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is a condition in which a person has a high blood sugar(glucose) level as a result of the bodyeither not producing enough insulin, or because body cells do not properly respond to the insulin

that is produced. Insulin is a hormone produced in the pancreas which enables body cells toabsorb glucose, to turn into energy. If the body cells do not absorb the glucose, the glucose

accumulates in the blood (hyperglycemia), leading to various potential medical complications.[2]

y Mechanism of insulin release in normal pancreatic beta cells

Classification

There are many types of diabetes,[3]

the most common of which are:

y Type 1 diabetes: results from the body's failure to produce insulin, and presently

requires the person to inject insulin.y Type 2 diabetes: results from insulin resistance, a condition in which cells fail to use

insulin properly, sometimes combined with an absolute insulin deficiency.y Gestational diabetes: is when pregnant women, who have never had diabetes before,

have a high blood glucose level during pregnancy. It may precede development of type 2DM.

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y Type 1 diabetesy Type 1 diabetes mellitus is characterized by loss of the insulin-producingbeta cells of the

islets of Langerhans in the pancreas leading to insulin deficiency. This type of diabetes

can be further classified as immune-mediated or idiopathic. The majority of type 1diabetes is of the immune-mediated nature, where beta cell loss is a T-cell mediated

autoimmune attack.[2]

There is no known preventive measure against type 1 diabetes,which causes approximately 10% of diabetes mellitus cases in North America and

Europe. Most affected people are otherwise healthy and of a healthy weight when onsetoccurs. Sensitivity and responsiveness to insulin are usually normal, especially in the

early stages. Type 1 diabetes can affect children or adults but was traditionally termed"juvenile diabetes" because it represents a majority of the diabetes cases in children.

y Type 2 diabetesy Type 2 diabetes mellitus is characterized by insulin resistance which may be combined

with relatively reduced insulin secretion. The defective responsiveness of body tissues toinsulin is believed to involve the insulin receptor. However, the specific defects are not

known. Diabetes mellitus due to a known defect are classified separately. Type 2 diabetes

is the most common type.y In the early stage of type 2 diabetes, the predominant abnormality is reduced insulin

sensitivity. At this stage hyperglycemia can be reversed by a variety of measures and

medications that improve insulin sensitivity or reduce glucose production by the liver. As

the disease progresses, the impairment of insulin secretion occurs, and therapeutic

replacement of insulin may sometimes become necessary in certain patients

Gestational diabetes

Labor induction may be indicated with decreased placental function. A cesarean section may be performed if there is marked fetal distress or an increased risk of injury associated with

macrosomia, such as shoulder dystocia.

A 2008 study completed in the U.S. found that more American women are entering pregnancywith preexisting diabetes. In fact the rate of diabetes in expectant mothers has more than doubled

in the past 6 years.[8]

This is particularly problematic as diabetes raises the risk of complicationsduring pregnancy, as well as increasing the potential that the children of diabetic mothers will

also become diabetic in the future.

Signs and symptoms

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arepolyuria (frequent urination), polydipsia (increased thirst) andpolyphagia (increased

hunger)

CausesType 2 diabetes is determined primarily by lifestyle factors and genes.[12]

Type 1 diabetes may be triggered by certain infections, with some evidence pointing at

Coxsackie B4 virus. There is a genetic element in individual susceptibility to some of thesetriggers which has been traced to particular HLA genotypes (i.e., the genetic "self" identifiers

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relied upon by the immune system). However, even in those who have inherited thesusceptibility, type 1 diabetes mellitus seems to require an environmental trigger.

Concordance among monozygotic twins is close to 100%, and about 25% of those with thedisease have a family history of diabetes. Genes significantly associated with developing type 2diabetes, include TCF7L2, PPARG, FTO, KCNJ11, NOTCH2, WFS1, CDKAL1, IGF2BP2,

SLC30A8, JAZF1, and HHEX.[22]KCNJ11 (potassium inwardly rectifying channel, subfamily J,member 11), encodes the islet ATP-sensitive potassium channel Kir6.2, and TCF7L2

(transcription factor 7like 2) regulatesproglucagon gene expression and thus the production ofglucagon-like peptide-1.

[2]Moreover, obesity (which is an independent risk factor for type 2

diabetes) is strongly inherited.[23]

Diagnosis

GlycosylatedhemoglobinandGlucosetolerancetest

A glucose tolerance test is the administration ofglucose to determine how quickly it is clearedfrom the blood and homeostasis is maintained.

[1]The test is usually used to test for diabetes,

insulin resistance, and sometimes reactive hypoglycemia. The glucose is most often given orallyso the common test is technically an oral glucose tolerance test (OGTT). The intravenous

glucose tolerance test (IGTT or IVGTT) is rarely used. The test may be performed as part of apanel of tests, such as the comprehensive metabolic panel.

