References:

-KUMAR AND CLARK MEDICINE TEXTBOOK

-MALAYSIAN CPG

MEDICAL
NOTES

CONTENTS

Diabetes mellitus and disorders in metabolism

Cardiology
Respiratory
Gastrointestine
Urology
Central nervous system
Musculoskeletal
Infectious disease
STD
Skin diseases

PAGES

MEDICAL NOTES2

DIABETES

Definition: chronic hyperglycemia d/t insulin insufficiency or insulin resistance

Pathogenesis of Type 1 DM
environmental fx (food/enterovirus)
+
susceptibility gene (HLA)

autoimmune destruction of the pancreatic islet

cell
(islet antigen- GAD)

Insulitis for many yearsdefective insulin

production
Pathogenesis of type 2 DM
Obesity + susceptibility gene
Clinical
Features

Insulin resistance

Glucose is not taken up by the cells even in the

presence of insulin bcoz of insulin resistance
Chronic hyperglycemia + increase islet cell
workload

Stupor

Ketone production

Shortnes
s of
breath

Hyperventilate to lower CO
level

Blurred
visions

Swelling of the eye lens

Beta cells exhaustion

TYPE OF
DIABETES

PRIMARY

MONOGENIC
-ie. MODY
TNDM
PNDM

SECONDARY

POLYGENIC
-ie. TYPE 1 &
TYPE 2 DM

ex:
-cystic fibrosis
-cushing's
syndrome

Reason

Weakened blood vessels

Neovascularization

Tingling,
pain, or
numbnes
s

Damage to the nerve

Nausea
&
vomiting

Ketone production

Abdomin
al pain

Delayed of stomach
emptying (gastroparesis)

Acetone
breath

Ketone production

Erectile
dysfuncti
on

Damage to the blood vessels

and nerves

Slow
healing
wound

Poor blood circulation and

immunosuppression

MEDICAL NOTES3

Diagnosis:
1. Venous plasma glucose
fasting
random
DM
11.1mmo
7.0mmol l/L
/L
*symptomatic pt; 1 abnormal value is diagnostic
*asymptomatic pt; 2 abnormal values is needed
*if less than these values, proceed with ogtt

2. OGTT
category
0-Hour
2-Hour
3. Other
Normal
<6.1
<7.8
IFG
6.1-6.9
IGT
7.8-11.0
DM
7.0
11.1
investigation
-done for detection of any associated
complication
FBC
BUSE
Urine protein
Liver biochemistry
Random blood lipid
ECG
Managements:
First line:
-lifestyle modification (diet & physical activity)
a. Oral hypoglycemic agents
-metformin
-thiazolidinediones
-sulphonylureas
-meglitinides
b. injection therapy
-incretin mimetic
-DPP4 inhibitors
c. other therapies
-acarbose
-orlistat
-rimonobant
-gastric banding/bypass
d. insulin
e. consult on
-maintaining lean body weight
-exercise and stop smoking
-foot care

Clinical
Feature
s

Reason

Polyuria

Due to osmotic diuresis that

results when blood glucose
levels exceed the renal
threshold

Polydipsi
a and
thirst

Due to loss of fluid and

electrolytes

Weight
loss

Fluid depletion

Lethargy

Glucose is not utilized by the

cells

Headach
e

Loss of fluid and electrolytes

Polypha
gia

Glucose is not utilized by the

cells

Fever or
rash

Increase susceptibility to
infection

Acantho
sis
Nigrican
s

Increase circulating insulin

/insulin resistance

Breakdown of fat and muscle

secondary to insulin
deficiency

MEDICAL NOTES4
MOA and side effects:
1. METFORMIN
-primary tx in T2DM
-inc insulin sensitivity,
-reduce gluconeogenesis & microvascular risk
-do not coz hypoglycaemia or weight gain
ANOREXIA
EPIGASTRIC PAIN
DIARHOEA
LACTIC ACIDOSIS

