Category Archives: DM

REVISION DIABETES

Past year questions

DIABETIC

1-Lines of treatment hyperTGdemia in diabetic pt (06,08)
2-Give short account on indication of insulin theraphy in type 2 DM
3-Mechanism in neuropathy in DM (95)
4-Cp of hypoglycemic coma (95)
5-Rx of DI (95)
6-Causes and pathogenesis of DKA (96,00)
7-Etiology and phatogenesis if hypoglycemia (02,05,07)
8-Rx of type-2 DM
9-Cardiovascular complication of DM (03)
10-Rx of DKA (03,08)
11-Skin changes in DM (03)
12-Enumerate 6 oral anti-diabetic agents (04,08)
13-Rx of diabetic microalbunuria (05)
14-Medical nutrition theraphy in DM (07)
15- Dx of gestational DM (07)
16-Approach to hyperglycemia pt (08)
17-Discuss non-pharma Mx of DM (08)
18-Features of Diabetic dyslipidemia (08)

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Loss of consciousness in DM

This is a question that one of my friends got for osce.
Lets discuss it briefly,
What are other causes of loss of consciousness in patients with DM?

In notes and books, its the usual DKA, hypoglycemia, stroke.

Ok.but then what else?? When we read this up in our notes have we really took some time to think what else can affect a DM PATIENT’S CONSCIOUSNESS?

Most probably no. And that , my dear ,is a problem. Because when medic is merely about memorizing its a problem..trust me it is.

Lets try to think outside the box. Hmmm DM PATIENTS.. So?? Is it only possible for his loss of consciousness to root from his disease? He’s like any human being too..so anything that may rip off our consciousness may do the same to these patients.

In some notes, are written answers like trauma, meningitis, encephalits, etc
Basically anything that may make him lose consciousness even though it may not be directly related to his diabetic state.
Hmm. What if he has diabetic nephropathy? Can his deteriorating kidney affect his condition?? Take for example.. Uremic encephalopathy? Or if his heart is affected which ends by cardiogenic shock? or if he has a concurrent hypertension which leads to heart failure, he could probably suffer complication due to that.or possibly hypertensive encephalopathy? There are so many causes you can think of.

I dont know whether this is right or wrong.but ill go into the depths of the deatils regarding this matter afterwards.its just something to incite my thoughts.

DKA AND HHS

A special case of potassium loss occurs with diabetic ketoacidosis. In addition to urinary losses from polyuria and volume contraction, there is also obligate loss of potassium from kidney tubules as a cationic partner to the negatively charged ketone, β-hydroxybutyrate.

so yes, i found that acidosis causes extracellular shift of potassium… but in DKA, the total potassium is low, but there is HYPERKALEMIA. so when treating.. its essential to measure serum potassium!! treatment may exarcerbate the danger of this situation!!!!

ok and you know insulin causes intracellular shift of potassium.

ok yes , this is acidosis so it would be wise to give bicarbonates to ‘tame’ this acidosis?????
NO.

from what i conceive after doing some reading, the use of bicarbonates is debatable. and not recommendable, UNLESS PH IS LESS THAN 7.

ok yes, bicarbonates are one of the lines of treatment in hyperkalemia and in DKA, HYPERKALEMIA CAN HAPPEN BUT REMEMBER THE TOTAL POTASSIUM IN THE BODY IS LOW.

somehow,it was stated that the bicarbonates causes a PARADOXICAL ACIDOSIS PF THE NERVOUS SYSTEM. WHY?

Concerns were raised that bicarbonate therapy might interfere with tissue oxidation and with the clearance or renal excretion of ketones, hence accounting for the paradoxical worsening of ketosis.

Bicarbonate therapy in patients with DKA appeared to be associated with increased obtundation and profound cerebrospinal fluid (CSF) acidosis in an early study [47]. A possible explanation for this observation may be the preferential movement across the blood-brain barrier of CO2 compared with bicarbonate during treatment of DKA, when both PCO2 and bicarbonate levels rise in the blood. It was postulated that rapid reversal of acidemia with bicarbonate might promote paradoxical CSF acidosis and contribute to adverse neurological outcomes.

the use of bicarbonates in DKA is indeed a complex subject by itself. so you can read further here about a study of bicarbs and dka.

personally ,to be safe, lets just stick to whats written in the books.

bicarbs and dka

hypoglycemia

important notes:
there is no definite numbers. it simply means low blood glucose level or relatively low.
in hypolycemia unawareness, its vital to treat them early because they go into coma faster!

what leads to hypoglycemia?
low levels of counterregulatory hormones
low source of glucose
hi insulin

renal impariment leads of hindered degradation of insulin hence decreasing requirements of insulin intake in diabetic patient! ( esp since they may have DM Nephropathy)

females. have overactive parasympathetic flow hence they are more liable to early postprandial hypoglycemia.

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