Glycated hemoglobin (hemoglobin A1c, HbA1c , A1C, or Hb1c; sometimes also HbA1c) is a form of

hemoglobin used primarily to identify the average plasmaglucoseconcentration over prolonged periods

of time. It is formed in a non-enzymatic pathway by hemoglobin's normal exposure to high plasma levels

of glucose. Glycation of hemoglobin has been associated with cardiovascular disease,nephropathy and

retinopathy in diabetes mellitus. Monitoring the HbA1c in type-1 diabetic patients may improve

treatment

1999 WHO Diabetes criteria[27]

Condition 2 hour glucose Fasting glucose

mmol/l(mg/dl) mmol/l(mg/dl)

Normal

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Impaired fasting glycaemia

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bodily systems significantly); a similarly confused connection between low dose alcoholconsumption and heart disease is termed the French Paradox.

[citationneeded]

y There is inadequate evidence that eating foods of low glycemic index is clinically helpfuldespite recommendations and suggested diets emphasizing this approach.[42]

y Diets that are very low in saturated fats reduce the risk of becoming insulin resistant and

diabetic.

[43][44]

Study group participants whose "physical activity level and dietary,smoking, and alcohol habits were all in the low-risk group had an 82% lower incidence ofdiabetes."

[13]In another study of dietary practice and incidence of diabetes, "foods rich in

vegetable oils, including non-hydrogenated margarines, nuts, and seeds, should replacefoods rich in saturated fats from meats and fat-rich dairy products. Consumption of

partially hydrogenated fats should be minimized."[12]

y There are numerous studies which suggest connections between some aspects of Type II

diabetes with ingestion of certain foods or with some drugs. Breastfeeding may also beassociated with the prevention of type 2 of the disease in mothers.[45]

y Medicationsy Some studies have shown delayed progression to diabetes in predisposed patients through

prophylactic use of metformin,

[40]

rosiglitazone,

[46]

or valsartan.

[47]

In patients onhydroxychloroquine forrheumatoid arthritis, incidence of diabetes was reduced by 77%

though causal mechanisms are unclear.[48]

Lifestyle interventions are however more

effective than metformin at preventing diabetes regardless of weightloss

y

Sulfonylureas

y First-generation agentso tolbutamide (Orinase)o acetohexamide (Dymelor)

o tolazamide (Tolinase)o chlorpropamide (Diabinese)

y Second-generation agentso glipizide (Glucotrol)

o glyburide (Diabeta, Micronase, Glynase)o glimepiride (Amaryl)

o gliclazide (Diamicron)

Meglitinides

y repaglinide (Prandin)

y nateglinide (Starlix)

Biguanides

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y metformin (Glucophage). Metformin may be the best choice for patients who also haveheart failure.

[4]Should be temporarily discontinued before any radiographic procedure

involving intravenous iodinated contrast as patients are at an increased risk of lacticacidosis.

y phenformin (DBI): used from 1960s through 1980s, withdrawn due to lactic acidosis

risk.

[5]

y buformin: also withdrawn due to lactic acidosis risk.[6]

Thiazolidinediones

y rosiglitazone (Avandia)

y pioglitazone (Actos)y troglitazone

:Insulintherapy

Insulin therapy is the treatment ofdiabetes by administration ofexogenousinsulin.

Insulin is used medically to treat some forms of diabetes mellitus. Patients with Type 1 diabetesmellitus depend on external insulin (most commonly injected subcutaneously) for their survival

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because the hormone is no longer produced internally. Patients with Type 2 diabetes mellitus areinsulin resistant, have relatively low insulin production, or both; certain patients with Type 2

diabetes, on rare occasions, may eventually require insulin if other medications fail to controlblood glucose levels adequately.

THE CASE HISTORY ON THE ENDOCRINOLOGYThe clinical diagnosis:

diabetum melitous, 1 type, the serious form, subindemnification.

the Angioretinopathia. An angiopathia of the bottom extremities. A distal

sensory polyneuropatia. Trophic infringements of calcaneal areas of both

stop. Amputating stump V of a finger left stops, III finger of the left arm. A

nephropathy III. A symptomatic hypertonia. Fatty dystrophia of a liver,

dyskinesia of biliferous ways. An ischemic disease, a stenocardia of a strain.

Normohromnaja an anemia.

NAMEPLATE DATA1. A surname, a name, a patronymic: ***** ********** **************2. Age: 46 flying3. A sex: man's4. A nationality: Russian5. Formation: srednetehnicheskoe6. A place of work, a trade: does not work - the invalid of II group; by a trade - thecarpenter7. A home address: . Pridonskoe

8. Date of entering in clinic: 15.07.20029. The diagnosis of the directed establishment: the Diabetic angiopathia of the bottomextremities

COMPLAINTS of the PATIENT AT ENTERINGOn whining, arching, sometimes - raking pains in the bottom extremities, especiallyexpressed in the field of a calcaneus, achille tendons and on border pljusnevyh bonesand phalanxes of fingers. Pains, the burning sensation, a pricking in stops of the patientconnects to purulent wounds on them.Purulent wounds in area achille tendons.Cramps in ikronozhnyh muscles which arise more often when the patient in time does

not accept the put medicine. Cramps are frequently accompanied by a plentifuldiaphoresis, a shiver in arms and in all a body, appreciable delicacy.Strong pressing headaches, especially bright in occipital and on border frontal andtemporal shares which amplify at change of weather, an emotional load. At considerablyexpressed headaches, accompanying with a giddiness and a nausea, sick measuredarterial pressure, and it appeared considerably increased - 240 and 130.Infringements of vision: all subjects seem shrouded in a mild screen, before eyesfrequently there is a hymenium which becomes more dense (" as ??") during an