- ADVERSE EFFECTS-

2. SULPHONYLUREA
bind to k+ channel of beta cell
ca2+ influx insulin secretion
-ADVERSE EFFECTHYPOGLYCEMIA & WEIGHT GAIN
3. TZD
-reduce insulin resistance
-reduce hepatic glucose production
-c/b use alone or in combination
-side effects:
weight gain
inc risk of heart failure
anemia & osteoporosis
ex- rosiglitazone & pioglitazone
4. MEGLITINIDES
-same as sulphonylureas
-ex: repaglinide
5. INCRETIN MIMETICS
-GLP1 & GIP (incretin from L cells of intestine)
-ex: exanatide
-2x daily injections
-promotes insulin release, glucagon
release
-reduce appetite, delays gastric emptying -induce weight reduction
Side effect: nausea and acute pancreatitis
6. DPP4 INHIBITORS
-Inhibit enzyme DPP4 which b/down incretin
-ex: sitagliptin, vildagliptin
-effective in early stage T2DM where insulin secretion is preserved.
Side effect: nausea
7. ACARBOSE
at brush borders
-reduce CHO absorption
fermentation
-SIDE EFFECTABDOMINAL DISCOMFORT
FLATULENCE
DIARHOEA

-Block alpha-glucosidase
-undigested starch

MEDICAL NOTES5
8. ORLISTAT
-lipase inhibitors
-reduce weight
-SIDE EFFECT: STEATORHOEA
9. RIMONOBANT
-induce weight loss
-SIDE EFFECT: MOOD CHANGES
10. GASTRIC BANDING/BYPASS
11. INSULIN
COMPLCATION:
* Injection site- allergic & lipohypertrophy
* Insulin resistance
* Weight gain- insulin increase appetite
* Hypoglycemia

PRACTICAL CHECKLIST:
A. HISTORY
Specific sx
Ex: Polyuria, Polydipsia,
Polyphagia,
Predispositio
n factors

> 35y, Family history,

Ethnic group,
Overweight, Physical
diabetes inactivity,
Hypertension, Obstetric
history of large babies or
Gestational diabetes,

-Cannabinoid

Risk factors

Systemic
review

Lifestyle
issue

MEDICAL NOTES6

Medication causing
hyperglycaemia,
Autoimmune disease
(personal and/or family
history of other
autoimmune diseases
e.g: hypo or
hyperthyroidism)
Personal or family history
of CVD, Smoking, HPT,
Dyslipidaemia
Cardiovascular
symptoms, Neurological
symptoms, Bladder and
sexual dysfunction, Foot
and toe problems,
Recurrent infections
(especially urinary and
skin)
Smoking, Alcohol,
Occupation, Eating and
physical activity

B. PHYSICAL EXAMINATION
C. INVESTIGATION
Baseline

others

Urinalysis: albumin,
microalbuminuria
Renal profile, blood
lipids
FPG, HbA1c
ECG ,TFT if indicated

acute

DKA
HHS
lactic acidosis
hypoglycemia

chronic

microangiopaht
y
macroangiopat
hy

diabetic
complicati
on

Weight and
waist
CVS

Eye
Feet

Peripheral
nerves

BMI and WC
BP, peripheral, neck
and abdominal system
vessels
Visual acuity,
cataract, retinopathy
Sensation and
circulation
Skin, pressure areas,
interdigital problem,
abnormal bony
architechture
Tendon reflex,
sensation, vibration

i. DKA
P/physiology: insulin deficiency with excess
uncontrolled catabolism.
Sx:

prostration, nausea, vomiting,

hormonal antagonists leading to

abdominal pain confusion, stupor,

coma

MEDICAL NOTES7
Signs:

ketone breath, hyperventilation,

Ix:

blood glucose, ketostick

ABG

Dx:

hyperglycemia+ ketonemia/

Mx:

-replace fluid lose

-replace electrolyte lose
-restore acid-base balance
-replace insulin deficient
-monitor blood glucose
-replace energy lose
-seek cause

ii. HHS

dehydration (dry skin),

subnormal

heavy ketonuria and acidosis

temperature

MEDICAL NOTES8