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100 clinical cases and osces in medicine pdf

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There is great need for a textbook of clinical medicine for the use of medical students Clinical Cases in Obstetrics and Gynaecology. Pages·· Clinical Cases And OSCEs In Medicine By David R. McCluskey. Reviewing makes you better. That claims? Many sensible words claim that by reading, your . Get Free Read & Download Files Clinical Cases And Osces In Medicine PDF . CLINICAL CASES AND OSCES IN MEDICINE. Download: Clinical.

Anyone taking thyroxine surreptitiously or being prescribed an excessive dose for the treatment of hypothyroidism may also present in this way. Immunology 6th Ed. The first-line antihypertensive agent in a person with diabetes and proteinuria should be an inhibitor of the renin—angiotensin system. The lung involvement can progress to fibrosis. The principal risk is that having one osteoporotic fracture is a strong risk for future fractures. Prompt initiation of steroids.

What issues need to be addressed apart from blood glucose control? CASE 1. A fasting plasma glucose level has been reported by the laboratory to be 8. A year-old woman presents to the surgery with lethargy. She has been profoundly thirsty and noticing blurring of her vision. Treatment with clotrimazole leads to a short amelioration of symptoms.

A year-old woman who has always been fit and well visits you shortly after her honeymoon. A finger-prick test in the surgery shows a blood glucose level of Arrangements are made for a repeat blood test after an overnight fast. A year-old man is found to have glycosuria on urine testing as part of a new patient assessment.

He asks your advice about driving.

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He has previously driven heavy goods vehicles and is keen to return to work. A couple of years after diagnosis. He is discharged on twicedaily insulin and after 6 weeks has established reasonable diabetic control with no hypoglycaemia. He is keen to reduce his medication and wants to know if the diabetes is disappearing.

He is treated with diet and subsequently oral agents. He loses weight and his glucose levels fall to such an extent that he is experiencing frequent hypoglycaemia. Diagnosis should never be made on the basis of glycosuria or stick testing of a finger-prick blood glucose alone although these may be useful for screening. Impaired glucose tolerance IGT is defined by a formal glucose tolerance test as a 2-h plasma glucose of 7. If symptoms are present i.

If symptoms are not present. Although this has been widely welcomed in the UK. This should lead to assessment of vascular risk factors and yearly screening of fasting plasma glucose. A fasting plasma glucose of 6. More recently. Diagnosis 5 Key concepts To work through the core clinical cases in this chapter. Given the provisional diagnosis of IFG. The patient should be quizzed about typical symptoms. Assuming that diabetes is not subsequently diagnosed by an OGTT.

Even in the presence of symptoms. Recommended levels of exercise are regular moderate physical activity for sedentary individuals and 30 min on 5 days a week for people who already take some moderate activity. A diagnosis of IGT increases the future risk of type 2 diabetes. Neither IFG nor IGT imparts any risk of specific small vessel complications and glycosuria related to a low renal threshold for glucose is a benign condition.

The advice on diet is also appropriate for the treatment of diabetes i. The detection of glycosuria has led to two tests to investigate the possibility of diabetes. The cardiovascular system should be examined for evidence of large vessel disease e. This may confirm a diagnosis of: It is assumed that IFG carries similar prognoses. Patients with IGT would be followed annually by means of a fasting plasma glucose level.

This patient has IFG because his fasting plasma glucose is in the range 6. The patient should be taught how to monitor the impact of these changes by testing their blood fingerprick testing. HbA1c as a baseline for future comparison. Regular screening at least yearly should be performed for diabetic retinopathy. In the UK most patients with type 2 diabetes are given a period of non-pharmacological management. Aspirin is not currently considered appropriate in this scenario.

The patient is at risk of both small vessel and large vessel disease. Blood pressure and lipids should be monitored and treated if necessary. She should be questioned for other symptoms of hyperglycaemia polyuria. The benefits of regular exercise should be stressed where appropriate. Current advice in the United States would lead to the immediate use of metformin alongside these lifestyle modifications.

There should also be a thorough examination of the cardiovascular system. Dietary advice. The diagnosis is already confirmed and additional tests are not necessary. Diagnosis 7 A6: Cardiovascular risk factors need to be addressed. In this case. These conservative measures are usually continued for at least 3 months. A family history should be elicited along with a drug history to exclude the use of diabetogenic drugs e.