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attack of strong headaches. The patient sees more precisely when has a rest and doesnot test any emotional discomfort.Gravity, pressure behind a breast bone which gripping pains sometimes join.Unpleasant sensations pass independently within 10-15 minutes, in dormancy calmdown much faster (in 5-7 minutes).

a Short wind arising at insignificant exercise stresses. Without a short wind can rise on1-st floor on crutches.Deterioration of appetite, dryness in a mouth, a constant heartburn.incidentally arising pains in the right the hypochondrium, sometimes bitter tastesaccompanying with feeling in a mouth. An edema of a belly and the right anticnemion.Whining back pains, which occurrence of the patient to anything does not bind. Painsamplify, stoped independently, last from 30-40 minutes till 1,5 o'clock, unpleasantemotions do not cause. An emiction 2-4 times day. At the night of the patient does notrise.the Stool regular, 1 once a day.Rising of evening temperature up to 37,5.

the HISTORY of the PRESENT DISEASECounts itself the patient during 21 years. For the first time has addressed to the doctor21 one year ago (in 25 flying) concerning sharp loss of weight (45-50 kg) for 2-3 years.Complained also of delicacy, a flaccidity, apathy, appreciable fatigability after a mildexercise stress, a strong diaphoresis. In a polyclinic on a residence the general analysisof a blood - a level of a glucose of 23 mmole/l has been made. The patient ishospitalized , lead a course of an insulin therapy. Felt like well, went for work, housesindependently applied preparations of an insulin.In the age of 36 and 41 years got in hospitals with the diagnosis " Gipoglikemicheskaja?a", Which came that the patient in time did not accept I peep. The loss ofconsciousness last no more than 3 minutes (from words of the patient).Constantly disturbed tooths - were blasted and were sick, approximately in 1997 year(the patient precisely does not remember) - false teeth (all).in the Summer 1999 years of the patient has wounded to stop in the field of a heel. Tothe doctor has not addressed, as a pain did not test, an erythema and a tumescence inthe field of a wound has not found out. The wound did not heal within 2 weeks,attributes of an inflammation have then appeared: a pain, a tumescence, an erythema,puffiness, has become inconveniently to attack a heel. The yellowish purulent dischargehas appeared. At a X-ray inspection the osteoporosis of both calcaneuses (from wordsof the patient) has been found out. Long treatment of a purulent wound appeared notsuccessful, periodically there come exacerbations. In 2000 year of the patient haspinned a little finger of the left leg, the wound also did not heal, then the purulentinflammation has become to be distributed, the gangrene began. Ablation of this fingeris lead. In this (2000) year the long finger of the left arm concerning a diabetic gangreneis amputated.

About 2001 years of the patient marks attacks of very high blood pressure (240 and130), accompanying with strong pressing headaches. In 2001 year infringements ofvision (a hymenium before eyes) have appeared.In the beginning 2002 years have appeared purulent is long not healing wounds and on

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other leg, with complaints to which exacerbation of the patient and have beenhospitalized during the present moment.to Words of the patient, the last 3 years he is treated in a hospital not less than 2 timesin year. Therapy is carried out concerning a high blood pressure and diabetic stops.Last time was hospitalized in April 2002 years. During the present moment accepts 8.00

- humulin NPH 16 ED + aktropid 8 ED; 17.00 - humulin R 5 ED, 22.00 - humulin NPH 10UNITS. In total for day of the patient receives 39.

the HISTORY of LIFE of the PATIENTWas born in Voronezh, in family of workers. Dews also developed in conformity with theyears. At school studied well, at known diligence - it is good. Has stopped prof. Those.

A school, has received a speciality of the carpenter - joiner. Worked on building objects.Periodically it was necessary to work in the street under adverse weather conditions(snow, a rain, a strong wind). From professional harmfulnesses marks an often raisingof gravities, contact to diabrotic and strongly smelling substances (a drying oil, paints,dissolvents). On work tried to not enter conflicts, with colleagues and the heads without

effort found common language. Now does not work, receives pension as the invalid of IIgroup. In the days off and holiday worked on a rate, sometimes - on the building objectsdemanding urgent delivery in operation.Smokes from 17-18 a flying. Now smokes a pack for 3 days, 3 years smoked on 2packs in day back. Alcohol does not use the last 5-7 flying, up to that - abused (" drankOnn??") .the Tuberculosis, oncologic, venereal diseases and AIDS denies. An allergy tofoodstuffs and medicinal substances, allergic diseases denies.It is married, to the son 19 flying.

