CBL- ENDOCRINE SYSTEM

Dr. Mehzabin Ahmed

CASE HISTORY
 AM is a 45 year old male who works as an accountant at
the local supermarket. He has been attending the
Diabetes Clinic for regular follow up since the past 5
years. He takes 40 units of Insulin (Humulin 70/30)
every morning about half an hour before breakfast. He
checks his sugar “ almost everyday”. He usually can
remember to check it once a day( fasting) and
sometimes remember to check it before dinner. He
produces a sugar chart that shows that his fasting blood
sugars are usually between 140- 180 and his pre- dinner
readings are around 200.
 On examination doctors explains to him that he is
moderately overweight (height= 5’4”; weight=1651bs;
body mass index [BMI]= 27.5kg per m2) and he has
stage 1 hypertension (BP= 145/95mmHg).
 His ECG is normal.
 But he has borderline lipid levels:
Total cholesterol =220mg per dL;
Low density lipoprotein [LDL] =115mg per dL;
High density lipoprotein[HDL] = 50 mg per dL;
Triglycerides = 210mg per dL.
 The doctor next examines his feet and notes that pulses are
2+ in both feet. No edema is present. No lesions are noted on
the dorsum, plantar surface, or between the toes. There is
good vibratory sensation over the great toe and 5th toe on the
left foot, but vibratory sensation is markedly decreased on
the right. Sensation to monofilament testing in stocking
distribution of the foot is absent.
 When the doctors asks him whether he has stopped smoking
he admits that he still smoke about two packs of cigarettes
each day. The doctor tells him that he must stop smoking,
take good care of his feet and go for brisk walks for half an
hour each day and report to him with a sugar chart after a
month.
 He also refer him to an Ophthalmologist for a funduscopic
examination and a Dietician to help him plan his meals. He
What type of Diabetes is AM suffering from? What are the
other types of diabetes mellitus?

 Type 1 Diabetes: Absolute Insulin deficiency

Auto immune
Idiopathic
 Type 2 Diabetes: Relative Insulin deficiency
Secretary defect
Insulin resistance
 Other specific types:
Genetic defects of beta cell function
Genetic defects in insulin action
 Diseases of the exocrine pancreas
Endocrinopathies
Drug or chemical induced
Infections
Uncommon forms of immune mediated diabetes
Other genetic syndromes sometimes associated with
diabetes
 Gestational Diabetes
 Why does AM have to take insulin each day?

 He has poor control of the hyperglycemia as a result of

insulin resistance.
 If patient has a poor blood glucose control despite
lifestyle changes and using oral medicines, Insulin may
be prescribed.
 Insulin must be injected under the skin using a syringe
and cannot be taken by mouth.
What is normal fasting and post-prandial blood sugar level?

 Normal fasting- <110mg/dl

 PPBS- <140mg/dl
 Why was AM asked to get tested for Glycosylated Hemoglobin?
 Glycosylated hemoglobin (HbA1c) is a weighted three-
month average of what the blood glucose has been.
 This test measures how much glucose has been sticking to the red
blood cells.
 It also indicates how much glucose has been sticking to other
cells.
 A high HbA1c is an indicator of risk for long-term complications.
 Currently, the ADA recommends an HbA1c of less than 7% to
protect oneself from complications.
 This test should be done every three months.
What are the complications that AM can develop if he does
not control his blood sugar levels?
 Emergency complications include diabetic coma.
 Long-term complications include:
diabetic retinopathy (eye disease)
diabetic nephropathy (kidney disease)
diabetic neuropathy (nerve damage)
peripheral vascular disease (damage to blood vessels)
high cholesterol, high blood pressure, atherosclerosis,
and coronary artery disease
What are risk factors in AM that can be modified to decrease
the changes of developing these complications?

Modifiable risk factors

 Smoking
 Obesity
 Hypertension
 Sensory loss over feet
 What is the significance of sensory loss over AM’s feet?
 Due to the sensory loss the patient fails to detect
minor trauma (unfelt trauma).
 With a diabetic foot, a wound as small as a blister
from wearing a shoe that's too tight can cause a lot of
damage.
 Diabetes decreases the blood flow, so the injuries are
slow to heal.
 When the wound is not healing, it's at risk for
infection.
 As a diabetic, the infections spread quickly.
Site:Foot Exam (http://www.diabetes.usyd.edu.au/foot/Fexam1.html)
Commonly reported symptoms
include:

Burning, feeling like the feet are on fire Freezing, like the feet are on ice,
although they feel warm to touch

Stabbing, like sharp knives Lancinating, like electric shocks

 What advice would you give AM about foot care?

 People with diabetes are prone to foot problems because of

complications caused by damage to blood vessels and nerves
and decreased ability to fight infection.

 Blood flow to the feet may become compromised and

damage to the nerves may cause an injury to the foot to go
unnoticed until infection develops.

 Death of skin and other tissue can occur. If left untreated,

amputation of the affected foot may ultimately be necessary
To prevent injury to the feet, diabetics should adopt a
daily routine of checking and caring for the feet as follows:
 Check your feet every day, and report sores or changes and signs of
infection.
 Wash feet every day with lukewarm water and mild soap, and dry
them thoroughly.
 Soften dry skin with lotion or petroleum jelly.
 Protect feet with comfortable, well-fitting shoes.
 Exercise daily to promote good circulation.
 See a podiatrist for foot problems, or to have corns or calluses
removed.
 Remove shoes and socks during a visit to the health care provider to
remind them to examine your feet.
 Discontinue smoking because it worsens blood flow to the feet.
Why did the doctors advice AM to undergo funduscopy?

Retinal changes in diabetic retinopathy

Role of a dietician in management of diabetes mellitus
 Meal planning includes choosing healthy foods, eating the right
amount of food, and eating meals at the right time. The health
care provider educates the patient on how much fat, protein, and
carbohydrates is required for the patient.
 Your specific meal plans need to be tailored to your food habits
and preferences.
 In type 2 diabetes, weight management and a well-balanced diet
are important. Some people with type 2 diabetes can stop
medications after intentional weight loss, although the diabetes is
still present.
 Consultation with a registered dietitian is an invaluable planning
tool.
 Lack of Insulin

Decreased Increased secretion of Increased

Anabolism Glucagon, Cortisol
Catabolism
Growth hormone &
Catecholamines Glycogenolysis↑
Gluconeogenesis ↑ → Wasting
Fatigue ← Hyperglycemia Lipolysis ↑ → Loss of weight
Valvitis ← Glycosuria Hyperketonaemia
↓
Polyurea ↓ Hypertension
Polydypsia ← Osmotic diuresis ↓ Hypothermia
Polyphagia Acidosis ↑
Peripheral
Tachycardia ← Salt & water Diabetic →
Vasodilation
Hypertension ← Depletion Ketoacidosis →
Hyperventilation