Done by:Ayana - sara qhatani – sara dhahry – elham

Lama – alaa – kholud - eilaf

Objective• At the end of this session, students will be able to:• Identify differential diagnosis of a case presented with the symptoms of

polyuria and polydipsia.• Identify the prevalence of diabetes mellitus (DM) in the Saudi community.• Discuss the classification of DM .• Discuss briefly about the diagnostic criteria for DM.• Identify the patho-physiological changes in a diabetic patient. • Enumerate and discuss the importance presenting signs & symptoms of DM.• Investigate appropriately a patient with DM.• Advice initial management plan for a patient diagnosed first with DM.• Discuss different medication used in DM management .• Identify importance of life style changes in diabetic patients.• Discuss screening criteria for DM.

Case Study• A 25-year-old man, who works as a clerk in a company, has

presented to the clinic today with the complaint of increased thirst, and increased urination . These complaints initiated for last few weeks. He admitted that he was in Makkah for Omra and started to have these symptoms, but he assumed that these symptoms were due to hard works and running from here to there in Makkah. But he is worried that the symptoms are continuing even he is back home and having usual sedentary life.

• He also complaint of generalized weakness, otherwise on other complaint. He is not known to have any other chronic illness.

• On examination:• Look well. His height is 160 cm and his weight is 98 kg. • Systematic examination revealed normal findings, apart from being obese.

Differential diagnosis of a case presented with the symptoms of poluria and

polydipsia

DM DI Psychological Polydipsia

check blood check ADH ask about sugar level level water intake

NEED TO BE TESTED

Diabetes Insipidus:

It is a condition characterized by excessive thirst and polyuria secondary to deficiency of ADH (cranial DI) or kidney does not respond to ADH (nephrogenic DI).

- No hyperglycemia or glucose in urine in case of diabetes insipidus.

Diabetes mellitus: causes poluria via a process called osmotic diuresis due to the high blood sugar leaking into the urine and taking excess water along with it.

DM MORE LIKELY

Pt complain of poluria ,polydipsia ,weakness have 2 risk factor : obesity & sedentary lifestyle

DM more common than DI.

DI LESS LIKELY

Pt Systematic examination is normal

usually come with other symptom ( dehydration, fever , vomiting ,diarrhea)

DI less common than DM

is a group of metabolic disorders characterized by hyperglycemia and abnormalities in carbohydrate ,

fat, and protein metabolism. It results from defects in insulin secretion, insulin sensitivity, or both .

points to be included in history taking

1 )C .O: How can I help you ?

2 )HPI: When did the symptoms start ?

Associated symptoms?e.g. loss of appetite , decrease vision

3 )Past medical history:Social Hx:

Occupation, education , smoking , alcohol , marital state , living condition. Family Hx:

Dm , hypertension , Tb , asthma Any other diseases? Surgical Hx .

MAIN THINGS

1 _family history of DM

2 _sex and age

3 _life style include diet & physical activity.

4 _Symptoms & when did they start .

5 _complication

prevalence of (DM) in the KSA

Study of WHO in 2004: 23.7%

From Ann Saudi Med. 2011 Jan:

Age

12_19

20_29

30_39

40_49

50_59

60_69

Above 70

Male

1,1%

4,4%

14,3%

29,9%

60,2%

71,8%

%65,7

Female

%2,6

%4,7

%10,8

%33

57,1%

64,9%

61,7 %

WHEN IS DMSUSPECTED

Non classic presentations

Infection

Skin (carbuncle

s)Urinary

tract infection

Ear infection (fungal)

No Infection

PruritusFatigueVisual

symptomsSensory

symptomsDelayed healing

Classic presentation

PolyuriaPolydipsiaPolyphagiaWeight loss

Hyperglycemic crisis

account for 5% to 10% of all cases.

Occur in childhood or early adulthood.

develops when the body’s immune system destroys pancreatic beta cells, causing absolute insulin deficiency.

Risk factors for type 1 diabetes may include autoimmune, genetic, and environmental factors.

There is a long preclinical period (up to 9 to 13 years) marked by the presence of immune markers.

Hyperglycemia occurs when 80% to 90% of β- cells are destroyed.

Individuals with type 1 DM are often thin and are prone to develop diabetic ketoacidosis if insulin is withheld or under conditions of severe stress.

LADA

Latent Autoimmune Diabetes in Adults (LADA) is a form of autoimmune (type 1 diabetes) which is diagnosed in individuals who are older than the usual age of onset of type 1 diabetes ( > 25

year ) .

Often, patients with LADA are mistakenly thought to have type 2 diabetes, based on their age at the time of diagnosis

MODY

caused by mutations in a number of different genes defects of insulin secretion.

Occur in late childhood, adolescence, or early adulthood.

diagnosis of MODY is based on presence of: - non-ketotic hyperglycemia

in conjunction with a family history of diabetes. -

DM accounts for as many as 90% of DM cases

This is the most common form of diabetes mellitus and is highly associated with a family history of diabetes, older age, obesity and lack of exercise, history of gestational diabetes, impaired glucose metabolism.