At parents and close relatives of a sugar diabetes never was.

the PRESENT CONDITION of the PATIENT

The general inspection: a condition of the average patient, consciousness clear, but thepatient is slightly delayed: questions answers slowly, very much razdumchivo, but it iscorrect. Position of the patient active. A look quiet, a little bit released. Body buildnormosthenic.Body height of 184 sm, mass of a body - 85 kg. An index of mass of a body: 85 /1,842=25,1the General feed normal.Integuments acyanotic, hardly yellowish, labiums slightly cyanochroic, the person a littlebit bloated; on stops, anticnemions, a back surface of brachiums and in the field of aulnar joint plural light brown nevuses pigmentosus in diameter from 0,5 up to 1 see areobserved. A skin dry, cold, on anticnemions and stops rasping, peeling, with white large(0,3-0,5 sm) flakes, the turgor of it is reduced. In the right ileal area - cicatrix after anappendectomia. On both stops in area achille tendons - purulent wounds of 1*2 and2*3,5 sm - trophic ulcers.Nails convex, remind hour glasses under the form. A pilosis on man's type, moderate.Hair on a belly, it is especial on a white line, long, rigid. Hair on a head and a bodyalmost completely gray-haired.

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the Expressed edema of the right anticnemion. Ascites (the level of a liquid is notdetermined).Cervical, subclavial lymph nodes are not enlarged, the submandibular lymph node of0,5-0,7 sm, slightly morbid, with a skin not commissured on the right is palpated.the Muscle system is well advanced, the tonus and force of muscles sufficient, morbidity

of muscles of an anticnemion, are occasionally observed their cramps.Bones and joints of a regular form, are not deformed, at a palpation and a palpationpainless. It is amputated V a finger left stops and III finger of the left brush.the Body temperature subfebrile - 37,5.System of organs of respiration: a chest of a normal form, type of respiration belly, afrequency of respiratory movements=16, a rhythm of respiration correct, respirationdeep. In dormancy of a short wind is not present. A percussion sound clear above allpulmonary fields. Border mild on a mammilar line - the bottom edge of 6 ribs, onaverage axillary - the bottom edge of 8 ribs. Mobility of pulmonary edge on the right - 3sm, at the left - 4 see. At an auscultation rigid respiration in the top third mild, further -vesicular is auscultated. Individual dry whistling rhonchuses.

System of organs of a circulation: borders of heart are displaced to the left: the rightborder - 1-2 sm to the left from a right edge of a breast bone, top - the top edge of 4-thrib, left - is displaced to the left on 2-3 sm from a mammilar line.

At an auscultation: cardiac sounds rhythmical, a tachycardia (up to 100 impacts in oneminute), a rhythm correct. On an apex cardiac sounds are amplified, 1-st is especial. Onan aorta - accent and splitting of 2-nd tone. Hums are not present.the Pulsation of vessels of a neck and a forearm is well expressed. The pulsation a.dorsalis pedis is weakened on both legs.Pulse of rhythmical, 96 impacts in minutes, good filling and a strain.a blood pressure at the moment of inspection - 150 and 90. Maximal - 240 and 130. In adormant state - 140 and 90.System of organs of digestion: the smell from a mouth is not present. Labiums slightlycyanochroic, a mucosa of an internal surface of labiums, cheeks, firm and a soft palate,a mucosa of gingivas acyanotic, wet. Tooths are not present - plug-in. Tongue of theusual size, bright - crimson, slightly wet, with flattened papillas, with the dark yellowishraid more expressed on the right.the Belly enlarged in size, " ?nuO?a??", participates in the act of respiration. At asuperficial palpation moderate morbidity is revealed in the field of legal hypochondriumand in epigastric area. An ascites.the Liver acts on 0,5-1 sm for edge of a rib arch. The sizes on Kurlovu: 6, 8 and 12 see.The edge of a liver in connection with an expressiveness of a hypodermic fatty tissueand an ascites is good for palpating it was not possible. The lien is not palpated.System of a uropoiesis: an emiction free, painless, 3-4 once a day. Occasionally there isa mild morbidity in the field of a loin. Sign Pasternatskogo from both sides negative.Endocrine system: body height of 184 sm, weight of 85 kg, an index of mass of a body25,1: FROM 93 sm, ABOUT 102 sm, FROM / ABOUT=93/102=0,9. The isthmus of athyroid gland by thickness 0,5-0,7 is palpated. The smell of an acetone from a mouthat the patient is not present. Vision has worsened for last year. Legs cold, sensations ofa burning sensation and a pricking - a polyneuropatia. Palpebral fissures of the usualform, sick a proportional body build, normal body height. Secondary sexual attributes

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are well expressed.Nervous system: the consciousness is kept, speech clear, slightly time-lapse, mildblock. Memory on the current events is well kept, reduced on the last events (the patientcannot remember as for a long time there was an event, forgets names of medicines).Mood equal, reduced. The patient is disturbing. Pupils in diameter of 3 mm from both

sides. A straight line and sodruzhestvennaja reactions to light are expressed,symmetric. Paresises and paralysises are not present, pain sensitivity is reduced in thefield of both stop.

the DATA of LABORATORY AND TOOL METHODS of INSPECTION:

the General analysis of a blood:28.0818.09a haemoglobin 7866erythrocytes 2,62,46*1012a colour parameter 0,9leucocytes 10,2*109relating to stab neutrophile 3 %

segmentojadernye 72 %eosinocytes of 5 %lymphocytes of 12 %monocytes of 8 %a rate of gravitation of blood 59the General analysis of urine (30.07): transparence N, relative density 1010, fiber of 2,3mg / l, leucocytes 2-3, erythrocytes 5-6, hyaline cylinders 0-1.the Biochemical analysis of a blood (18.09): a urea 14,0, a creatinine 209, the generalfiber 63.the Biochemical analysis of a blood(16.08): nuclear heating plant 17, ALT 30, a bilirubinthe general 5,0, a urea 14,6, a creatinine 172, a cholesterin 5,3, lipoproteins 6,5, aprothrombin ratio 86, an amylase of a blood 5,0, the general fiber 69.

