Diabetes mellitus is a chronic metabolic disease. Diabetes is increasing at an alarming rate all over the world and particularly in India. Body cells require glucose which produces energy required for daily activities. The food we eat turns into glucose after digestion. Glucose enters the blood stream and reaches different body cells. Insulin is like a key which opens the body cell doors to allow glucose to enter. In the absence of enough insulin glucose cannot enter the cells. Glucose remains in the blood stream in high amounts resulting in hyperglycemia. This abnormal blood glucose level is called diabetes mellitus.
It is not a single disease, but a group of diseases, characterized by chronic hyperglycemia (elevated levels of glucose in the blood) from various reasons, mainly due to impaired glucose metabolism.
Long term hyperglycemia leads to disorders like myocardial infarction, stroke, kidney diseases and diabetic retinopathy. Diabetic retinopathy affects the vision and may even leads to blindness. The OA is likely to encounter patients with diabetes. Patients with diabetes may have cataracts or glaucoma. Learning about diabetes will help the OA provide proper care and comfort to these patients.
Overview of physiology
The beta cells of the islets of langerhans produce a hormone, insulin. The islets of langerhans are situated in the pancreas, a yellowish gray gland situated behind the stomach.
The pancreas has many functions in addition to insulin production. The pancreas also produces digestive enzymes and other hormones.
- Type I diabetes
- Type II diabetes
- Gestational Diabetes
- Juvenille Diabetes
Etiology and risk factors
Type I diabetes mellitus
Genetic factors: This is genetically linked with (Human Leucocyte Antigen) HLA on chromosome 6. It is speculated that these HLA molecules provide antigens to produce auto- antibodies specific to islets of langerhans.
Immunologic factors: auto antibodies against the islets of langerhans destroy the beta cells affecting insulin production.
Environmental factors: It has been proposed that some virus or toxins may cause the beta cell destruction.
Type II Diabetes mellitus
|Ages||: Insulin resistance tends to increase with age over 40 years|
|Obesity||: The insulin secreted is not sufficient for the cells|
|Family History||: If the father or mother has diabetes, the chances of the child getting diabetes are increased|
|Lack of physical||: This leads to impaired glucose|
Type I Diabetes
- This generally occurs in young, lean patients.
- It is characterized by the marked inability of the pancreas to secrete insulin
- These patients are dependent on exogenous insulin to sustain their lives
Type II diabetes
In type II diabetes the body cells are resistant to insulin and there may be insulin deficiency
- This group of patients develops diabetes at an older age, after 40 years
- These patients are usually over weight
- The treatment modalities are diet control, weight reduction, oral anti diabetic drugs and insulin injection if necessary
Flow chart-pathophysiology of diabetes
- Deficiency of insulin
- Cells cannot access the calories contained in the glucose without insulin
- Liver releases glucose
- Glucose concentration in blood exceeds capacity of renal tubules to reabsorb
- Loss of water and minerals
- Thirst - polydipsia
Symptoms of diabetes
Symptoms of diabetes occur because body tissues are not able to utilise glucose. The classical symptoms include polyphagia, polydipsia and polyuria.
Patients have increased appetite, and eat more than usual. This is because cells are starved of glucose since glucose is not able to enter cells. Although a diabetic eats more, the cells do not get enough glucose.
Patient passes large volumes of urine. Normal urine does not contain glucose. In the diabetics, kidneys are unable to reabsorb the excess glucose, so it appears in the urine. When glucose appears in urine, it drains a lot of water with it causing excessive urination.
It is excessive thirst due to loss of water from the body. Other symptoms may include
4. Fatigue and weight loss in diabetes
In order to obtain energy, cells start using body fat and protein for energy instead of glucose. This leads to weight loss and tiredness.
Some people may not have any symptoms. DM is accidentally discovered in some persons during routine examination of urine and blood.
- Blood glucose - the presence of abnormally high blood glucose levels is the criteria by which the diagnosis of diabetes should be made.
