulins?
regular humulin, novolin
what is the onset, peak, & duration of short-acting insulins?
onset - 30 to 60 min
peak - 2 to 5 hr
duration - 5 to 8 hr
what are some intermediate-acting insulins?
nph
what is the onset, peak, & duration of intermediate-acting insulins?
onset - 1 to 2 hr
peak - 4 to 12 hr
duration - 18 to 24 hr
what are some long-acting insulins?
lantus, glargine, levemir
what is the onset, peak, & duration of long-acting insulins?
onset - 1 to 2 hr
peak - none
duration - 20 to 24 hr
what are some treatments for hypoglycemia?
oral - 15 to 20 g glucose (juice, soda, bread, crackers)
IV - 25 to 50 mL D50
IM - 1 mg glucagon
what are some complications of type 1 diabetes?
hypoglycemia (BG less than 65), which causes SNS & CNS compensation
DKA (body gets energy from fat & releases glucagon & cortisol, which lowers pH & causes electrolyte imbalances)
dawn phenomenon (increased BG in the morning due to growth hormone, glucagon, & cortisol release)
somogyi effect (increased BG in the morning due to excessive insulin at bedtime)
what are some complications of type 2 diabetes?
metabolic syndrome (increased triglycerides & LDLs & HTN)
decreased immune response
vascular disease
neuropathy
how do you manage type 1 diabetes?
treatment - insulin, isotonic fluids
considerations - vitals, i/o, BG, potassium
how do you manage type 2 diabetes?
treatment - oral medications (increase insulin, lower insulin resistance, & slow reabsorption of carbs)
considerations - BG, diet, exercise, weight loss, carb intake, alcohol restriction
what are some self-care strategies for diabetes?
infection control - hygiene, dental visits, foot care
weight loss - diet, exercise, medications
travel - carry snacks & medical id, walk every 2 hours to prevent DVT
what are some complications of gastric bypass surgery?
short term - DVT, pressure ulcer, infections
long term - band slippage, obstruction, hernia, vitamin deficiency, anemia, dumping syndrome
what are some risk factors for metabolic syndrome?
obesity, HTN, smoking, hypercholesterolemia
how do you manage metabolic syndrome?
reduce cholesterol, smoking cessation, lower BP, reduce BG
how do you manage obesity?
diet - reduction of 500 to 1000 calories/day, loss of 1 to 2 lb/week
exercise - 30 min/day of moderate intensity
behavioral therapy - food logs, social support
medication - phentermine, lorcaserin, orlistat (Xenical)
surgery - gastric bypass, gastric banding, sleeve gastrectomy
what are some dietary considerations for a patient with a cardiac disorder?
decreased saturated fats & cholesterol
increased complex carbs
fat intake as 25-35% of total calories
increase omega 3s
high fiber
DASH - grains, veggies, fruits, nuts, dried fruit, lean meats, dairies
what is included in the history assessment of the GI system?
dietary practices, nutrition, preventative health, weight changes, appetite changes, stool changes, pain
what is included in the physical assessment of the GI system?
inspection - hernia (bulging masses), aneurysm (pulsatile masses), jaundice, cullen’s sign, hemorrhoids
auscultation - bowel sounds
percussion - tympany (gas), dullness (fluid, constipation)
palpation - peritonitis (rigid, pain, guarding), mass
what do hypoactive bowel sounds indicate?
ileus, constipation
what do hyperactive bowel sounds indicate?
ileus, diarrhea, IBD
what do bruits indicate in the GI system?
arterial obstruction
what are some diagnostic studies for the GI system & what do they correlate to?
h/h - blood loss
cbc - blood loss, infection
cmp - liver, electrolytes, creatinine
pt/inr - clotting
ua - kidney infection
occult blood - GI bleed
amylase/lipase - pancreatitis
gastric analysis - pH, h. pylori, GI bleed
LFTs (AST/ALT) - increased with alcohol, statins, & Tylenol
KUB x-ray
ultrasound
endoscopy
barium study (**contraindicated if perforation is suspected)
what are some age-related changes of the GI system?
slowing function, dysphagia, loss of appetite, constipation, incontinence
what is stomatitis?
painful inflammation of the oral mucosa
primary - ulcer, canker sore, herpes
secondary - decreased immune response from chemo & radiation
what are the clinical manifestations of stomatitis?
dry, red, cracked mucosa; mouth ulcers; open/bleeding sores; pain
how do you manage stomatitis?