Assay Reberga (15.07): a daily urine 2,0, minute - 1,38, a creatinine of a blood - 172mmole/l, a creatinine of urine - 15,4 mmole/l, a filtration - 123,5 mmole/l (65-120),reabsorbtsija 98,9 (98 - 99) mmole/l.Glikemichesky a profile (15.07 : 8.00) - 19,1, 11.00 - 23,8, 14.00 - 11,3, 17.00 - 13,0,21.00 - 15,2 mmole/l.Glikemichesky a profile (13.09 : 8.00) - 9,7, 11.00 - 12,4, 14.00 - 8,4 mmole/l.an electrocardiogram:the Sinus tachycardia, an electric axis of heart - a normal position,a heart rate=100 impacts in minute, attributes of a hypertrophy of the left auricle and aleft ventricle. Ischemic changes on a forward wall and a septum of heart.the Tank. Crop on sensitivity of a flora to antibiotics: Oxacillinum, erythromycin,Cefazolinum, tsiprofloksatsin, Vancomycinum.

the DIAGNOSISdiabetum melitous, 1 type, the serious form, subindemnification. An angioretinopathia.

An angiopathia of the bottom extremities. A distal sensory polyneuropatia. Trophicinfringements of calcaneal areas of both stop. Amputating stump V of a finger left stops,III finger of the left arm. A nephropathy III. A symptomatic hypertonia.

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the SUBSTANTIATION of the DIAGNOSIS AND DIFFERENTIAL DIAGNOSISTaking into account, that disease began in pullet age (23-25 flying), proceededzlokachestvenno (high parameters of a glucose of a blood, predilection to hypoglycemiccomas, fast progressing, a forwardness of serious complications), the family anamnesisnot burdened on a sugar diabetes, we assume: diabetum melitous, 1 type, the serious

form. Taking into account complaints of sick vision to deterioration only in last year,absence of exercise stresses, stressful situations, traumas, we assume: anangioretinopathia, oslozhdenie diabetum melitous. For specification of a condition of thepatient and the diagnosis: consultation of the oculist, viewing of an out-patient dossier.Taking into account paleness, a cold snap of a skin of anticnemions, weakening ofpulse a. dorsalis pedis, characteristic complaints of the patient, the long experience ofsmoking, we assume: an angiopathia of the bottom extremities. We can think and of abeginning obliterating endarteritis. For specification - consultation angiohirurga. Takinginto account complaints of the patient on parestezii, cramps in ikronozhnyh muscles,changes pain chuvstvitelnsti, presence of trophic ulcers, dryness and an ecdysis of askin, we assume: a distal sensory polyneuropatia. Trophic infringements of calcaneal

areas of both stop (" diabetic ?Oa") . For specification: consultation of the neurologist,a roentgenogram of anticnemions and stop. Taking into account presence purulentseparated from a wound, an appreciable edema only one leg (right), a proof subfebrilefervescence of the patient, we assume a bacterial infection of a trophic ulcer right stops.For acknowledgement of the diagnosis: a tank. Crop, definition of sensitivity ofmicroorganisms to antibiotics, crop of a blood on a sterility. Taking into account theexpressed proteinuria (2,3 g/l), the expressed arterial hypertension, normal rate of aglomerular filtration, duration of disease about 23 flying, complaints of the patient onwhining, nagging pains in the field of a loin, we assume: a nephropathy III. Forspecification of the diagnosis: ultrasonic of kidneys, consultation of the nephrologist.Taking into account cases of rising of a blood pressure up to 240 and 130, complaints ofthe patient to the strong headaches, arisen year back, some odutlovatost his persons,we assume: a symptomatic hypertonia (renal). For specification: More carefulinterrogation of the patient: whether there were in family sick hypertonic diseases,whether there were at him attacks of rising of a blood pressure, whether they wereaccompanied by unpleasant sensations. Studying of an out-patient dossier. Taking intoaccount block of the patient, a memory impairment: we assume: initial attributes of anencephalopathy? Taking into account presence of pains at a palpation in the righthypochondrium, feeling of a bitter taste in a mouth, abusing alcohol a little bit flyingback, we shall assume: a dyskinesia of biliferous ways. For specification of thediagnosis: consultation of the gastroenterologist to lead duodenalnoe intubation, toinvestigate chemical properties of a gall. It is possible, that the fatty dystrophia of a liver(diabetum melitous in an anamnesis, abusing alcohol) is observed. Taking into accountlow parameters of a haemoglobin and erythrocytes of a blood, the normal CENTRALPROCESSING UNIT, the expressed tachycardia, paleness of integuments of thepatient, we assume: normohromnaja an anemia. Considering progressing of an anemia,morbidity in a zone of an epigastrium, presence of a liquid in an abdominal cavity, andalso smoking of the patient, we assume: a bleeding. Taking into account, that atpatients diabetum melitous pain sensitivity can be reduced, lead: macroscopical and ananalysis of a feces (to estimate colour, a consistence, presence of a blood).