- Benedict's test to determine urine glucose
- Glucose tolerance test
|Normal||Impaired Glucose Tolerance||Diabetes|
|Fasting Value||< 5.5mmol/L||5.5 - 7.7 mmol/L||> = 7.8 mmol/L|
|2-hour Value||< 7.8 mmol/L||7.8 - 11.0 mmol/L||> = 11.1 mmol/L|
Oral glucose tolerance test
Performing an oral glucose tolerance test is necessary only when random or fasting blood glucose values do not establish the diagnosis.
- Instruct the patient not to restrict diet during the 3 days preceding the test.
- The patient should fast for 12 hours immediately before testing.
- The test is usually scheduled in the morning.
- A fasting blood sample to determine plasma glucose level is taken. (If the plasma glucose level is =/> 7.8 mmol/L, no need for further testing)
- 75g of glucose, diluted in 250 ml of water, is given by mouth, within 5 minutes
- After 2 hours, a second blood sample is taken, and the plasma glucose level is determined
Diagnostic criteria - as defined by the world health organisation
Any patient on at least two occasions has
- Fasting plasma glucose levels of 140 mg/dl
- PPS > 200mgms
- GTT-2 hours sample with 200mg or greater will be considered as diabetic
Treatment of diabetes consist of three main components
The main goal of treatment is to normalize the blood sugar level in an attempt to reduce the development of complications
There are five components in the treatment of diabetes.
- Drugs - oral hypoglycemic agents, insulin injection
Diet and exercise are the corner stone of diabetic management.
Balanced food within permitted calorie limits as prescribed by the doctor is taken. Sugar containing items have to be avoided. High fiber diet is encouraged.
Exercise helps in glucose utilization and maintenance of weight.
Oral hypoglycemic drugs
Used in Type I diabetes life long and in Type II diabetics when blood sugar is not well controlled with oral agents.
Types of insulin
|Short acting||- Duration of action is from 2 hours to 8 hrs|
|Intermediate acting||- In this type of insulin action starts after 4 hours effective for 24 hours|
|Long acting||- Effective for 24-36 hrs|
Complications of diabetes: Acute complications
- Diabetic ketoacidosis
- Hypoglycemic attack
- Ischemic heart disease, heart attack (silent, common)
- Renal failure
- Tingling of fingers and toes, foot ulcers due to neuropathy
- Nephropathy and renal failure
- Diabetic retinopathy
- Urinary tract infections
The diabetic patient who comes to an ophthalmic unit may develop hypoglycemia or ketoacidosis. The difference between hypoglycemia and hyperglycemia is given below.
Points to differentiate between hypoglycemia and hyperglycemia
|Skin||Dry and Cold||Warm & moist|
|Pulse||Faint and fast||Normal or high|
|Breathing pattern||Deep & sighing||Normal|
|Breath smell||Fruit odour||Normal|
|Treatment||I.V. fluids, insulin||I.V. glucose (25%dextrose)|
Treatment of acute complication
- Occurs when blood sugar is < 60mgms
- Sugar containing foods in conscious patient.
- Unconscious patient - 50ml of 25% dextrose followed by 10% dextrose drip for 12-24 hours.
2. Diabetic ketoacidosis
- Occurs due to infection, stress, or stopping drugs. It is an acute complication.
- Diabetic ketoacidosis can be life threatening if untreated.
- Rapid correction of dehydration by IV fluids - normal saline or ringers lactate.
- Hourly intravenous insulin.
1. Fill in the blanks
- Drugs that reduce blood sugar are called _________.
- Type II diabetes is called _________.
- Daonil is ________________ drug.
