Diabetes Mellitus

January 29, 2012Cruz, C., Cruz, M., Medieta

OBJECTIVES Identify pertinent findings from the history and physical

examination that would contribute to the diagnosis of diabetic ketoacidosis

Provide a systematic approach in diagnosing patients with

diabetes mellitus and its complications

Learn how to manage patients with diabetes mellitus

Patient Profile

R.E. 28-year-old male Single, Filipino, Roman Catholic From Quezon City Admitted for the first time at

UERMMMCI on June 26, 2012

Patient Profile

Doesn’t drink alcoholic beverages Non-smoker

Chief Complaint

Vomiting few hours PTA

Source and Reliability The patient himself, his sister and

parents with fair reliability

HISTORY OF PRESENT ILLNESS 7 hours prior to admission

7 episodes of vomiting Palpitations Generalized body weakness Increased flatulence No fever, headache, abdominal pain, changes

in BM

Past Medical History Hypertension - 2006

Usual BPs: 80-110/50-80Highest BP - 170/90On Metoprolol 50 mg BID (am, pm)

Diabetes Mellitus Type 1 - 2006On Insulin HN 25 ‘u’ SC ODNo regular follow-up check-up with physician

Past Medical History

Atrophic Kidney (2006) S/P appendectomy at 10 years old

Family History

Hypertension, Diabetes Mellitus and asthma – maternal

Review of SystemsOrgan System

Symptoms

General (-) significant weight loss

Skin (-) lumps, (-) sores, (-) itching, (-) changes in color; (-) changes in hair or nails, (-) changes in size or color of moles

Head (-) headache, (-) head injury, (-) dizziness and (-) light-headedness

Eyes (-) icteric sclerae, (-) pale palpebral conjunctivae

Ears (-) discharge, (-) hearing loss, (-) tinnitus

Nose (-) frequent colds,(-) discharge, (-) itching, (-) nosebleed

Mouth/Throat

(-) dentures, (-) hoarseness,(+) dry oral mucosa, (-) frequent sore throats

Neck (-) swollen glands, (-) no thyroid enlargement, lumps, (-) pain and stiffness

Respiratory (-) cough, (-) hemoptysis, (-) dyspnea, (-) wheezing,

CVS (-) dyspnea, (-) orthopnea, (+) palpitations

GIT (-) dysphagia, (-) nausea, (+) vomiting, (-) melena, (-) jaundice, (-) indigestion, (-) fatty food intolerance, (-) acholic stool, (-) changes in bowel movement

GUS (-) dysuria, (-) polyuria, (-) nocturia; (-) hematuria, (-) retention, (-) bleeding

Organ System

Symptoms

Reproductive

(-) menorrhagia, (-) dyspareunia, (-) PCB

Musculoskeletal

(-) ankle pain, (-) swelling, (-) redness, (-) no history of trauma

Psychiatric (-) nervousness, (-) tension, (-) mood changes, (-) depression, (-) memory change

Neurologic (-) change in sensorium, (-) memory loss

Hematologic (-) pallor, (-) easy bruising or bleeding

Endocrine (-) excessive sweating, (-) excessive thirst or hunger

Review of Systems

PHYSICAL EXAMINATION

Admitting Physical Examination

General Appearance

Awake, conscious, coherent and in distress

Vital Signs BP = 140/100 mmHg; HR = 130 bpm; RR = 18 cpm; Temperature = 36.4C; BMI =

Admitting Physical Examination

Head and Neck

Anicteric sclerae, pink palpebral conjunctivae, dry oral mucosa, breath -fruity smell, no tonsillopharyngeal congestion, no cervical lymphadenopathyOphthalmologic examination:

Admitting Physical Examination

Chest and Lungs

Symmetric chest expansion, no retractions, clear breath sounds

Cardiovascular

Adynamic precordium, tachycardic, regular rhythm, distinct S1 S2, no murmurs appreciated