For small vessel complications. Other cardiovascular risk factors include the following. Most clinicians would request a measure of long-term glycaemic control e. One might expect there to have been a short duration of symptoms days to weeks.

Clinical Guideline Patients will need to be taught how to monitor blood glucose using finger-prick tests and to understand the concepts of hypo. Blood should be taken for a laboratory plasma glucose. Autoantibodies e.

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Dietary advice will be needed and appropriate targets for blood glucose levels agreed. Frequent contact over the early days and weeks after diagnosis will be essential. Answers to further questions will probably support this view but should not dissuade you from it.

Insulin levels. They will also need to be shown how to test blood or urine for ketones and understand the significance of these. Near-patient plasma ketone testing is now available and should be performed to exclude diabetic ketoacidosis DKA and to inform the patient of this possibility as part of their initial education. Assessment should focus on the conscious level and circulatory state of the patient because she could easily be acidotic. If the patient is fit. In the absence of ketonuria.

The patient needs to be treated with insulin and so should be in a setting where the necessary expertise is available in the UK. This diagnosis is based on the age of the patient and the presence of ketones in the urine.

No laboratory confirmation is necessary. A baseline level of glycaemic control would usually be requested HbA1c and a screen for associated autoimmune disease especially thyroid function may be checked. A strong family history of early-onset type 2 diabetes affecting siblings. In a typical case of type 1 diabetes. The minority of patients who go on to develop diabetic nephropathy which usually manifests clinically after 15—25 years of disease are prone to premature cardiovascular disease and are more susceptible to the other small vessel complications.

Of a higher priority are matters that may have an immediate impact. Patients should also be aware that rapid lowering of blood glucose level can induce these symptoms. The first of these is hypoglycaemia. Diagnosis 9 A5: By virtue of her younger age at onset. This patient should be given counselling about future pregnancy exemplary diabetic control is necessary in the periconception period to reduce the risk of fetal abnormality and driving.

The risks of specific diabetic complications and large vessel disease can be dealt with over the following months and years. The continued autoimmune b-cell destruction ultimately means that insulin will be required. Note that regulations are changing at the time of going to print and readers are advised to avail themselves of the most recent DVLA guidance from its website.

By strict adherence to diet and regular exercise. Regarding his group 1 motor car and motor cycle licence. Pancreas transplantation is becoming a feasible option in type 1 diabetes but is typically limited to patients with advanced complications. Glucose levels tend to rise with age. In the case presented. The prospect for a cure of diabetes is some way off in type 2 diabetes but may be possible for type 1 diabetes.

These may allow for patients treated with insulin to drive LGVs but with frequent monitoring and regular specialist review. He should also advise his insurance company of his change in health status.

There are the same provisos regarding visual complications. This is certainly the case as far as medical and insurance matters are concerned. If the use of insulin is temporary. Licences are split into two groups groups 1 and 2.

Licences are granted for This patient should be advised to notify the DVLA that he is taking insulin and that.

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People with type 1 diabetes may go through a period in the weeks to months after diagnosis where insulin can be withheld. This applies to both oral agents and insulin in patients with type 2 diabetes. Recent advances in islet cell transplantation have allowed patients to become independent of insulin for more than 2 years. On examination. A year-old man has recently been diagnosed with type 2 diabetes. She is symptomatic with lethargy.

He denies any symptoms and has previously refused to consider insulin. What are the treatment options? What factors influence the choice of therapy? What would be the preferred choice of treatment?

How would the impact of treatment be assessed? What are the potential complications? What issues need to be addressed when the patient has fully recovered? A year-old man with type 2 diabetes is currently treated with gliclazide mg twice a day and metformin mg three times a day. A fit year-old woman with type 2 diabetes had been started on metformin after strict dietary adherence failed to control her symptoms.

Her blood pressure is normal. There is early peripheral neuropathy and foot pulses are absent. He is known to have hypertension and takes bendroflumethiazide 5 mg once a day.

He has normal visual acuity but fundal photography shows hard exudates encroaching on the left macula. He claims good dietary adherence but is overweight kg.