salt rinses q4, topical analgesics, moisturizers, antifungals (for thrush), antivirals, lidocaine
what are some complications of stomatitis?
dysphagia, xerostomia
what is a hiatal hernia?
portion of the stomach protruding through LES into the esophagus
sliding - due to trauma, genetics, or anatomy
rolling - due to anatomical deficit
what are the clinical manifestations of a hiatal hernia?
sliding - heartburn, regurgitation, chest pain, dysphagia, belching
rolling - fullness & breathlessness after eating, suffocation, angina worsened with laying down
what are some complications of a hiatal hernia?
sliding - GERD
rolling - obstruction, incarcerations, volvulus, iron deficiency anemia
how is a hiatal hernia diagnosed?
upper abdominal x-ray, endoscopy, barium swallow, EGD
how do you manage a hiatal hernia?
smaller, frequent meals, elevate HOB after eating, weight loss
medication - antacids, PPIs, H2 blockers
surgery - nissen fundoplication (**gold standard)
what is gastroesophageal reflux disease (GERD)?
acid reflux from the stomach into the esophagus, causing inflammation
how is GERD diagnosed?
pH monitoring, esophageal motility testing, EGD, barium swallow
what are the clinical manifestations of GERD?
heartburn, wheezing, coughing, dyspnea, sore throat, lump in throat, choking, regurgitation
what are some complications of GERD?
airway spasms, bronchitis, pneumonia, esophagitis (ulceration/scar tissue), esophageal stricture, barrett’s esophagus (metaplasia)
how do you manage GERD?
antacids, PPIs, H2 blockers, prokinetics
what is the difference between lefort 1, 2, & 3 with oral trauma?
1 - mandible
2 - mandible, orbital
3 - mandible, orbital, temporal
how do you diagnose oral trauma?
blood cell count, serum chemistry analysis, ABG, x-ray, CT/MRI
what are the clinical manifestations of oral trauma?
increased RR, stridor, SOB, decreased O2, tachycardia, changes in LOC, bleeding, swelling, edema, loss of teeth, pain
what are some complications of oral trauma?
short term - airway compromise, aspiration of teeth, infection, inadequate nutrition, cerebrospinal leak (meningitis)
long term - pain, TMJ, disfigurement
how do you manage oral trauma?
establish & maintain airway, control bleeding, prophylactic antibiotic
how is esophageal cancer classified?
squamous cell carcinoma - upper 2/3 of esophagus
adenocarcinoma - lower 1/3 of esophagus
how do you diagnose esophageal cancer?
barium swallow, CT, PET, endoscopic ultrasonography, thoracoscopy, laparoscopy
what are the clinical manifestations of esophageal cancer?
progressive dysphagia, inability to eat, unintentional weight loss
how do you manage esophageal cancer?
yoga, meditation, spirituality, religion, nutrition
surgery - esophagectomy (interventions: parenteral fluids, NG, high calorie/protein, upright position, observe for leakage, IS, infection prevention)
how do you diagnose gastritis?
x-ray, endoscopy, histological exam, fecal occult blood test, biopsy, CBC, B12
what are the clinical manifestations of gastritis?
epigastric pain, weight loss, decreased appetite, blood in stool or emesis, dehydration, hypovolemic shock
how do you manage gastritis?
fluid replacement, smoking cessation, pain management, removal of cause, vitals, i/o, cbc, cmp, monitor for blood, decrease use of NSAIDs
medication - H2 blockers, PPIs, antacids, sucralfate, antibiotics, B12
surgery - vagotomy, gastrectomy, pyloroplasty
diet - NPO to clear liquids; bland foods; no caffeine; small, frequent meals
what does epigastric pain indicate?
gastritis, duodenal ulcer
what are the clinical manifestations of gastroenteritis?
anorexia, distention, dehydration, electrolyte imbalance, hyperactive bowels, hypotension, dry mucus membranes
how do you diagnose gastroenteritis?
history, stool culture, PCR
how do you manage gastroenteritis?
fluid replacement, antidiarrheals, pepto-bismol, antiemetics, antibiotics
diet - NPO to clear liquids; bland foods; no caffeine or milk; small, frequent sips of fluid
what is peptic ulcer disease?
erosion & ulceration of GI mucosa from hydrochloric acid & pepsin
for what condition is it common to have no symptoms?
peptic ulcer disease (due to lack of sensory fibers; silent ulcers are common in elderly & with NSAIDs)
what are the clinical manifestations of peptic ulcer disease?
