Endocrine
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| CM complications: chronic hyperglycemia leads to: | nonenzymatic glycation of proteins & produces tissue damage
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| DM dx criteria | 1 of these (A1c ≥6.5% ; FPG ≥ 126 mg/dL; 2 hour GTT ≥ 200 mg/dL (75g load); RPG ≥ 200 mg/dL PLUS DM sx (polyuria, polydipsia, wt loss, blurred vision), w/ confirmation of other criterion on another day (required for first 3)
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| Alert Values: FBS (female) | < 40 and > 400 mg/dL (DUMC = <50 and >350)
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| Prediabetes / IFG lab | FPG 100 - 125 mg/dL
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| Impaired glucose tolerance | 2 hr plasma glucose (75g GTT) 140 – 199 mg/dL
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| Values assoc w/ diabetic retinopathy | FBS 126 mg/dL; 2 hr GTT 200 mg/dL; HgbA1c of 7%
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| Created when proinsulin splits into insulin & this product | C-peptide (connecting peptide)
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| C-peptide: used mostly in: | newly diagnosed diabetics
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| C-peptide: Type 1 diabetes: | decreased levels
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| C-peptide: Type 2 diabetes: | normal or high levels
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| C-peptide: can be used to identify: | gastrinoma spread or malingering (low C-peptide with hypoglycemia may reflect abuse of insulin)
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| Glucose Testing: Venous serum: benefits / reflects | Benefit of independence from hematocrit
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| Glucose Testing: Venous serum: reflects: | reflects tissue glucose
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| Glucose Testing: Capillary: benefits | Rapid, no centrifugation required, home monitoring
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| Glucose Testing: Urine: Requires: | normal renal glucose threshold
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| Random plasma glucose (RPG or RBS): | Any time of day without regard to last meal
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| Fasting blood glucose (FPG or FBS): | No caloric intake for at least 8 hours
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| Oral glucose tolerance testing (OGTT or GTT): | Timed blood draw after oral load of a specific amount of glucose
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| Meds that increase glucose | diuretics, estrogens, beta blockers, corticosteroids
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| Meds that decrease glucose: | acetaminophen, alcohol, propanolol, anabolic steroids
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| Factors affecting Glucose & Glucose Tolerance | Meds; Activity level; stress; Liver dz; Hormonal tumors; Pancreatic disorders; PG
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| Types of stress that increase glucose | trauma, acute illness, general anesthesia, burns
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| O’Sullivan or 1 hour GTT | 50g oral glucose with blood draw in 1 hour (normal < 140 mg/dL)
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| 2 hour GTT | 75g oral glucose with blood draw in 2 hours
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| 3 hour GTT | 100g oral glucose with blood draw just prior to oral load (fasting) and then at 1, 2 & 3 hours
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| 2 hour GTT Interp: FPG (mg/dL) | Normal GTT <100; Impaired Glucose Tolerance 100-125; DM ≥ 126
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| 2 hour GTT Interp: 2 hrs after glucose load | Normal GTT <140; Impaired Glucose Tolerance 140-199; DM ≥ 200
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| 3 hour GTT Interp: Normal | Fasting <95 mg/dL ; 1 hr <180 mg/dL; 2 hr <155 mg/dL; 3 hr <140 mg/dL
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| 3 hour GTT Interp: Abnormal = | 2 or more values above reference range
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| 3 hour GTT Interp: Equivocal = | 1 value above reference range
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| Diabetic control correlates highly with: | pt education & motivation
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| Monitoring Diabetic Ctrl: Urine testing (downside): | Delayed information
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| Monitoring Diabetic Ctrl: Blood glucose testing | Current status; Self-monitoring recommended by ADA; Continuous monitoring systems available
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| Monitoring Diabetic Ctrl: Glycosylated hemoglobin (A1c): upside: | Long term control
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| Monitoring Diabetic Ctrl: Fructosamine | Good for some populations
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| Home Blood Glucose Monitoring: most common = | Fingerstick; Other sites (forearm/thigh) used, but may have 20 min lag time compared to finger
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| Home Blood Glucose Monitoring: Helps guide self mgmt of: | exercise, diet & meds
