DIABETES CASE DIABETES CASE PRESENTATIONSPRESENTATIONS

11stst - diagnosis - diagnosis

Case 1Case 1 Male, 24 yrs oldMale, 24 yrs old Presents in the ER for nausea, vomiting, Presents in the ER for nausea, vomiting,

abdominal pain, shortness of breathabdominal pain, shortness of breath No known medical conditions, BMI = No known medical conditions, BMI =

21kg/m221kg/m2 In the last month has noticed increased In the last month has noticed increased

thirst and passing water and lost almost 15 thirst and passing water and lost almost 15 kgkg

Clinical examination: dehydration, BP = Clinical examination: dehydration, BP = 125/65 mmHg, HR = 110/min125/65 mmHg, HR = 110/min

??

Case 2Case 2

Female, 39 yrs oldFemale, 39 yrs old Presents at the GP accusing fatigue Presents at the GP accusing fatigue

and frequent urinationand frequent urination No known medical conditions, No known medical conditions,

BMI=29 kg/m2, has 5 children BMI=29 kg/m2, has 5 children (healthy, normal birth weight)(healthy, normal birth weight)

Has an aunt with diabetesHas an aunt with diabetes

??

Case 3Case 3

Male, 34 years oldMale, 34 years old Presents at the dermatologist for Presents at the dermatologist for

reccurent Staphyloccocus infectionreccurent Staphyloccocus infection Does not present other symptomsDoes not present other symptoms Smoker, sedentary lifestyle, BMI = 32 Smoker, sedentary lifestyle, BMI = 32

kg/m2kg/m2 Father with diabetes and hypertensionFather with diabetes and hypertension

??

Case 4Case 4

Female, 65 yrs oldFemale, 65 yrs old Presents to the ophthalmologist for Presents to the ophthalmologist for

decreased eyesightdecreased eyesight Fundoscopy shows microaneurisms, Fundoscopy shows microaneurisms,

hemorrhages and macular edemahemorrhages and macular edema BP = 155/90 mmHg, BMI = 35 kg/m2BP = 155/90 mmHg, BMI = 35 kg/m2 Has a sister and mother with diabetesHas a sister and mother with diabetes

??

Case 5Case 5

Male, 51 yrs oldMale, 51 yrs old Needs surgery for disc herniationNeeds surgery for disc herniation Tests before surgery find: blood Tests before surgery find: blood

glucose level = 176 mg/dlglucose level = 176 mg/dl BMI = 33 kg/m2, TA = 160/80 BMI = 33 kg/m2, TA = 160/80

mmHgmmHg Sedentary due to chronic back painSedentary due to chronic back pain

??

Case 6Case 6

Female, 41 yrs oldFemale, 41 yrs old Presents at the GP for the annual Presents at the GP for the annual

check-up; at the age of 37 she had check-up; at the age of 37 she had gestational diabetes and she checks gestational diabetes and she checks her blood glucose level annuallyher blood glucose level annually

BMI = 29,5 kg/m2BMI = 29,5 kg/m2 Fasting blood glucose level = 118 Fasting blood glucose level = 118

mg/dlmg/dl

??

Diagnosis of diabetesDiagnosis of diabetes Symptomatically:Symptomatically:

Classic symptoms (polyuria, polydipsia, Classic symptoms (polyuria, polydipsia, polyphagia, weight loss)polyphagia, weight loss)

KetoacidosisKetoacidosis Acute infectious complicationAcute infectious complication Chronic complication: Chronic complication:

EyesEyes KidneysKidneys NeurologicalNeurological MacrovascularMacrovascular

Asymptomatically:Asymptomatically: Random testsRandom tests Active screeningActive screening

Criteria for the diagnosis of Criteria for the diagnosis of diabetes mellitusdiabetes mellitus

Symptoms of diabetes plus casual plasma glucose Symptoms of diabetes plus casual plasma glucose concentration ≥200 mg/dl (11.1 mmol/l). Casual is concentration ≥200 mg/dl (11.1 mmol/l). Casual is defined as any time of day without regard to time defined as any time of day without regard to time since last meal. The classic symptoms of diabetes since last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight include polyuria, polydipsia, and unexplained weight loss.loss.

oror FPG ≥126 mg/dl (7.0 mmol/l). Fasting is defined as FPG ≥126 mg/dl (7.0 mmol/l). Fasting is defined as

no caloric intake for at least 8 h.no caloric intake for at least 8 h.oror

2-h post-load glucose ≥200 mg/dl (11.1 mmol/l) 2-h post-load glucose ≥200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as during an OGTT. The test should be performed as described by WHO, using a glucose load containing described by WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved the equivalent of 75 g anhydrous glucose dissolved in water. in water.

