A lady with vomiting. A 23-year-old female student presents to her GP 5 days after returning from a...
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Transcript of A lady with vomiting. A 23-year-old female student presents to her GP 5 days after returning from a...
A lady with vomiting
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.
Initial management
• Fingerprick blood glucose in GP surgery simply reads "high" on meter.
How would you manage her?
How would you manage her?
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.
What tests would you arrange and what might you expect to find?
What tests would you arrange and what might you expect to find?
• ABG
• UE
• Blood glucose
• CXR
• ECG
Initial treatment I
• Her tests confirm that she is acidotic (pH 7.03) and blood glucose is 46 mM.
How would you manage her now?
How would you manage her now?
• Fluids
• Insulin
• Potassium replacement as necessary
• Ng tube
• ?ITU
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.
What do you do now?
Next step
• After 48 hours of intravenous insulin, her urinary ketones have cleared completely and she is eating and drinking.
monitoring
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.
Change over
• The medical team has decided that the patient is stable enough to be changed over to a sub-cutaneous insulin regime.
How long before stopping the insulin infusion should the first sub-cutaneous insulin dose be given?
She asks you about the long-term implications for her health of
developing diabetes.
Long term complications
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
retinopathy
ischaemic heart disease
Diabetic Nephropathy
An insidious clinical syndrome characterised by persistent albuminuria, elevated blood
pressure and , if left untreated ,a relentless decline in GFR
What is diabetic nephropathy ?
20 40 12010060 80
Kidney
function
age
Kidney function and age
100%Diabetic kidney
disease
Detected and treated
trouble
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
- 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
Lewis, E. J. et al. N Engl J Med 1993;329:1456-1462
ACE inhibitors and diabetic nephropathy
Cumulative incidence in patients with DN
What is glycosylated haemoglobin
betaalpha
haemoglobin
betaalpha
haemoglobin
betaalpha
haemoglobin
HbA1C
HbA1CHbA
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
DCCTThe Diabetes Control and Complications Trial
1993
Retinopathy in Patients with Type 1 DM Receiving Intensive or Conventional Therapy-
9.1%
7.2%