1DDX: LECTURE 49 – APRIL 18TH, 2007

DIABETES MELLITUS

HYPOGLYCEMIA (INSULIN SHOCK)

Drug-induced: Symptoms in hypoglycemia: from stimulation of sympathetic nervous system (adregenergic). Can be from
too much insulin: brain and nervous system react.
Non-drug related: Fasting hypoglycemia: from exercise or Reactive/Post-prandial: provoked by a meal
Symptoms are adrenergic: shaking, sweating and palpitations, secondary to catecholamine release. All are related to
adrenaline.
As sugar drops further, get neuroglycopenic symptoms: Confusion, irritability, headaches, abnormal behaviour, weakness,
diplopia, inappropriate affect,
Nocturnal hypoglycemia: Occurs more commonly in insulin-dependent individuals. People usually wake up with this
(despite what is says in the

What do you see in a patient experiencing ketoacidosis? Increased respiration rate because the respiratory system is
trying to balance out the metabolic acidosis: this will make you more alkaline than acidic. Will smell sweet in room. BP
will be low: they have had polyphagia, polydypsia… they have lost fluid.

Profound hyperglycemia and ketoacidosis is found in usually found in TYPE I only: because type 2 diabetics have enough
insulin so that they aren’t put into ketoacidosis. Can happen in type 2, but usually the result of stress or trauma.

In children, Ketoacidosis: presents differently: they will have abdominal pain and elevated WBC (not sure why), so it is
often misdiagnosed.

Different comas: know the symptoms and understand the symptoms. Be able to DDX. What do you do? Eg. Can’t give
sugar to someone who is hyperglycaemic: it will make it worse.
Hyperglycemic (D) NKHHC (Non-ketotic) Hypoglycemic
Etiology Blood glucose>insulin Symptomatic Insulin excess = insulin
hyperglycemia, fluid intake shock
inadequate; dehydrated
(10L loss), osmotic diuresis
Symptoms P: weak and rapid, Skin: dry, CNS alterations, extreme P: full and rapid. Skin:
warm. Intense thirst, hyperglycemia, without clammy, cold, pale, intense
acetone breath, dry mouth, marked hyperketonemia. hunger. Respiration is
respiration is increased, Hyperosmolarity, mild decreased. Irritability,
Seizures, CNS alteration, metabolic acidosis tremulousness, confusion,
altered consciousness weakness, lethargy,
seizures
Treatment Airways, breathing, ER! Increase blood volume, Give sugar.
circulation, oxygen, ER. low insulin
Some of the symptoms of hyper and hypo are the same (altered consciousness)

Chronic complications: person has been diabetic for some time.

What would you see in the eye? Cotton wool patches on eye. This is nerve cell damage (infarction). They can go away at
times (?) but will reappear. Would also see cataracts and glaucoma
See exudates: get fat and protein that leak out and accumulate in the back of the eye. (see picture at end of these notes)

Slide 2 of pictures: The disk is damaged. This is papilledema: acute swelling due to pressure. Pressure on optic nerve,
starts to push disk forwards. Can be from increased intracranial pressure: With a brain tumour, may also see this
happening: brain is swelling through orbits.

Slide 3 of pictures: Enlargement of the cup, Look at cup ratio (between cup and disk itself.) This is glaucoma. Fewer
vessels around optic disk.

Slide 4: vessels look like they are having problems. Cotton wool exudates (the white patches), hemorrhage (at 1 o’clock
from disk). Some bleeding was present in this patient. This was a case of hypertensive retinopathy (234/120 in this
patient at time of presentation).

Slide 5: Papular eruptive xanthoma: this indicates that there is a lipid problem. If it erupts: have to act quickly. Usually an
LDL problem. Can be secondary to diabetes, liver problems, hormone-related.
DDX LECTURE 49, APRIL 18TH, 2007 – PAGE 1
Skin tags can be evident in the years before Type 2 is diagnosed. This is a normal finding, but seems to be a link
between skin tags and blood sugar, especially over 35 (clinical evidence).

Page 4
Slide 1: Depressed lesions, feels pock-marked. They arise in crops. Resolve, but take a long time, and often recur. Side
effect of glucose being bound to the tissues (free glucose in blood due to reduced absorption). Collagen is damaged by
glucose, not healing properly. Skin reacts because it can’t get rid of its by-products, take in nutrients. Glucose bound to
blood cells, collagen, and it just isn’t functioning properly.

3 types of ulcers: Venous/stasis, arterial, neuropathic.

Slide 3: Medial and lateral aspect of malleoli. Rough texture, very dry, scaling, dryness. Would feel warm due to stasis.
Venous blood is staying in the area. Pulses would be there, because the pulse comes from the arterial system. Heels are
purple due to blood leaking into the tissue.

Slide 4: this is the medial aspect of the foot. Venous flare. See whole area where lots of veins present. See it in people
on their feet a lot.

Slide 5: another venous ulcer. Know the location: medial/lateral malleolus. Will be very dry, eczema. Some pain in all
venous ulcers. Looks worse than what it is.

Slide 6: This is “atrophy blanche”. There has been some scarring, healing from venous stasis. Related to previous
ulceration. When you see it in patient, ask them about it.

Page 5
Slide 1: Arterial ulcers: Pulses are diminished or absent. Tissue can’t get any nutrients from blood. Picture in notes is of
erosion over tibia (can see the bone). This will be very painful. Ulcer is quite deep compared to venous ulcer. Will see it
in areas where arterial blood supply is poorest: on the shin, dorsum of foot and tips of the toes. Patient is susceptible to
infection.

Slide 2 and 3: Neuropathic ulcers. These develop at pressure sites from trauma (shoe rubbing, injury). Check for
vibration sense in diabetic patients: put on the MTP joint and move proximally if they can’t feel it. DDX for diabetic
neuropathy: posterior column disease, B12 deficiency. Can get lots of improvement from in diabetics with B12 injections.
Before neuropathy develops, they will lose sense of fine touch. Test for this. Next, achilles reflex will be diminished. 3rd
test is joint position sense: move big toe from sides. After it progresses through these stages, will progress to ulceration.
Can track progression through physical exam.

Venous ulcers Arterial ulcers Neuropathic ulcers

Location Lateral and medial Dorsum of foot Bottom of foot: pressure
malleolus sites
Pulses Normal Diminished or absent Usually reduced.
Pain Some pain Painful Don’t feel anything.

DDX LECTURE 49, APRIL 18TH, 2007 – PAGE 2

Diabetic Retinopathy http://www.eyeweb.org/DR.htm

This is what someone with diabetic retinopathy would see.

http://www.lowvisionclub.com/articles/seewhatisee.html

DDX LECTURE 49, APRIL 18TH, 2007 – PAGE 3