He is mildly symptomatic with lethargy. Does this mean that I will never need go on to injections? Can I try an insulin pump instead? If metformin is ineffective or not tolerated. Metformin is the first-line agent.

In the UK. Their major side effect is nausea. Like the gliptins. This means that diet and then tablet and injectable therapies will ultimately fail and.

This regimen has the advantages of simplicity but is ultimately doomed to fail with patients needing fast-acting insulin to prevent postprandial hyperglycaemia. Pioglitazone also increases the risk of bone fracture and may be associated with a small increase in bladder cancer.

As sulphonylureas act by increasing endogenous insulin secretion. Gliclazide is the most commonly prescribed sulphonylurea in the UK. In patients who do not achieve target with metformin and a sulphonylurea. This can either involve the addition of three pre-meal injections a standard basal bolus regimen or a change to two pre-meal injections of premixed insulin. Pioglitazone often induces weight gain and can cause oedema. The target would be a HbA1c level below 7.

Gliptins can be used with insulin but GLP-1 injections are currently unlicensed for this combination. NICE suggests an initial target below 6. Unless the patient is very symptomatic or glucose levels are particularly high. Insulin can be added to oral therapy. Before the initiation of insulin.

This also has the advantage that patients can stop taking many tablets. The options include pioglitazone. There are various ways of starting insulin in type 2 diabetes. These third-line agents do not induce hypoglycaemia but their side effects differ. The loss of b-cell function is a progressive disorder and is not modified by commonly used hypoglycaemic therapies although more modern agents may have this benefit.

The gliptins are weight-neutral and have a placebo-like side-effect profile. Glucose control for patients with diabetes mellitus 13 Key concepts To work through the core clinical cases in this chapter. If the target is not achieved.

They also induce weight loss in a significant number of patients. These side effects are less pronounced if the dose is increased slowly. More modern preparations of this and other sulphonylureas allow for single daily dosing. The firstline agent would be metformin. The treatment options are wide and include the following: On the other hand. The bendroflumethiazide could be stopped and replaced with an ACE inhibitor.

HBGM will provide immediate feedback to the patient on which aspects of the diet worsen his glucose levels and can be seen to be an essential aspect of patient empowerment. The patient should be made aware of the symptoms of hyperglycaemia and should make contact if these worsen. He currently takes a high-dose thiazide diuretic. The technical options to assess the glycaemic response are near-patient usually self- testing of blood glucose and laboratory testing HbA1c levels. This patient is said to have type 2 diabetes.

A reasonable course of action would be to advise on diet see answer A4 to Case 1. His symptoms are mild. Assuming that he does not become more symptomatic.

HbA1c also allows for targets to be set. HbA1c levels provide a long-term indication of glycaemic control typically quoted to be 2—3 months and. Home blood glucose monitoring is commonly taught to patients in this scenario. Unless a patient or the clinician is going to manipulate therapy based only on the results of HBGM and this is unlikely to be the case here. The choice of therapy is influenced by factors including the level of symptoms.

Do not forget that a change in blood pressure therapy means that blood pressure monitoring will need to be performed on a monthly basis and. Although a dietary assessment is reasonable and should be performed as part of the annual diabetes review.

Her current dose of metformin is not at the maximum recommended. Symptomatic improvement is the main aim of therapy. In this setting. Given her age. Type 2 diabetes is a progressive disease and so failure of diet and then oral monotherapy to control her symptoms should be anticipated and not attributed to failure on the part of the patient.

Note that the possibility of diabetic foot complications does not influence the treatment choices. If UTI is confirmed by urine culture.

HbA1c testing could also be performed for comparison with the pretreatment level. If the patient remains symptomatic and her HbA1c remains very high.

The treatment options include: Given that the patient is already performing HBGM. The reduction achieved with any of these therapies is likely to be the same. Glucose control for patients with diabetes mellitus 15 CASE 1. UK guidelines suggest a sulphonylurea as second-line. Options include a gliptin. Although hyperglycaemia causes lethargy and frequency.

Both can cause nausea and vomiting. Although he is not on maximal doses of metformin. This will allow him to see how simple the procedure can be and if. Exenatide can be prescribed as a twice-daily or once-weekly preparation. Given the risk of weight gain.