2. Choose the correct answer
a. Symptoms of diabetes mellitus include all except
- All the above
b. Chronic complications of diabetes include
- Ischemic heart disease
- Diabetic retinopathy
- All by the above
c. Treatment of hypoglycemia
- 25% in dextrose
- injection insulin
- Tab. Daonil
3. Match the following
- Hypoglycemia - PPBS >200mg
- Hyperglycemia - Blood sugar < 60mg
- Type I D.M - NIDDM
- Type II DM - IDDM
4. Choose the correct
a. Daonil is an
- Oral hypoglycemic drug
- Oral hyperglymic drug
- Antihypertensive drug
Hypertension is a very common disorder affecting 25% of the population. It is a major risk factor for coronary heart disease, cerebral, renal and peripheral vascular disease. It is called the silent killer because people with hypertension are often symptom free.
Definition - hypertension
Hypertension is defined as a systolic blood pressure greater than or equal to 140mmHg and/or a diastolic blood pressure greater than or equal to 90 mm hg occurring in a patient on at least three separate occasions.
Classification of hypertension
Hypertension can be divided into 2 groups
- Primary hypertension
- Secondary hypertension.
Primary hypertension is the most common - 95% of patients with raised blood pressure are in this category.
This is also called essential hypertension. There is no known cause, we only know the effects.
At times people show a rapid rise in blood pressure with a risk of death within a year or two - this is known as malignant hypertension.
Of the remaining 5% who have secondary hypertension, most are a result of renal disease, endocrine diseases, vascular disease, or neurogenic disorders.
Most of the people are affected with benign hypertension, in other words, stable. It is compatible with a long life. In this chapter the emphasis is given to primary hypertension and it will be explained in detail.
No one's blood pressure is constant. Exercise, a sudden burst of anger, all of these can raise our normal blood pressure readings. But generally, they don't raise our blood pressure to dangerous levels for long periods of time. In the absence of high blood pressure symptoms, hypertension is diagnosed based on several blood pressure readings taken over a period of time.
Etiology & predisposing factors of primary hypertension
As described earlier the etiology for primary hypertension is not known. Predisposing factors are
- Diets high in cholesterol
- Heavy alcohol intake
- Lack of physical activity
- Over stimulation with coffee,tobacco
- Familial tendency
Etiology - secondary hypertension
- Acute glomerulonephritis
- Chronic renal disease
- Renal artery stenosis
- Renal vasculitis
- Adrenocortical hyperfunction (Cushing's sydrome)
- Coarction of aorta
- Polyarteritis nodosa
- Aortic insufficiency
- Brain tumors and increased cranial pressure
- Polyneuritis, bulbar poliomyelitis
The systemic arterial pressure is a result of
- Cardiac output - Cardiac output is determined by stroke volume and heart rate.
- Peripheral vascular resistance - Control of peripheral resistance is maintained by autonomic nervous system and circulating hormones.
- Any factor producing an alteration in peripheral resistance, heart rate, or stroke volume affects the systemic arterial pressure.
The stabilising mechanism regulating blood pressure
The baro receptors
They are found in the carotid sinus, aorta and in the walls of the left ventricle. They monitor the level of pressure in the arteries. When the blood pressure lowers, this tries to raise the blood pressure or lowers the blood pressure when it is high. The exact reason why this control fails in hypertension is unknown.
Body fluid volume
Changes in fluid volume affect the blood pressure. If the body has excess salt and water, the blood pressure rises. This happens when there is alteration in kidney function of excreting water and salt.
Renin angiotensin system
Renin is an enzyme secreted by the kidney when the blood pressure decreases. The following flow chart explains how the blood pressure raises due to the action of renin and angiotensin.
|Category||Systolic BP (mmHg)||Diastolic P(mmHg)|
|Normal||Less than 130||Less than 85|
|Stage 1 Hypertension||140-159||90-99|
|Stage 2 Hypertension||160-179||100-109|
|Stage 3 Hypertension||180 & above||110 & above|
Blood pressure decreases
Kidney secretes renin
Angiotensin II → Vaso constriction
Raised blood pressure
Stimulates aldosteron secretion
Increased retention of sodium and water
Elevated blood pressure levels
Also when there is inappropriate renin secretion there is increased peripheral vascular resistance which causes essential hypertension.
