Exam

Diabetes Overview

Focus on typical diabetics (Type 1 and Type 2).

Excludes VKA (Diabetic Ketoacidosis) and HHS (Hyperglycemic Hyperosmolar State).

Important History Gathering Questions

Recognize symptoms of hypoglycemia and hyperglycemia.

Frequency of hyper/hypoglycemic episodes.

Patient's specific glucose thresholds for symptoms (e.g., feeling symptoms at 70, 80, or 90).

Individual Variation in Symptoms

Symptoms vary by patient; for example:

• Type 1 diabetic may feel sick at 50 if used to higher blood sugars.
• Type 2 diabetic who runs high may feel extremely sick at 150.

Three P’s of Diabetes

Polyuria: Frequent urination (e.g., many visits to the bathroom).

Polydipsia: Excessive thirst, especially at high blood sugars.

Polyphagia: Extreme hunger, body craving glucose.

Laboratory Assessments

A1C Test: Measures average blood sugar over the past 3 months.

• Goal is under 7, ideally under 6.

Fingerstick Blood Glucose (FBG): Immediate blood sugar level check.

• Continuous Glucose Monitors (CGMs) offer continuous monitoring.

Challenges for Patients

Pain of repeated finger pricks can lead to noncompliance with monitoring.

Importance of access to resources (e.g., social services) to support patient compliance.

Diabetes and Kidney Health

Diabetics are at risk for kidney damage due to high glucose levels damaging renal perfusion and function.

Importance of regular assessments of kidney function.

Surgical Considerations for Diabetics

Risk of poor healing and complications such as hypo/hyperglycemia during fasting before procedures.

Type 1 diabetics are at higher risk due to more extreme sugar fluctuations.

Complications from Alcohol Use

Alcohol can lead to lactic acidosis in patients on metformin, which is harmful to the kidney.

Caution is advised for patients using metformin, especially around surgical procedures and IV contrast.

Hyperglycemic Hyperosmolar State (HHS)

Defined as severe hyperglycemia without ketones, resulting from dehydration.

Medical emergency requiring urgent treatment (blood sugars often over 600).

Common in elderly or undiagnosed patients, typically occurring with Type 2 diabetes.

Signs and Symptoms of HHS

Confusion, altered consciousness, severe dehydration, respiratory distress.

Risk of chronic complications like renal issues and potential for multi-organ failure.

Interventions for HHS

Initial admin of normal saline, then hypotonic fluids as needed.

Close monitoring of electrolytes, especially sodium and potassium, during treatment.

Insulin therapy may be indicated, prescribed as a continuous infusion.

Diabetic Ketoacidosis (DKA)

More common in Type 1, precipitated by noncompliance, illness, or infection.

Features enduring high blood sugars, metabolic acidosis, and ketone production.

Identifying DKA

Patients may present with the three P’s, fruity breath, abdominal pain, and severe dehydration.

Level of consciousness monitoring is critical; trends toward confusion or lethargy indicate severe status.

Laboratory Diagnosis for DKA

• Blood glucose over 250, positive ketones in blood and urine, and ABGs indicating metabolic acidosis.

Dosing and Treatment for DKA

IV fluids and continuous monitoring of electrolytes and glucose are crucial.

Insulin administration requirements must adjust based on glucose levels and signs of ketosis diminishing.

Education for Diabetic Patients

• Importance of regular hydration (at least 2 liters per day) and increased during illness.
• Emphasis on recognizing symptoms of high and low blood sugar and seeking help when necessary.
• Teaching sick day rules and adherence to medication guidelines.