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Consultation of the surgeon, the gastroenterologist. To recommend antianemicpreparations (Durules, Totema) .Uchityvaja complaints of the patient to pains in the fieldof heart, ischemic changes of a myocardium, attributes of a hypertrophy of the leftdepartments of heart (on an electrocardiogram), constantly high blood pressure, weassume: Ischemic disease, stenocardia. The differentiation is required: strains or

dormancy: detailed inquiry of the patient about his position, a condition, mood at themoment of occurrence of cardiac pains. If necessary - an exercise tolerance test.Probably also: an ischemic disease and a myocardiosclerosis as result of a diabeticmacroangiopathia (vessels of heart are amazed). Consultation of the cardiologist, at thedecision of a question on necessity koronaroarteriografii - the cardiosurgeon. Takinginto account block of the patient, some odutlovatost his persons, presence in ananamnesis of serious endocrine disease - to hand over a blood on TTG and 4. Weshall deny a hypothyroidism.Thus, the diagnosis it is possible to add to the following points: a fatty dystrophia of aliver, a dyskinesia of biliferous ways, a diabetic macroangiopathia, an ischemic disease,a stenocardia of a strain. An anemia.

THE LEAF OF PURPOSES:

1. the Table 9.2. 8.00 - humulin NPH 16 ED + aktropid 8 ED; 17.00 - humulin R 5 ED, 22.00 - humulin NPH 10

UNITS. In total for day of the patient receives 39.3. Tab. Erythromycini 0,25 - on 2 tablets of 5 times in day.4. Dressings with a lavage of wounds of 3 % solution 22 (Sol. Hydrogenii peroxydi diluta - 20 ml)

and hlorgeksidinom (5. Sol. Chlorhexidini 0,05 % - 500 ml). An aseptic bandage.

THE DIARY OF THE PATIENT18.09. The surgeon. Granulating wounds on each side achille tendons, the area about 7sm2. On walls of a wound - the purulent - necrotic discharge, is lead a partial cut ofwalls and a bottom of a wound. Positive dynamics, the area ranevoj surfaces isobserved decreases. To continue dressings.the Curator. Complaints to whining pains in the field of anticnemions and stop. Notstrong headache, a hymenium before eyes. Subfebrile temperature (37,1) Morbidityat a palpation in epigastric area. The patient is acyanotic, delayed, tired. Blood pressure150 and 90, pulse 96, a frequency of respiratory movements 16. A tachycardia, cardiacsounds rhythmical, clear, intensifying of tones on an apex of heart, accent and splittingof 2-nd tone on an aorta.19.09. The surgeon. A trophic ulcer with scanty serozno-hemorrhagic separated.the Curator. The patient recently has woken up, therefore looks delayed. The head does

not hurt, the hymenium before eyes is kept. Complaints to whining pains in ikronozhnyhmuscles. Temperature 37,0. a blood pressure 145 and 80, pulse 92 impacts inminute, a frequency of respiratory movements 14. The nystagmus is not present. Painsensitivity on stops is reduced.

the EPICRISIS***** ********** **************, 46 flying has acted 15.07 with complaints to pains, aburning sensation, a pricking in ikronozhnyh muscles, presence on both legs is long not

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healing purulent wounds. 5-th finger on left stop and 3-rd - on the left brush areamputated. Marks dryness in a mouth, headaches, a giddiness, a hymenium beforeeyes. Strong delicacy. It is sick of a sugar diabetes during 21-22 flying. The flying was illat 23-25, is acute, has lost in weight *gt; 40 kg. At initial hospitalization the level of aglucose in a blood has made 23 mmole/l. Constantly accepts preparations of an insulin.

For the last 3 years the condition has worsened: trophic ulcers have appeared, visionhas worsened, headaches and rising of a blood pressure up to 240 and 130 haveappeared. Objectively: presence on both stops in area achille tendons of trophic ulcerswith yellowish purulent separated. The expressed tachycardia (pulse about 100-105 inone minute). The patient is acyanotic, the plentiful diaphoresis is observed. The smell ofan acetone is not present. Level of a glucose of a blood at 11.00 (15.07) - 23,8 mmole/l.the infection of wounds by a staphylococcal flora, sensitive to erythromycin,Oxacillinum, Cefazolinum Is revealed. The expressed proteinuria (2,3). On anelectrocardiogram - attributes of ischemic changes of a forward wall and a septum ofheart. On the basis of an anamnesis, inquiry, the inspection, the given laboratory andtool methods of treatment, the diagnosis is put: diabetum melitous, 1 type, the serious

form, subindemnification. An angioretinopathia. An angiopathia of the bottomextremities. A distal sensory polyneuropatia. Trophic infringements of calcaneal areas ofboth stop. Amputating stump V of a finger left stops, III finger of the left arm. Anephropathy III. A symptomatic hypertonia. A fatty dystrophia of a liver, a dyskinesia ofbiliferous ways. An ischemic disease, a stenocardia of a strain. Normohromnaja ananemia.Disease proceeds hardly, with a plenty of burdensome complications, the forecastunfavourable.the Patient received preparations of an insulin (39 ED in day), an antibiotic erythromycin(2,5 g in day), dressings of wounds were carried out; the table 9 is appointed. Duringa presence in hospital the condition of the patient by way of correction diabetummelitous has improved (a level of a glucose has considerably come nearer to normal),but the general condition of the patient has become complicated by an anemia. Ingeneral treatment can be estimated as effective.References to the local doctor: To advise the patient to carry out exercises forconservation and improvements of a trophicity of extremities, to keep to a diet,supervise a level of a glucose in a blood, to eat it is high-grade and it is various. Thepatient should to stop smoke. To advise it to wear convenient clothes and footwear. Tosupervise a blood pressure of the patient, to pick up to it antianginalnye preparations,constantly to watch a level of a cholesterin and blood lipids.

