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REGUB Medicine: T1DM (ii) (DKA (risk factors (T1DM, poor nutrition,…
REGUB Medicine: T1DM (ii)
Microvasc comps
retinopathy
background
in 70-90% over a long duration
dot + blot haemorrhages
microaneurysms
exudates
cotton wool spots (localised retinal infarcts causing interruption in axoplasmic transfer through retinal ganglion cells)
may not progress, can regress with good control
visually acuity usually normal @ this stage
pre-prolif
ischaemia occurring
dot aneurysms (hypercellular saccular outpouchings of capill wall)
blot haemorrhages (vasc occlusion)
cotton wool spots (retinal N fibre infarcts due to ischaemia)
hard exudates (lipid + protein, due to excessive vasc permeability)
venous beading
prolif
new vessels @ disc vs new vessels everywhere (neovascularisation)
new vessels fragile + prone to rupture - significant haemorrhage
fibrosis
scar tissue
majority progress to no perception of light in 5 yrs due to vitreous haemorrhage + tractional detachment of retina
Tx: focal laser photocoagulation
retinal burns will be visible after (black spot scars)
retinal pigmentation + atrophy
target = inhibit VEGF
Advanced
vitreous haemorrhage
tractional (due to scar tissue) retinal detachment
rubeosis iridis
neovascularisation of iris
painful
can cause hyphema (blood in ant chamber) + neovasc glaucoma (dramatic increase in intraocular pressure which can lead to severe + permanent visual loss)
neuropathy
motor
sensory
mixed (sensorimotor) - peripheral polyneuropathy
compression neuropathy - carpel tunnel (type of entrapment syndrome)
cranial N palsies - focal neuropathies aka mononeuritis multiplex
autonomic neuropathy
restrictive tachycardia
postural hypotension
bowel dysfunction (diarrhoea/constipation)
arrhythmia
bladder dysfunction
impotence
glove + stocking = most common: burning/tingling, starts distal, spreads proximal
small fibre neuropathies cause contractors (shorthand tendons, claw foot deformity aka hammer toe. Due to improper weight-bearing - increased pressure on metatarsal heads - more susceptible to trauma - ulcers)
NB correct shoes, padded socks, orthotics - reduce risk of amputation
if an ulcer hard skin (calyces) around it its due to high pressure joints
80% of LL amputations preceded by ulcers
50% of amputations in Ire due to DM
Charcot foot
rare
neuroarthropathic joint
excessive inflamm - triggers osteoclasts - increased bone resorption - weakened bones prone to collapse (e.g. arch)
patient can't feel pain so continues to walk on it
nephropathy
natural hx: hyperglyc - increased GFR - microalbuminuria - frak proteinuria (takes 5-10 yrs)
next: decreased GFR - nephrotic syndrome - ESRD (30-40% progress to this over approx 15 yrs, can be slowed with good control
dipstick not for screening (doesn't detect microalbuminuria)
screening - early morning spot urine corrected for creatinine - ACR (albumin-creatinine ratio)
2.5+ mg/mmol in males
3.5+ mg/mmol in females
Macrovasc comps
CAD
cerebrovasc disease
PAD
ACEi in diabetic renal disease
1st line for HTN + normotensive microalbuminuria in T1
In DM afferent art to glom is bigger than efferent - high pressure - glom BM damage
ACE dilates both arts equally
SEs
cough (if this happens switch to ARBs)
angioedema (lips, tongue)
hypercalc
teratogenicity
DKA
life threatening hyperglycaemic comp of DM
may be 1st presentation
higher mortality in elderly
3 dx criteria
ketonaemia > 3mmol/L or significant ketonuria (>2 on standard urine sticks)
blood glucose > 11 or known DM
bicarb < 11mmol/L +/or venous pH<7.3
risk factors
T1DM
poor nutrition
missed/inadequate insulin
sepsis
trauma
surgery
corticosteroid use
illicit substance use
symptoms
polyuria
polydipsia
weight loss
lethargy
N+V
abdo pain
muscle cramps
signs
tachypnoea + Kussmaul's breathing
ketotic breath
neuro signs (reduced GCA, confusion, seizures, coma)
vol depletion (decreased skin turgor, dry mucous membranes, tachycardia, low JVP, hypotension, oliguria)
absent bowel sounds
management
correction of vol deficits
IV insulin
K monitoring/replacement
acidosis correction
IV antibiotics as per hosp guidelines