Clearly the patient is not keen to go on insulin and the reasons for this need to be explored. Symptomatic improvement he may recognize and admit to symptoms in retrospect. He should also monitor his weight.

A dietary assessment is reasonable because weight gain is highly likely with insulin. UK guidelines suggest their impact on glycaemic control and weight should be assessed after 6 months. The choice of therapy is influenced by the natural history of the condition.

Twice-daily insulin using fixed mixtures before breakfast and evening meal is a simple regimen that may seem less daunting than basal bolus where the patient injects fast-acting insulin before each meal and a night-time injection of long-acting insulin.

The progressive nature of type 2 diabetes is such that almost all patients will end up on insulin if they survive for long enough. Insulin thus becomes a leading option. Suggest to the patient that he tries insulin for a period. Addition of pioglitazone or a gliptin triple therapy is an alternative but is often a disappointing combination in this type of scenario. HbA1c will be the ultimate assessment with a lower target 7. If a GLP-1 receptor agonist is preferred by the patient many people hate the idea of insulin.

Insulin resistance. There are also preliminary data that gliptins and GLP-1 agents can slow the progression of b-cell dysfunction. The pump is a small device and can easily be carried in a belt or holster. CSII are available in the UK but this is not a good reason for using one because the amount of finger-prick testing is typically increased.

As a result of b-cell failure. The exception to this rule of progressive glycaemic deterioration may be patients who are obese at diagnosis and manage to lose vast amounts of weight.

Maturity-onset diabetes is the old term for non-insulin-dependent diabetes. Type 2 diabetes is not currently regarded as an indication for pump use. NICE has advised that pump therapy can be made available to people with type 1 diabetes where multiple insulin dose therapy has failed to achieve good glycaemic control.

One can argue that if an individual with type 2 diabetes lives for long enough. This can be used as a justification for early exposure to the use of insulin handling injection devices. Ultimately these agents will fail and the patient may need insulin to achieve reasonable glycaemic control. The natural history of this condition has been convincingly demonstrated and is one of progressive deterioration in blood glucose control.

In addition. The use of an insulin pump involves the insertion of a cannula into the subcutaneous tissue. This is felt to reflect progressive loss of b-cell function over time. He takes no other medication and has had no treatment for complications. What questions would you ask the patient and why? What investigations would you request? What are the differential diagnoses related to diabetes?

He was diagnosed at age 12 years. A year-old man with type 1 diabetes has joined your practice. There has been no pain or redness affecting his eyes and he has not had headaches. The symptoms are worse at night when he is in bed. A year-old man is diagnosed with type 2 diabetes by his local optometrist. Discomfort in his hand often disturbs his sleep.

His diabetic control is poor but stable. There is no discomfort in his feet during the day and his exercise tolerance has been unaffected. Having attended the clinic regularly as a child. Is this true? The diabetes annual review aims to detect diabetes complications at an early stage and institute therapy before there has been irreversible damage e.

There is crossover between the small and large vessel complications — e. Long-term complications of diabetes are traditionally divided into diabetes-specific small vessel complications meaning that only patients with diabetes are at risk and diabetes-non-specific large vessel complications increased risk in diabetes but not limited to patients with diabetes.

Diabetic small vessel complications 21 Key concepts To work through the core clinical cases in this chapter. The small vessel complications are: During periods of poor glycaemic control e.

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Visual acuity should be tested. Note that patients may be unaware of the extent of loss of vision if the good eye compensates. Although his attendance at clinic has been sporadic. Changes in vision related to poor glycaemic control usually enhanced long vision and difficulty reading may affect both eyes and can be variable over short periods.

In the vast majority of cases. The symptoms are usually slow in progression but patients may report abrupt changes. Digital images may also be requested. He should be asked about symptoms of UTI e. Symptoms of cataract progression include halos around bright lights.

This will allow detection of a cataract by examination of the red reflex and also detection of retinal abnormalities by direct visualization. Maculopathy may give either a slow or a sudden loss of vision in one eye. A family history of hypertension and ischaemic heart disease are also more common in patients at risk of diabetic nephropathy. Blood should be sent for HbA1c to assess glycaemic control.