gastric ulcer - burning, gassy, worse after meals, not relieved by antacids
duodenal ulcer - burning, epigastric pain, worse when fasting, relieved by antacids
what are some complications of peptic ulcer disease?
hemorrhage, penetration, perforation, adenocarcinoma, obstruction
how do you diagnose peptic ulcer disease?
biopsy (H. pylori), endoscopy, barium swallow, CBC, liver enzymes, serum amylase, stool examination
how do you manage peptic ulcer disease?
rest, smoking cessation, fluid/blood replacement, pain management
medication - antacids, PPIs, H2 blockers, sucralfate, misoprostol (**not in pregnancy)
surgery - endoscopy, vagotomy (to reduce acid production), pyloroplasty (widening of stomach opening), gastrectomy
diet - bland food; avoid eating within 2 hr of bedtime; avoid spicy food, caffeine, & alcohol
what are the clinical manifestations of gastric cancer?
heartburn, abdominal pain, feeling full, back pain, anorexia
advanced - iron deficiency anemia, palpable mass, enlarged lymph nodes, weakness, fatigue, weight loss, metastasis
what does back pain indicate?
gastric cancer
how do you diagnose gastric cancer?
upper GI endoscopy, barium swallow, biopsy, CT, CBC
how do you manage gastric cancer?
chemo, radiation, surgery, antiemetics, opioids, vitamins, NG
what is a hernia?
protrusion of abdominal contents due to weakened abdominal wall
what are some risk factors for hernias?
obesity, smoking, malnutrition, pregnancy, wound tension, medications, heavy lifting, abdominal surgery, straining
how do you diagnose a hernia?
physical exam, herniography with contrast, CT/MRI
what are the clinical manifestations of a hernia?
strangulation, pain, vomiting, distention, fever, tachycardia
how do you manage a hernia?
surgery - herniorrhaphy (to fix hernia), hernioplasty (to fix hernia & add mesh), temporary colostomy, binder
**surgery is immediately required to prevent gangrene
what is a hemorrhoid?
swollen vein in anorectal area that can be internal or external
how do you diagnose a hemorrhoid?
external - inspection
internal - digital exam, anoscope, sigmoidoscopy
what are the clinical manifestations of a hemorrhoid?
pain, pruritis, bleeding, prolapse
what are some complications of hemorrhoids?
infection, pain, urinary retention, impaction, sphincter damage, bleeding, abscess
how do you manage a hemorrhoid?
surgery - ligation, bipolar/infrared/laser coagulation, sclerotherapy, cryosurgery, hemorrhoidectomy
what are the clinical manifestations of irritable bowel syndrome?
pain improved with defecation; loose, frequent stools; distention; mucus; sensation of incomplete evacuation; fatigue; headache; sleep disturbances
what are some complications of IBS?
psychosocial effects, isolation, malabsorption
how do you manage IBS?
nutrition diary, high fiber, stress reduction, ginger, antidiarrheals, imodium, avoid trigger foods, smoking cessation
what is irritable bowel disease a combination of?
crohn’s & ulcerative colitis
what are some triggers of IBD?
infection, medication, smoking
what does crohn’s disease affect?
mouth to anus
what does ulcerative colitis affect?
large intestines & mucosa
what are the clinical manifestations of IBD?
diarrhea, cramps, fever, weight loss, fluid/nutrition imbalance, anemia, delayed growth, mouth ulcers, rectal bleeding, skin/joint/eye irritation
how do you diagnose IBD?
CBC, CRP
how do you manage IBD?
rest; perianal care; small, frequent meals; alleviate stress
diet - avoid chocolate, milk, caffeine, citrus, & alcohol
medication - antimicrobials (Cipro), glucocorticoids (dexamethasone, budesonide), antidiarrheals (Lomotil, Imodium)
what is narcotic bowel sydrome?
narcotic-induced constipation
what are the clinical manifestations of narcotic bowel syndrome?
chronic, intermittent cramping; abdominal pain
how do you manage narcotic bowel syndrome?
wean off narcotics, antidepressants, fluids, treat withdrawal
what is short bowel syndrome?
100 cm or more is removed in a bowel resection, affecting absorption
what are the clinical manifestations of short bowel syndrome?
diarrhea, steatorrhea
how do you manage short bowel syndrome?
fluid/electrolytes, nutrition, PPIs, opioids, antidiarrheals
diet - high carb, low fat, fiber, small meals, TPN