Admitting Physical Examination

Abdomen Flat, normoactive bowel sounds, soft, severe diffuse abdominal pain, no organomegaly

Extremities

Full and equal pulses,no cyanosis, no edema

Neurologic

Essentially normal with slight difficulty in understanding and answering questions

SALIENT FEATURES

Salient Features 28-year-old male Diabetic and hypertensive Vomiting Palpitations Generalized body weakness Decreased appetite Increased flatulence Dry oral mucosa, breath with fruity smell Severe diffuse abdominal pain No changes in BM

ADMITTINGIMPRESSION

Diabetic Ketoacidosis; DM Type 1, uncontrolled; Hypertension

Salient Features

Diabetic Nausea and vomiting Palpitations Generalized body weakness Decrease in appetite Breath with fruity smell Tachycardia Severe diffuse abdominal pain Difficulty in understanding and

answering questions

Diabetic Ketoacidosis Acute complication Nausea and vomiting Abdominal pain Hyperglycemia Kussmaul respirations and a fruity

odor on the patient’s breath Lethargy and central nervous

system depression

Diabetic Ketoacidosis

Absolute insulin deficiency Counterregulatory hormone

excess Ketosis Metabolic acidosis

CBG

At the ER: 391

Arterial Blood GasPanels (At Room Air) 12.03.11 HD1

pH 7.08

pCO2 15

pO2 135

HCO3 4.04

Base Excess (ECF) -25.6

Oxygen Saturation 98%

Total Carbon Dioxide 4.90

Metabolic acidosis

UrinalysisColor Yellow

Turbidity

Reaction

Specific Gravity 1.030

Protein Negative

Sugar +++RBC 0-1-/hpf

WBC 0-1/hpf

Casts None

Bacteria Rare

Epithelial cells Few

Mucus Threads None

Crystals None

Yeast Cells None

Serum Ketones

Panels 06.26DOA

BUN 19

Creatinine 140

ECC kg 31.43@32kgml/min

Serum Chemistries

Positive

Diabetes Mellitus Diabetes mellitus (DM) comprises a group of

common metabolic disorders that share the phenotype of hyperglycemia

National Kidney Foundation: K/DOQI Guidelines

Diagnosis

Symptoms of diabetes plus random blood glucose concentration >/= 11.1mmol/L (200mg/dL)

Fasting plasma glucose >/= 7.0mmol/L (126mg/dL) or

2-hour plasma glucose >/= 11.1mmol/L (200mg/dL) during an oral glucose tolerance test

Risk Factors:

Family history of diabetes (i.e., parent or sibling with type 2 diabetes)

Obesity (BMI 25 kg/m2)

Habitual physical inactivity Race/ethnicity (e.g., African American, Latino,

Native American, Asian American, Pacific Islander)

Previously identified IFG or IGT History of GDM or delivery of baby

>4 kg (>9 lb)

Risk Factors:

Hypertension (blood pressure 140/90 mmHg)

HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L)

Polycystic ovary syndrome or acanthosis nigricans

History of vascular disease

Diabetes Mellitus Type 1

1A- Autoimmune beta cell distruction which leads to insulin deficiency

1B – develop insulin deficiency by unknown mechanisms and are ketosis prone

Harrison’s Principles of Internal Medicine (17th ed.)

Effects of Insulin:

Diabetes Mellitus

Type 2Variable degrees of insulin resistance,

impaired insulin secretion and increased glucose production

Harrison’s Principles of Internal Medicine (17th ed.)

Diabetes Mellitus Type 2 Risk Factors

Harrison’s Principles of Internal Medicine (17th ed.)

MODY Autosomal dominant Early onset of hyperglycemia Impairment of insulin secretion

Acute Complications of Diabetes Mellitus

Diabetic Ketoacidosis

Chronic Complications of Diabetes Mellitus

Chronic Complications of Diabetes Mellitus

Thank you!