Classification of diabetes Classification of diabetes mellitus (1)mellitus (1)

Type 1Type 1 beta-cell destruction, usually leading to beta-cell destruction, usually leading to

absolute insulin deficiencyabsolute insulin deficiency AutoimmuneAutoimmune IdiopathicIdiopathic

Type 2Type 2 may range from predominantly insulin may range from predominantly insulin

resistance with relative insulin deficiency resistance with relative insulin deficiency to a predominantly secretory defect with to a predominantly secretory defect with or without insulin resistanceor without insulin resistance

Classification of diabetes Classification of diabetes mellitus (2)mellitus (2)

Other specific typesOther specific types Genetic defects of beta-cell functionGenetic defects of beta-cell function Genetic defects in insulin actionGenetic defects in insulin action Diseases of the exocrine pancreasDiseases of the exocrine pancreas EndocrinopathiesEndocrinopathies Drug- or chemical-inducedDrug- or chemical-induced InfectionsInfections Uncommon forms of immune-mediated diabetesUncommon forms of immune-mediated diabetes Other genetic syndromes sometimes associated Other genetic syndromes sometimes associated

with diabeteswith diabetes Gestational diabetesGestational diabetes

Pre-diabetesPre-diabetes

Impaired fasting glycaemia Impaired fasting glycaemia (IFG):(IFG): Blood glucose level (fasting) = 110 – Blood glucose level (fasting) = 110 –

125 mg/dl125 mg/dl

Impaired glucose tolerance Impaired glucose tolerance (IGT):(IGT): Blood glucose level (2 hrs at OGTT) = Blood glucose level (2 hrs at OGTT) =

140 – 199 mg/dl140 – 199 mg/dl

Risk factors for type 2 diabetes Risk factors for type 2 diabetes (screening)(screening)

Age ≥45 yearsAge ≥45 years Overweight (BMI ≥25 kg/m2)Overweight (BMI ≥25 kg/m2) Family history of diabetes (i.e., parents or siblings Family history of diabetes (i.e., parents or siblings

with diabetes)with diabetes) Habitual physical inactivityHabitual physical inactivity Race/ethnicity (e.g., African-Americans, Hispanic-Race/ethnicity (e.g., African-Americans, Hispanic-

Americans, Native Americans, Asian-Americans, and Americans, Native Americans, Asian-Americans, and Pacific Islanders)Pacific Islanders)

Previously identified IFG or IGTPreviously identified IFG or IGT History of GDM or delivery of a baby weighing > 9 lbsHistory of GDM or delivery of a baby weighing > 9 lbs Hypertension (≥140/90 mmHg in adults)Hypertension (≥140/90 mmHg in adults) HDL cholesterol ≤35 mg/dl (0.90 mmol/l) and/or a HDL cholesterol ≤35 mg/dl (0.90 mmol/l) and/or a

triglyceride level ≥250 mg/dl (2.82 mmol/l)triglyceride level ≥250 mg/dl (2.82 mmol/l) Polycystic ovary syndromePolycystic ovary syndrome History of vascular diseaseHistory of vascular disease

Definition of Metabolic Definition of Metabolic SyndromeSyndrome

Initial evaluation of the Initial evaluation of the diabetic patientdiabetic patient

History taking – personal and family History taking – personal and family historyhistory

Clinical examinationClinical examination

Height, weight (BMI), waist Height, weight (BMI), waist circumferencecircumference

TestsTests

Definition and classification of Definition and classification of obesityobesity

WHO Classification  WHO Classification  BMI BMI (kg/m2) (kg/m2)

Risk of co-Risk of co-morbidities morbidities

UnderweightUnderweight <18.5  <18.5  Low (but risk of other Low (but risk of other

clinical problems clinical problems increased) increased)

Normal range Normal range  18.5 - 24.9  18.5 - 24.9  Average Average

OverweightOverweight  

Pre-obese  Pre-obese  25 - 29.9  25 - 29.9  Increased Increased

Obese Class Obese Class I  I  30.0 - 34.9  30.0 - 34.9  Moderate Moderate

Obese Class Obese Class II  II  35.0 - 39.9 35.0 - 39.9 Severe Severe

Obese Class Obese Class III  III  > 40.0 > 40.0 Very severe Very severe

Types of obesityTypes of obesity

AbdominalAbdominal (central) obesity (central) obesity Men Men ≥ 94≥ 94 cm cm Women Women ≥ 80≥ 80 cm cm

Gluteo-femGluteo-femooralral obesity obesity MenMen < 94 < 94 cm cm WomenWomen < < 8080 cm cm

DyslipidemiaDyslipidemia

TTyyppeses ofof ddyyslipidemislipidemiaa

(mg/dl)(mg/dl)

CChholesterololesterol TriglTriglyyceridcerid

eess

HHyyperper--

chcholesteroleolesterolemimiaa

BorderBorder 190190 -- 249249

<< 150150 moderatemoderate 250250 -- 300300

severesevere >> 300300

HHyyperper--trigltriglyycerideceride

mimiaa

moderatemoderate

< 190< 190150150 –– 400400

severesevere >> 400400

MMixt ixt hyhyperlipideperlipide

mimiaa

moderatemoderate 190190 -- 300300 150150 –– 400400

severesevere > 300> 300 >> 400400