Autonomic neuropathy rare may also be present. Blood pressure should be repeated after a period of rest and then follow-up arrangements for more blood pressure checks over the next 2—3 months to establish whether there is a persistent elevation. Nerve conduction studies will confirm a diagnosis of both peripheral diabetic neuropathy and carpal tunnel syndrome. The feet should be examined for evidence of peripheral neuropathy and reduced circulation.

If diabetic nephropathy is confirmed. Excessive use of the hands e. Bloods to exclude hypothyroidism and vitamin B12 deficiency more common with metformin treatment should also be requested. Given the association of carpal tunnel syndrome with myxoedema.

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They are most useful in the latter. Haematuria is not typical of diabetic nephropathy and so renal ultrasonography should be arranged to exclude other causes rare in this setting. People with type 1 diabetes and diabetic nephropathy are at high risk of other complications. Diabetic small vessel complications 23 A2: A midstream urine specimen should be sent for culture to exclude a UTI. Carpal tunnel syndrome is common at night.

Coexisting diabetic retinopathy is almost inevitable and so arrangements for dilated fundoscopy should be made. Peripheral neuropathy symptoms to which burning dysaesthesiae may be added are of gradual onset.

It may be associated with loss or change of sensation in the hand. If UTI is excluded. In addition to the albuminuria. Peripheral pulses should be examined. Examination of the feet for abnormal sensation using monofilaments and vibration sensation as screening tools can be done. Ulceration painless should be excluded and skin care assessed. In advanced cases. In carpal tunnel syndrome there may be sensory loss over the palmar aspects of the first three and a half fingers and wasting of the thenar eminence.

There may appear to be a paradox in that diabetes is now the most common cause of end-stage renal failure in the western world and renal dialysis as a result of diabetes is becoming more frequent. Specialist foot care treatment and advice should be given. This has led to a risk categorization with varying levels of input. This is likely to represent a genetic predisposition to diabetic nephropathy. In type 2 diabetes. Normal feet low risk — all newly diagnosed patients should receive basic foot health advice and subsequently be reviewed on an annual basis.

There should be easy access to a shoe-fitter. Foot care advice should be given and the need for vascular assessment reviewed. This relates. The level of resource directed towards diabetic foot care should be dictated by the individual needs. Continued improvements in blood pressure. Taking the example of type 1 diabetes. This assessment can be carried out by a doctor. He has no significant medical history apart from diabetes and he does not smoke.

She takes gliclazide 80 mg twice a day. Are further assessments required before the italicized finding provokes a drug intervention? If drug therapy were indicated. She has a history of angina. A year-old woman with type 2 diabetes is under regular review. He takes metformin 1 g twice a day and has an HbA1c level of 7. A random total cholesterol is 5. Blood pressure recordings over the previous 6 months have shown similar levels. What sort of follow-up is indicated? What other issues need to be addressed with regard to cardiovascular risk?

Random total cholesterol is 5. A random total cholesterol is 4. A year-old man with type 2 diabetes has a new person check in primary care. She has minimal background diabetic retinopathy and slightly diminished sensation in her feet.

She injects insulin using a basal bolus regimen and does not smoke. Some studies suggest that IGT carries a similar cardiovascular prognosis to overt type 2 diabetes. Diabetic large vessel complications 29 Key concepts To work through the core clinical cases in this chapter.

There is a focus on coronary heart disease prevention both primary and secondary in diabetes management. This is in stark contrast to the major impact of blood pressure and lipid control on cardiovascular outcomes in patients with type 2 diabetes. Microalbuminuria screening is also recommended in this context as a marker of early vascular disease. People with diabetes get the same large vessel disease as people who do not have diabetes.

This implies that glucose control is not the dominant issue and is consistent with the limited impact of glycaemic control in many studies. Simvastatin should be prescribed. There is currently no evidence that fibrates produce cardiovascular benefits in patients with diabetes. If the lipid targets are not achieved with this dose. Liver function tests LFTs and creatine kinase should be checked before initiation of statin treatment but probably do not need to be checked again.

The evidence that improving blood glucose control and reducing weight would have a major impact on coronary heart disease risk in this case is weak.

Total cholesterol is not altered by recent food intake unlike triglycerides. Patients should be aware of the risk of muscle pains. For most patients. In contrast. An electrocardiogram ECG may be helpful because evidence of left ventricular hypertrophy would imply long-standing hypertension.