Vascular auto regulation
Vascular auto regulation is the capacity of blood vessels to alter their resistance according to the blood flow. This means it should decrease the vascular resistance when the blood flow is decreased and increase the vascular resistance when the blood flow is increased. In hypertension this mechanism fails which results in increased sodium and water retention. This increases the blood pressure.
- Chest pain
- Nose bleeds
- Vision changes
There may not be any symptoms and patient's hypertension may be detected only in routine examinations.
- Coronary heart disease
- Cerebro vascular accident
- Peripheral vascular disease
- Hypertensive retinopathy
- Renal disorders
Diagnosis of hypertension
- BP readings - high on 3 separate occasions
- Evidence of endovsan olamase - eye, cardiac or renal involvement
Physical assessment and Investigations
- Blood pressure measurement
- Fundus examination of the eyes to observe any vascular changes.
- Assessment to rule out systemic diseases.
- Route urine examination which will include protein, red blood cells, pus cells and casts -The presence of these may indicate the presence of renal disease.
- Chest x-ray to rule out left ventricular enlargement that results from hypertension.
- ECG to determine the degree of cardiac involvement.
- Assessment for psycho social factors that aggrevate the clients hypertension.
Life style modifications
- Low fat, low carbohydrate diet
- High fiber diet
- Weight reduction
- Stop smoking
- Reducing alcohol consumption.
Mild hypertensive patients can be managed by diet control and weight reduction initially. If there is no response then drugs can be used for management.
Anti - hypertensive Drugs
Principal drugs used in treatment are
Eye and hypertension
Uncontrolled high blood pressure speeds up the normal aging of blood vessels in the eye. The constant force of the high blood pressure can make them weak and lose their elasticity. Uncontrolled hypertension can result in arterio venous compression, hemorrhages, exudates, and papilledema of optic fundus (edema of the optic nerve at its point of entrance into the eye ball). The appearance of retina has been found to be a reliable index of the severity and prognosis of hypertension.
Symptoms and signs of hypertensive retinopathy
Hemorrhages around retinal vessels are signs hypertension is affecting the eyes and a person's vision. Vitreous hemorrhage is common in hyper tensive patients.
- Narrowing of arteries
- Arterio-venous (AV) junction changes.
- Deposits of lipids (fats) in the eye.
- Cotton - wool spots (CWS-micro infarctions).
- Bleeding into the eye and complications like scarring, and pull on the retina leading to retinal detachment.
- Vein occlusions leading to sudden loss of vision and can cause growth of new vessels in the eye.
- In severe cases swelling of optic disc called papilledema occurs.
What can be done?
- Regular eye exams
- Good control of blood pressure
- Laser may be done in certain cases
Between 100 and 150 million people around the globe suffer from asthma. Asthma attacks all age groups but often starts in childhood. It is a disease characterized by recurrent attacks of breathlessness and wheezing, which vary in severity and frequency from person to person. In an individual, they may occur from hour to hour or day to day. Asthma cannot be cured, but can be controlled. Asthma is on the increase due to rapid urbanisation.
Asthma is an intermittent, inflammatous, reversible, obstructive airway disease in which trachea, & bronchi react in a hyperactive way to certain stimuli.
Types of asthma
Caused by known allergens such as dust, pollens, animals, food, etc.
Idiopathic non allergic asthma
This is not related to specific allergens. Factors such as common cold, respiratory tract infections, exercise, and stress may be responsible.
This has both the charecteristics of allergic and non allergic.This is the most common type of asthma.
Initial exposure to allergen
Antibodies are attached to mast cells (Mast cells are normally found in the body tissue. when stimulated they release histamine that causes allergic signs)
Re-exposure to allergen
Antigen and antibody binds
Release of mast cell products- histamine and other factors
Obstruction / narrowing of airway due to
- Contraction of smooth muscles around the bronchi
- Swelling of mucous membrane that line the bronchi
- Excessive mucus production within the bronchi
Frequently the asthmatic attack occurs at night.