Diabetes Lifestyle Choices

y Regular exercise is one of the best ways to help the cells use glucose efficiently and keepthe blood sugar from climbing to dangerous levels. Exercise also helps the body to lose

weight and use insulin more effectively. In the long term, it may also reduce insulinresistance.

y Instead of eating three large meals, have several smaller meals throughout the day to keepinsulin and blood sugar steady. Do not go longer than three hours without eating.

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y Don't smoke or expose yourself to second hand smoke. Diabetics are more vulnerable toheart and kidney damage, both of which are linked to smoking.

y Poor circulation and nerve damage can lead to foot ulcers in diabetics. Ensure goodcirculation in the feet by wearing shoes that fit well.

Diabetes Diet

y Eat foods that are rich in fiber. Fiber slows intestinal absorption of sugar and smoothesout blood sugar levels. Pears, beans, barley, blackberries and chick-peas are some sources

of fiber.y Okra is prescribed in Ayurveda as a remedy for blood sugar. Okra is quite delicious as a

steamed or roasted vegetable.y Prickly pear cactus is available in the Mexican sections of the grocery store. The pads can

be diced and used in a salad or taco. It helps with diabetes, obesity and elevated bloodcholesterol.

y Dandelion greens are hypoglycemic and they can be juiced or chopped into salads and

soups. Ingesting dandelion can improve lipid profiles, cholesterol and triglycerides indiabetic patients.

y Cinnamon, nutmeg, cashew, cayenne, ginger, turmeric, bay leaf, coriander seed, turnip,

lettuce, cabbage, cranberry, papaya fruit, millet, Jeruselam artichoke, barley, oats andbuckwheat are a few other foods helpful for a diabetic. Incorporate some of them into

your diet everyday.

Diabetes Herbal Remedies

y Turmeric Therapy ForDiabetes

One tsp of turmeric is added to some gooseberry(amla) juice and this mixture is

consumed everyday. Alternatively, turmeric extracts or capsules can be taken. This isvery effective in normalizing the blood glucose levels and reducing insulin resistance.

.Read other Turmeric home remedies.

y Fenugreeklowers Blood Sugar

Fenugreek is a good blood-sugar lowering herb. It is also cheap and can be easily workedinto dishes. It has a high soluble fiber content and alkaloids, which help with delayed

gastric emptying, slow carbohydrate absorption and glucose transport. Fenugreek may

also increase the number of insulin receptors in red blood cells and improve glucoseutilization in peripheral tissues, thus showing anti-diabetic properties in the pancreas andother organs. Read otherFenugreek home remedies.

y Onion and Garlic help Sugar Metabolism

Onions and garlic are significant hypoglycemic. The allicin and diallyl disulphidechemicals present in these lower glucose levels by competing with insulin in the liver.

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Clinical studies have shown that allicin in garlic combines with Vitamin B1 and stimulatethe pancrease to release more insulin. It also arrests the chemical receptors that deactivate

insulin. Onion and garlic not only help with insulin normalization, but also providesignificant cardiovascular benefits as well. Read other Garlic home remedies .

y Cinnamon helps Type 2 Diabetes

Cinnamon is beneficial to Type 2 diabetes as it can reduce blood sugar levels and

increase the body's natural production of insulin. It can also improve cholesterolmetabolism, remove artery-damaging free radicals from the blood and improve the

functioning of the blood vessels. Try to consume half a teaspoon of cinnamon beforebreakfast, for about 40 days. You can also add cinnamon in your diet by sprinkling it in

your cereal, tea or entree. .Read other Cinnamon home remedies.

y Aloe Vera Diabetes Home Remedy

Aloe juice is believed to lower blood sugar levels in people with type 2 diabetes. Aloecontains two chemicals - mannose and glucomannon; mannose helps open up the blood

vessels and glucomannon helps in triglyceride production. Check out food grade Aloejuice in your neighbourhood. Read other Aloe home remedies.

y Chicory Benefit ForDiabetes

Chicory is very beneficial to diabetics as it contains Inulin, a fiber that has a lowglycemic index and controls blood sugar levels. It can be used as a sweetner and added to

beverages. Chicory not only helps with blood sugar, but also reduces the serum LDLcholesterol levels in the blood. .Read other Chicory home remedies. .

y Neemreduces Insulin dependency

Neem can reduce insulin requirements without altering blood glucose levels. Regular

consumption of neem decoction or neem tablets is an effective alternative therapy fordiabetes. Read other Neem home remedies.