At the same time. Issues include whether fasting lipids are required. Most clinicians would. Lipids should be repeated after 3 months of treatment and.

The total cholesterol warrants consideration in terms of primary prevention of cardiovascular disease. One needs to give consideration to glycaemic control. Patients on ACE inhibitors and angiotensin II receptor blocker should have renal function and electrolytes checked at regular intervals every 6 months because renal function can deteriorate at any time.

An interim target blood pressure of mmHg is appropriate. Screening for microalbuminuria in patients with type 1 diabetes is part of the diabetes annual review. It aims to detect the early stage of diabetic nephropathy before the onset of dipstick-positive proteinuria.

This would typically be an ACE inhibitor. Diabetic large vessel complications 31 minimum of three recordings over a 3-month period would be appropriate. The first-line antihypertensive agent in a person with diabetes and proteinuria should be an inhibitor of the renin—angiotensin system. The literature strongly supports reduction of her systolic pressure using drugs to a target of less than mmHg.

Further attention to weight. Aspirin is not currently recommended at this stage. This patient with diabetes. Attention to glycaemic control. A typical second-line agent in this case would be a calcium channel blocker or a low-dose diuretic. Once stabilized. The effect of drug therapy may take 2 months to become apparent. In either case. Additional tests are required if the dose of ACE inhibitor or angiotensin II receptor blocker is increased. For a substantial proportion of people with diabetes.

No treatment should be instituted on the basis of this one-off finding. In this age group there is no evidence to support the use of long-term lipid-lowering therapy or aspirin. Urinary albumin excretion rates are highly variable.

Once a definitive diagnosis has been made. If microalbuminuria is confirmed. The test should be performed on a first-voided urine sample and. A further consideration in this case. This person has no evidence of coronary heart disease and she is currently normotensive. If a diagnosis of persistent microalbuminuria is made and the patient opted to take an ACE inhibitor. The issue surrounds the validity of this screening result. In well-controlled patients. This is definitely the case if the repeat urine tests are negative.

Evidence supports the use of ACE inhibitors to delay the progression of microalbuminuria towards diabetic nephropathy. Patients with this complication have increased premature morbidity and mortality as a result of end-stage renal failure.

Apart from advice on keeping her weight under control and taking regular exercise. Diabetic nephropathy is a clinical syndrome of persistent proteinuria. Patients with known coronary heart disease should receive secondary prevention with aspirin prescribed at a dose of mg once daily. Added to this is the tendency for blood pressure to rise with age and obesity. This advice.

All of the major classes of antihypertensive agent can be used in patients with diabetes and raised blood pressure. For patients with no evidence of coronary heart disease. Current guidelines support the use of ACE inhibitors as first-line in diabetes. This difficulty is made worse by the lowering of target levels. A previously well year-old woman presents to the general practice surgery with a h history of abdominal pain and vomiting. The diabetes is treated with four injections of insulin a day and his control is regarded as excellent.

What is the likely diagnosis? What investigations would be performed? How would the diagnosis be confirmed? An year-old man who is known to have type 1 diabetes is found unconscious in his front garden. On direct questioning. His regular medication is bendroflumethiazide 5 mg once a day. He had been noted to be lethargic over the previous few weeks and had been incontinent of urine on a couple of occasions. Vital signs are normal but he is clinically dehydrated.

A year-old man has been found collapsed at home by a care assistant. He was previously independent but known to have hypertension.

He had been playing football earlier in the day but had not complained of symptoms at that time. Key concepts To work through the core clinical cases in this chapter, you will need to understand the following key concepts. Patients usually experience warning symptoms and signs of hypoglycaemia, which prompt them to take treatment in the form of glucose. These are often listed as adrenergic related to autonomic nervous system and neuroglycopenic brain hypoglycaemia ; however, in reality patients will have warnings that are a combination of the two.

Hyperglycaemic coma may be a presenting feature of diabetes or the result of intercurrent illness, manipulation of insulin usually DKA or concomitant medication HONK.

In many cases, the cause remains unknown. Symptoms include lethargy, thirst, polydipsia, polyuria, nocturia, blurred vision and diminished conscious level, although unconsciousness is uncommon below 5 per cent. Patients with DKA hyperventilate as a result of the acidosis and have sweet-smelling ketones on their breath.

