interactive case discussion diabetes
TRANSCRIPT
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Interactive Case
DiscussionBy:
Mohd Safwan
Siti Noor Atikah
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Mr. A 32 years old Malay male teacher Single
Presents himself to clinic as he worried about his weight andhealth. He had been persistently gaining weight for last 2years as he gained 18kg throughout those years.
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Discussion Points 1
What further history would you elicit from
this patient?
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Further history
He was chubby since secondary school, which it was a boys school,he doesnt have problem with his friends though he quite frequently
teased by his friend due to his appearance.
The problem started during his university time, he got difficulty in
mingle around with his other female colleagues as he was not
confident about his appearance.
He found himself difficult to approach lady for a date even, because
of the issue and end up single until now.
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Further history
No polyuria, polydipsia, polyphagia, weight loss, nocturia, fatigue
and altered vision. He tried to lose his weight many times before but found difficult to
be persistent and ultimately give up.
Both her parents are overweight and diabetic.
Doesnt smoke or taking alcohol.
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Further examination findings
Well looking obese man BP : 118/80mmHg
Antropometric measurements;
Weight 100kg
Height 170cm
BMI kg/m2
Waist to hip circumference
ratio
34.6
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How to diagnose?
Discussion Points 2
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Commonsymptoms:
PolyuriaPolydipsiaTirednessWeight loss
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Capillary Blood
Glucose:
5.7mmol/L
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Fasting Venous Plasma
Glucose:
6.7mmol/L
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OGTT
FPG:7.2 mmol/L
2 Hours PPG:
12 mmol/L
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Discussion Points 3
Summarize his current problems.
How would you manage this gentleman
now?
What is his target blood sugar?
How to use the insulin injection?
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Futher assess:
Risk factor andDM complication
Cardiovascular
Respiratory
Abdominal
Relevant
Examination
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HbA1c: 7%
TG:
HDL:LDL:
Albuminuria
Creatinine/BUNUrine microscopy
ECG
Normal
In this patient:
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Summary of his Problem:
1. He is obese.
2. Having difficulty in exercise as hardly to
do it persistently and ultimately give up.
3. Also having difficulty in diet control.
4. With family history of diabetes mellitus
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Management of diabetes
mellitus
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PLIMS
Patient education
Lifestyle modification
Investigation
Medication/Drug therapy
Safety netting/Follow up
Principle of management
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Patient education
Educator consist of doctor, nurse, assistant
medical officer, health education officer,
dietitian and others.
Objectives:
1. To reassure and alleviate anxiety.
2. To understand the disease, its management
and complication.
3. To promote compliance and self-care.
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Content:
Diet Exercise
Medication
Stop smoking, alcohol Complications (acute and chronic)
Self-care/self blood glucose monitoring
(SBGM)/foot care Psychosocial adaptation to diabetes
(occupation)
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Lifestyle modification
Physical activity
Medical nutrition therapy (MNT):
Prevention of diabetes1. Weight loss
2. Balanced diet
3. Take high fibre diet
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Management of diabetes
1. Meal timings should be regular &synchronised with medication time actions.
2. Diet consist of carbohydrate from cereal,
fruits, vegetables, legumes, and low fat orskimmed milk.
3. Limit intake of saturated fatty acids, trans-
fatty acids, and cholesterol to reduce risk ofCVD.
4. Reduced sodium intake
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Investigation
Venous plasma glucose
- fasting plasma glucose (FPG)
- random plasma glucose (RPG)- Oral glucose tolerance test (OGTT)
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Assessment of cardiovascular risk and end organ
damage:- blood pressure
- glycosylated haemoglobin (HBA1c)
- BMI
- lipid profile- renal profile
- urine analysis particularly for albuminuria
- ECG- eye; visual acuity & fundoscopy
- feets; pulses & neuropathy
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Drug management and Follow Up
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Oral Anti-Diabetic (OAD) Agents
1. Biguanides (metformin)
Does not stimulate insulin secretion, but lowers blood glucose by decreasing
hepatic glucose production.
Lower plasma glucose up to 20% as 1st line drug treatment esp. in
overweight/obese patient.
Should not be used in ptn with impaired renal function, liver cirrhosis, CCF,
recent MI, or any other condition that cause lactic acid accumulation.
2. -glucosidase inhibitors (AGIs) (acarbose)
Act at the gut epithelium to reduce the rate of digestion of polysaccharidesin the proximal small intestine by inhibit -glucosidase enzymes.
Should be taken with meals.
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DPP-4
enzymeprevent
breaks down
GLP-1
&GLP
insulin
glucose
glucagon
DPP-4 inhibitor
_
= glucose
3. Dipeptidyl peptidase-4 (DPP-4) inhibitors (sitagliptin)
Act by inhibit DPP-4 enzyme. This enzyme break downs the incretins
GLP-1 and GIP that are released in response to meal. By preventingGLP-1 and GIP inactivation, insulin will increase and glucagon is
suppressed. This drives blood glucose levels towards normal.
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4. Insulin secretagogues Sulphonylureas (Sus)
SUs lower plasma glucose by increasing insulin secretion.
Major SE is hypoglycemia, but 2nd generation Sus (glimepiride, gliclazide
MR) cause less risk of hypoglycemia & less weight gain.
Taken 30 min before meal.
Insulin secretagogues Non-Sus or Meglitinides
Short acting insulin secretagogues which lower plasma glucose by
increasing insulin secretion, they bind to different site within the SU
receptor.
Taken 10 min before meal.
5. Thiazolidinediones (TZDs)
Act by increasing insulin sensitivity of muscle, adipose tissue, & liver to
endogenous & exogenous insulin (insulin sensitizer)
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Insulin therapy
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Thank you