y Amla reduces Blood Sugar

One teaspoon of Amla juice mixed with a cup of bitter gourd juice is prescribed by

naturopaths as it stimulates the Pancreas and it will secrete enough insulin for reducing

blood sugar. Amla seeds or dried amla is equally invaluable for the control of Diabetes..Read other Amla home remedies.

y Mango Leaves forDiabetics

Diabetics fear ripe mangoes for their high sugar content! But, mango leaves help

normalize insulin levels in the blood. Boil a few mango leaves in water and allow it tosaturate through the night. Consume the filtered decoction in the morning for diabetic

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home remedy. Alternatively, dry mango leaves, powder and store. Add about a teaspoonand boil in water and consume the filtered decoction. .Read otherMango home remedies.

y Ashwagandha Treatment ForDiabetic Neuropathy

Ashwagandha, renowned for its adaptogenic and anti-inflammatory properties is veryeffective in cases of diabetic neuropathy. It improves the weakness, fatigue and weightloss due to diabetes. Ashwagandha can be consumed as capsules or tinctures. Read other

Ashwagandha home remedies.

y Tinospora help forDiabetes

Tinospora is very effective in resolving the symptoms of diabetes. Boil the stem pieces in500 ml of water for 30 minutes. Drink 50 ml of this tinospora extract twice daily for a

month. There will be a marked improvement in the condition. Read other Tinosporahome remedies.

y BitterGourd Diabetes Remedy

Bitter gourd or Karela(in Hindi) or balsam pear is a vegetable grown in Asia, Africa andSouth America. It contains a hypoglycemic or insulin-like principle, termed as "plant

insulin". It has been found to lower blood and urine sugar levels. Bitter gourd contain alectin which links together with insulin receptors and provide a way for managing Type 2

diabetes.Excessive usage of bitter gourd can cause diarrhea and abdominal discomfort. People

with hypoglycemia or low sugar levels should not take this.

y Gymnema kills Sugar Cravings

Gurmar, another name for Gymnema, means "killer of sweet" in Sansktrit. It can lowerblood sugar, blood fats, triglycerides, and cholesterol, and repair the liver, kidney and

muscle tissues. It shows potential for fixing pancreas malfunction, raising insulin outputto normal levels. Gymnema also acts on taste buds and the surface of the intestines, and

reduces the appeal for sugary foods. It is promising herb for both Type I and Type IIdiabetes.

y Stevia, the better sweetner

Stevia is thirty times sweeter than sugar and yet has 1 calorie per 10 leaves, and it istotally natural. It has a long history of use in South America and holds promise as asweetener for diabetics. Stevia has been found to lower blood sugar and blood pressure. It

also does not cause tooth decay like regular sugars.

y Green Tea's role in Diabetes

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Green Tea contain catechins and epicatechins, plant compounds belonging to the flavonolcategory. They are powerful antioxidants and found to be beneficial for diabetes. Green

tea can be consumed as a beverage, or a decaffeinated version can be ingested ascapsules.

y Apple Cider Vinegar usage forDiabetes

Apple cider vinegar has shown to reduce the raise of blood sugar after the consumption

of a high carbohydrate meal. Fermented foods like apple cider vinegar that contain aceticacid has been shown to lower blood sugar by helping store excess glucose in the liver,

thus reducing the body's rate of glucose production and absorption. Try to purchase applecider vinegar that is least processed and dark. Two teaspoons of apple cider vinegar can

be diluted in a cup of water and taken before the meal. You could also add the vinegar toyour salad or main course.

Diabetes, Healing With Supplements

y Vitamin C

Vitamin C helps prevent the sugar inside the cells from converting to sorbitol, a sugaralcohol that cells can neither burn for energy nor move out. Vitamin C may also be

beneficial in diminishing the damage to proteins caused by free radicals. Dietary sorbitolis not a danger to diabetics though, as it is poorly absorbed and is not transported into the

cells. Citrus fruits, guava and papaya are rich in Vitamin C. More on Vitamin C.

y Vitamin E

Diabetics need more anti-oxidant protection than normal, Vitamin E helps alleviate someof those risks to the heart. Diabetics are two to four times more vulnerable to heart

conditions. Vitamin E reduces the tendency for sugar to stick to proteins in the blood andcan lower the percentage of triglycerides.More on Vitamin E

y Magnesium

Magnesium is Anti-diabetic: It helps release insulin, maintenance of pancreatic insulinproduction cells, and maintenance of affinity and number of insulin receptors. More on

Magnesium.

y Chromium

Deficiency in Chromium not only affects sugar metabolism, but worsen the secondarysymptoms of numbness, tingling and pain in the hands and legs. Chromium is a key

player in sugar metabolism and hooks up with insulin in transporting sugar through thecell membrane and into the cell. Brewer's yeast, wheat germ, whole grains, cheese, soy

products, onions and garlic are rich in chromium.

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y B Complex Vitamins

Vitamin B6, B12 and Biotin have important roles to play in sugar metabolism.

Vitamin B6 deficiency can cause glucose intolerance, there is an abnormal

increase in blood sugar after eating. People with diabetes tend to be low in B

Vitamins, partly because the disease uses up most of them or they are

improperly absorbed and excreted in the urine.