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They may also have mildly raised plasma glucose levels, so the severity of their condition should not be judged on this measure. Abdominal pain, masquerading as an acute abdomen, is frequently present. In HONK, patients are severely dehydrated and glucose levels are always very high. The prognosis in HONK is poor as a result of the concomitant illnesses coronary heart disease, renal disease, cardiovascular disease seen in this usually elderly cohort. The likely diagnosis is hyperosmolar non-ketotic coma, which usually affects older people with type 2 diabetes and can be the presenting feature as in this case.

Precipitating causes include concurrent medication, including thiazide diuretics, and intercurrent illness a UTI being possible in this scenario.

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Extremely high plasma glucose levels may be seen, as in this case. Hyperglycaemia has already been demonstrated. Plasma ketones should be within normal limits, and there should be no acidosis confirmed by ABGs or venous bicarbonate. Attention to airways, breathing and circulation, as necessary. Gain intravenous access and set up an intravenous infusion. Cardiac monitor. Treatment should then be given with intravenous insulin and intravenous fluids while monitoring electrolytes Box 1.

The prognosis for HONK remains poor 20—30 per cent.

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Patients are at high risk of thromboembolism and congestive cardiac failure as a result of the fluid regimen. As a result of age and comorbidity, ischaemic heart disease, renal failure and stroke are common. Aspiration of gastric contents may occur in the setting of reduced consciousness. Monitor glucose every hour using meter and laboratory testing. Continue insulin infusion for at least 2 h.

Despite the level of presenting glycaemia, management of the diabetes often does not involve insulin and some patients manage on diet only. The patient needs to be given dietary advice and specific diabetes education on issues such as monitoring and foot care. This would usually involve the specialist diabetes nurse and a dietitian.

Other aspects of cardiovascular risk need to be assessed and, in this case, blood pressure medication may be changed from a high-dose thiazide to an ACE inhibitor. The likely diagnosis is diabetic ketoacidosis. This is an emergency complication of type 1 diabetes and can be the presenting feature, as in this scenario.

Precipitating causes include intercurrent illness e. UTI and withholding insulin in an established case of type 1 diabetes. Abdominal pain and vomiting are common and can lead to the erroneous diagnosis of an acute abdomen.

Note that the hyperglycaemia is often not pronounced. The patient should be admitted to hospital. Intravenous access should be established for blood tests and infusion, and a cardiac monitor attached. The prognosis for DKA should be good, given that it affects young people who rarely have other significant comorbidities.

Cerebral oedema may occur during treatment, although the cause of this complication is unknown. The diagnosis of DKA implies that the patient has type 1 diabetes and will require life-long insulin. She will therefore need to be educated about the condition, and taught to inject insulin and how to.

Continue insulin infusion for at least 24 h and no urinary ketones. She will need to be given information about the immediate complications of her condition hypoglycaemia, DKA and advised to avoid pregnancy until good glycaemic control is achieved. Ultimately she will need to understand the long-term risks of small and large vessel disease.

These issues are best addressed by a diabetes nurse specialist and a formal education programme. The likely diagnosis is hypoglycaemia. As a general rule, an unconscious person with diabetes is hypoglycaemic until proved otherwise. This diagnosis is very likely in an otherwise fit young person who takes insulin. Precipitating factors in this case may be the exercise earlier in the day the effects of exercise can last for many hours and tight glycaemic control, which may provoke hypoglycaemia unawareness.

Treatment can be initiated without any investigation and before the hypoglycaemia has been confirmed indeed, a satisfactory response to treatment will itself confirm the diagnosis. Finger-prick blood glucose testing will confirm a low blood glucose level.

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In an unconscious patient the two main options are administration of glucagon or intravenous dextrose. Glucagon may be available because patients with type 1 diabetes are encouraged to keep a supply for this type of emergency. It comes as a powder that must be dissolved in water a vial of sterile water is part of the kit.

Patients can suffer injury if they have lost their warnings of hypoglycaemia. In older patients, hypoglycaemia may present with neurological signs typical of stroke. There is increasing evidence to implicate frequent hypoglycaemia as a risk factor for cardiovascular disease.