When a person has an asthmatic attack, usually they have
- Cough with tightening of the chest
- Difficulty in breathing, especially expiration. It is more prolonged than inspiration
- The patient uses accessory muscles of respiration
- Later cyanosis may occur
The asthmatic attack may last from 30 minutes to several hours and may subside spontaneously. Occasionally it may last longer, which may be life threatening. This condition is referred to as status asthmaticus.
- History will disclose factors which precipitate asthmatic attacks
- X-ray during acute attacks may reveal hyperinflation and flat diaphragm
- Sputum clear, white, foamy
- Arterial blood gas reveals hypoxia. The PCO2 level will be high
Asthma treatment is of utmost importance. Asthma can be controlled but not cured. It is not usually fatal, but it can become life-threatening if it is not treated or controlled. Asthma can produce respiratory failure Treatments:
- Broncho dilators - Inj, and tablets salbutamol, deriphylline, aminophylline, terbutalin
- Corticosteroids - efcorlin, solumedvol, decadron
- Saltrulamol (tablets, inhaler, syrup)
- Deriphyclone (given in injection and tablets)
- The two goals of emergency care for an acute asthmatic attack are
- Improve oxygenation and ventilation
- Relieve bronchospasm
- New early asthma treatment can prevent fatalities
- Observe the respiration and check pulse
- Establish an airway and assist ventilations if necessary (mouth-to-mouth breathing if the patient is not breathing)
- Enquire if the patient uses any medication for asthmatic treatment. Shake the inhaler and spray once in the air. Have the victim breathe in and out once. Then insert the inhaler and assist with three applications of the medication
- Inform the physician
- Stay calm and keep the patient as calm as possible; stress, cold and emotional intensity worsen the asthma
- Keep the victim in a position of comfort, usually seated
- If they don't have an inhaler, Asthalin nebuliser, inj. deriphylline (IV) and steroid can be given as per doctor's order. Oxygen may be started
- If you do not anticipate aspiration, give the patient warm fluid by mouth
- Identification of stimuli and avoid contact with that stimuli
- Prevention and proper management of common cold.
The most common way of taking treatment is with an inhaler - or "puffer" which delivers a precisely measured dose of a medicine in aerosol or fine powder form. The two main types of medicines used in inhalers are relievers and preventers.
Medicine helps to open up the airways and works rapidly. It is used at the beginning of an asthmatic attach. Common reliever medicines include salbutamol (Ventolin), terbutaline and ipratropium. Inhalers containing these medicines are coloured blue.
These can be used together with relievers, and are for preventing symptoms. Most preventers are inhaled corticosteroids, usually referred to simply as steroids. They reduce the inflammation in the airways.
If asthma is quite severe or unpredictable, it may be necessary to take a course of steroids in tablet form. These work in the same way as inhaled preventers, by reducing inflammation.
Nebulisers make a mist of water and asthma medicine that is breathed in. They can deliver more of the drug to exactly where it's needed than conventional inhalers can. This is particularly critical in the event of a serious asthma attack.
A spacer is a long tube that clips on to the inhaler. At the other end of the tube is a mouthpiece or mask that the patients breathes in and out of.
I. Fill in the blanks
- Saltrulamol is a __________.
- Asthma is an inflammatory ___________ obstructive airway disease.
II. Choose the correct answer
1. Inj. aminophyline given in case of
- Status asthmaticus (acute asthmatic attack)
- Heart block
- Ischemic heart disease
2. Emergency care for an acute attack includes
- Improve oxygenation and ventilation
- Relieve bronchospasm
- Back rest
- All of the above
III. Match the following
- Broncho dilaters - Efeorlins
- Corticosteroids - Respiratory tract infection
- Allergic asthma - Salbutamol
- Non allergic asthma - Dust, pollution