It usually begins as insulin resistance, where the cells do not use insulin properly .

As the need for insulin rises, the pancreas gradually loses its ability to produce insulin.

Form of glucose intolerance diagnosed in pregnant women.

occurs more frequently among African Americans, obese women and women with a family history of diabetes.

requires treatment >>> normalize maternal blood glucose levels to avoid complications in the fetus.

Women who had GDM have a 20% to 50% chance of developing diabetes

Other specific types of DM

Uncommon causes of diabetes (1% to 2% of cases) include:

- Endocrine disorders (e.g. acromegaly, Cushing’s (syndrome

-Exocrine pancreas (e.g. pancreatitis)

-medications (e.g. glucocorticoids, pentamidine, niacin, and α- interferon).

DiagnosisInvestigation

Urine test: - Detect glucose - Detect proteinuria - For ketone determination - For Pregnant diabetic woman to check adequate nutrition and glycemic control

Pre- diabetic It’s a state of abnormal glucose homeostasis characterized by the presence of impaired FPG, GTT , or both.

It is often described as the “gray area”

between normal blood sugar and diabetic levels

Diagnosed by:

1 )signs or symptoms: 2) lab investigation

- Constant hunger . - FPG 100-125 mg/dl

- Blurred vision. - 2hPG 140-199 mg/dl

-weakness. - HbA1c 5.7-6.4 %

- Unexplained weight loss .

important clinically because :

When lifestyle changes such as -eating healthy foods

-physical activity in daily routine -maintaining a healthy weight

may be able to bring your blood sugar level back to normal and prevent development DM 2.

important lab investigation for a patient who is presenting with DM as follow up:

HbA1c at least twice a year in patients meeting treatment goals on a stable therapeutic regimen.

Screening for DM

Screening for type 2 DM should be performed every 3 years beginning at the age of 45.

But considered at an earlier age and more frequently in individuals with risk factors.

Pregnant women should be assessed for GDM at their first prenatal visit and proceed with glucose testing if at high risk.

The recommended screening test is:

fasting plasma glucose (FPG) Normal FPG is less than 100 mg/dL

Or less than (5.6 mmol/L).

Treatment

Initial Treatment

• Advice on diet and exercise recommendations for people with diabetes.

• Check for risk factor : stop smoking. blood pressure control. cholesterol-lowering.

Type 1

Regular insulin given subcutaneously, requiring injection 30 minutes prior to meals.

Lispro, aspart, and glulisine insulins have shorter durations of action than regular insulin, injection 10 minutes prior to meals.

Neutral protamine hagedorn (NPH) is intermediate-acting. contribute to a labile glucose response, nocturnal hypoglycemia, and fasting hyperglycemia.

Glargine and Detemir are long-acting “peakless” human insulin analogs that result in less nocturnal hypoglycemia than NPH insulin when given at bedtime

Type 2

Symptomatic patients may initially require insulin or combination oral therapy to reduce glucose toxicity (which may reduce β-cell insulin secretion and worsen insulin resistance).

Sulfonylureas : stimulating insulin secretion.

Meglitinides : stimulating insulin secretion in presence of glucose.

Biguanides (metformin) : enhances insulin sensitivity of both hepatic and peripheral (muscle) tissues.

Thiazolidinediones (Glitazones) : enhance insulin sensitivity in muscle, liver, and fat tissues indirectly. Insulin must be present in significant quantities for these actions to occur.

Insulin for patient who doesn't maintain good control of blood sugar with drugs.

Life style modification

studies included people with IGT and other high-risk characteristics for developing diabetes.

They found that lifestyle changes can prevent or delay the onset of type 2 diabetes among high-risk adults.

In the Diabetes Prevention Program, a large prevention study of people at high risk for diabetes, the development of diabetes was

reduced 58% over 3 years.

Complication & How to prevent it

The major organs and body systems involved in diabetes complications are the:

eyeskidneysnervesheart and blood vessels

gums

Eye Problems:Cataracts, Retinopathy, glucoma

To prevent: Keep blood pressure and blood sugar levels in check.

make sure the eyes are examined on the schedule prescribed by the doctor

Kidney Disease (Diabetic Nephropathy)High blood sugar can damage the blood vessels in the kidneys.

To preventmaintain good blood sugar control by following

the diabetes treatment plan .regular blood pressure and urine albumin tests checks up.

Nerve Damage (Diabetic Neuropathy)can involve nerves in many different parts of the body. The most common early symptoms are numbness, tingling, or sharp pains in the feet or lower legs.

To preventcontrolling blood sugar levels with diet, exercise, and diabetes medications will help reduce risk.

Heart and Blood Vessel Diseasesheart attack ,stroke and blockage of blood vessels in the legs and feet, which can lead to foot ulcers.

To preventmaintain a healthy weight .

check blood lipid and blood pressure regularly to be sure they're in a healthy range.

Reference

-Kumar & Clark's Clinical Medicine (Saunders, 2009).

-Pharmacotherapy: A Pathophysiologic Approach, 8th Edition [Joseph DiPiro]

-Davidson's Principles and Practice of Medicine