With regard to the treatments, intravenous dextrose can cause phlebitis and glucagon is associated with nausea and vomiting. You need to find out the cause of the event too much insulin, too much exercise or too little food and then provide education to prevent future recurrence.

In this case, the active issues would be manipulation of the treatment regimen to be able to cope with exercise and possibly a relaxing of glycaemic control to reduce the risk of hypoglycaemia and decrease hypoglycaemia unawareness. Patients will understandably be concerned that they may become hypoglycaemic by taking insulin without food. The patient should perform more frequent finger-prick testing, at least every 4 hours.

This will allow detection of hypoglycaemia; if, as is likely, glucose levels rise, additional insulin rapid acting may then be needed. For patients with type 1 diabetes, vomiting should raise the possibility of DKA and urine ketones should be checked at least twice a day. Near-patient plasma ketone testing is now more frequently performed by patients with type 1 diabetes, and they should be educated on the levels that may need medical intervention.

In young people with type 1 diabetes, dehydration can develop very quickly and a low threshold for seeking medical advice should be promoted. Patients should be aware of the actions to take during illness and how to access appropriate advice probably not NHS Direct.

This will mean telephone numbers of the diabetes specialist nurse team and agreed guidelines for out-of-hours management of diabetes emergencies. It is vital that the partner of a person with diabetes is aware of the symptoms and signs of hypoglycaemia and is able to take appropriate action. There is little to be lost by instituting treatment without confirmation of the diagnosis, however.

Assuming the patient is alert, this involves taking food by mouth, usually in the form of glucose tablets: Patients with diabetes should always carry some form of glucose replacement; Dextrosol tablets are recommended because they are less palatable than sweets and so less likely to be consumed as treats.

A longer-acting carbohydrate such as bread or biscuits should then be consumed. If the patient is semiconscious, a glucose gel can be administered via the buccal membrane. Glucostop is a glucose gel supplied in a plastic bottle with a nozzle.

The gel can be squeezed into the mouth between the teeth and cheek and is absorbed into the circulation without the need for swallowing. If the patient is unconscious, he or she should be placed into the recovery position.

These typically apply to type 2 diabetes. The diagnosis of type 1 diabetes, if suspected, should never be delayed by requesting investigations such as a glucose tolerance test or HbA1c, which may take days to be reported. A diagnosis of diabetes should never be casually applied to a patient, since it is likely that this can never be erased from their medical record and will have a major impact on their insurance premiums e.

This shows the importance of laboratory testing rather than near-patient testing in type 2 diabetes. Diabetes has major implications for driving, the authorities being particularly interested in hypoglycaemia and the presence of complications such as retinopathy and peripheral neuropathy.

The regulations are constantly changing, and readers should refer to the relevant website for the latest situation for their country. Targets for glycaemic control, typically measured by HbA1c, should be tailored according to the circumstances of the individual, bearing in mind the downsides of treatment hypoglycaemia, weight gain. There are several therapeutic options that may be used to lower blood glucose currently seven classes.

The choice will be guided by considerations of cost, safety, efficacy and patient preference. Cost pressures have had a major impact on national guidelines, such as those of NICE. Small vessel, diabetes-specific complications affect the eyes, feet and kidneys. Large vessel complications, affecting the coronary, cerebral and peripheral arteries, are more common in people with diabetes, and hence there are aggressive blood pressure and lipid targets.

The impact of tight glycaemic control, especially in people with established large vessel disease, is a controversial topic. An unconscious person with diabetes should always be suspected of being hypoglycaemic. In a person with diabetes who has abdominal pain and vomiting, diabetic ketoacidosis should be excluded. Although pleased about the weight loss. Her partner has insisted that she seek a medical opinion.

What do you think the likely diagnosis is? What tests could you do to confirm this? What tests would help establish the cause? What is the initial management? CASE 2. Patients often find that their short-term memory is impaired. Proximal myopathy weakness of the thigh and arm muscles makes their muscles ache and. Skin changes are rare. Their clinical courses are usually independent and unpredictable. If present. In addition to sore eyes. In all patients with hyperthyroidism even if iatrogenic.

Increased exposure of the cornea and conjunctiva leads to grittiness and soreness of the eyes. Fertility is reduced. Hyperthyroidism 47 Key concepts To work through the core clinical cases in this section.

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