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| Home Blood Glucose Monitoring: upside: | Improves blood glucose control through immediate patient feedback
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| HbA1c: In normal people: | 3-6% of hemoglobin is glycosylated in the form A1c
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| HbA1c: Provides info: | that spot blood checks may miss; info about LT glycemic ctrl (previous 8-12 wks)
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| HbA1c: Normalizes: | within 3 weeks of normoglycemic levels
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| HbA1c & RBCs: | Older RBCs have higher HbA1c levels; pts w/ episodic or chronic hemolysis who have larger proportion of young RBCs might have spuriously low levels
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| HbA1c monitoring | Does not require fasting; Goal < 7% HbA1c; Lowering by any amount will improve health outcomes
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| If HbA1c if > 7% : | adjust therapy
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| HbA1c: If good DM control: | check HbA1c 1-2 times yearly
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| HbA1c: If suboptimal DM control: | check HbA1c every 3 months
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| Fructosamine = | = glycated albumin or glycated serum protein
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| Fructosamine reflects: | hyperglycemic period within the last few weeks
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| Fructosamine gives info about: | short term glycemic control
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| Fructosamine: useful for: | patients with chronic hemolytic anemias that cause shortened RBC life span; Limited use in pts w/ low serum albumin (nephrotic state or hepatic disease)
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| Fructosamine: Normal values: | vary in relation to serum albumin (1.5-2.4 mmol/L when serum albumin is 5 g/L)
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| Acute Complications of Diabetes | Diabetic coma; DKA
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| Diabetic ketoacidosis = | Pronounced hyperglycemia with insulin deficiency
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| DKA: lab values | Hyperglycemia > 250 mg/dL or glycosuria 4+ ; Acidosis with blood pH < 7.3; Serum bicarb < 15 mEq/L; Serum positive for ketones
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| Screening for Chronic Complications of Diabetes | Ocular comps; Nephropathy; Peripheral neuropathy; CVD (Heart dz; PVD)
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| Pronounced hyperglycemia with insulin deficiency = | DKA
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| DM: Ocular Complications | Retinopathy; Cataracts; Glaucoma; pts w/ DM need an annual ophthalmologic exam
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| Diabetic Retinopathy: microaneurysms = | Small blow-out swellings of blood vessels
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| DM Retinopathy: Exudates = | Small leaks of fluid from damaged blood vessels
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| DM Retinopathy: hemorrhages | Small bleeds from damaged blood vessels
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| DM Retinopathy: Blood vessels: | may become blocked, causing reduced blood & oxygen supply to small sections of the retina; New abnml vessels may grow from damaged vessels (AKA proliferative retinopathy); new vessels are delicate & bleed easily
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| Test for DM Nephropathy: | urine microalbumin
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| Urine microalbumin: more sensitive than: | dipstick protein
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| Urine microalbumin: May use: | albumin:creatinine (A:C) ratio
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| Urine microalbumin: Correlates with: | nocturnal systolic blood pressure
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| Treatment of renal failure due to DM: | renal transplant more promising than dialysis (if patient eligible)
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| Most common complication of DM: | Neuropathy
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| Characterize DM Neuropathy | Distal symmetrical polyneuropathy with loss of motor & sensory function, esp. of long nerves
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| DM Neuropathy clinical features | Painful diabetic neuropathy with hypersensitivity to light touch; Diabetic gastroparesis; Erectile dysfunction
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| Diabetic Foot Ulcer | Painless due to peripheral neuropathy; pt unaware unless vigilant with & able to do self exams; Prone to infection & enlargement
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| Test for Diabetic Foot Ulcer with: | 10g monofilament test ; Comprehensive foot exam
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| Screening for Complications of Diabetes: Eye | Funduscopic exam by optometrist or ophthalmologist for retinopathy
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| Diabetes Screening: USPSTF Guidelines (2008) | No need to screen asymptomatic adults with BP ≤135/80; Should screen adults with HTN (sustained BP >135/80)
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