Presenting problems in diabetes mellitus
Hyperglycaemia
Symptoms of hyperglycaemiaThirst, dry mouth
• Polyuria
• Nocturia
• Tiredness, fatigue, lethargy
• Change in weight (usually weight loss)
• Blurring of vision
• Pruritus vulvae, balanitis (genital candidiasis)
Headache
• Hyperphagia; predilection for sweet foods • Mood change, irritability, difficulty in concentrating, apathyNausea
Rapid weight loss are prominent in type 1 diabetes but are often absent in patients with type 2 diabetes, many of whom are asymptomatic or have nonspecific complaints such as chronic fatigue and malaise.
Uncontrolled diabetes is associated with an increased susceptibility to infection and patients may present with skin sepsis (boils) or genital candidiasis, and complain of pruritus vulvae or balanitis
Physical signs in patients with type 2 diabetes at diagnosis depend on the mode of presentation. In Western populations, more than 80% are overweight and the obesity is often central (truncal ‘ abdominal). Obesity is much less evident in Asians. Hypertension is present in at least 50% of patients with type 2 diabetes. Although dyslipidaemia is also common, skin lesions such as xanthelasma and eruptive xanthomas are rare.
Xanthelasma
Eruptive xanthoma
Presentation with the complications of diabetes
Patients with longstanding diabetes are at risk of developing a variety of complications and as many as 25% of people with type 2 diabetes have evidence of diabetic complications at the time of diagnosis.Diabetes may be first suspected when a patient visits an optometrist or podiatrist, or presents with hypertension or a vascular event such as an acute myocardial infarction or stroke. Blood glucose should therefore be checked in all patients presenting with such pathology.
Diabetes emergencies
1- Diabetic ketoacidosis2- Hyperglycaemic hyperosmolar state
3- Hypoglycaemia
Diabetic ketoacidosis
Diabetic ketoacidosis (DKA) is a medical emergency and remains a serious cause of morbidity, principally in people with type 1 diabetes. Mortality is low in the UK (approximately 2%) but remains high in developing countries and among nonhospitalised patients.
Mortality in DKA is most commonly caused in children and adolescents by cerebral oedema, and in adults by hypokalaemia, acute respiratory distress syndrome and comorbid conditions such as acute myocardial infarction, sepsis or pneumonia.
In established type 1 diabetes, DKA may be precipitated by an intercurrent illness because of failure to increase insulin dose appropriately to compensate for the stress response. Sometimes, there is no evidence of a precipitating infection and DKA develops because of errors in selfmanagement.
Clinical features of diabetic ketoacidosis
Symptoms• Polyuria, thirst
• Weight loss
• Weakness
• Nausea, vomiting
• Leg cramps
• Blurred vision• Abdominal pain
Signs
• Dehydration
• Hypotension (postural or supine)
• Cold extremities/peripheral cyanosis
• Tachycardia
• Air hunger (Kussmaul breathing)
• Smell of acetone• Hypothermia
• Delirium, drowsiness, coma (10%)
The cardinal biochemical features are:
• hyperketonaemia (≥ 3.0 mmol/L) or ketonuria (more than 2+ on standard urine sticks)• hyperglycaemia (blood glucose ≥ 11.1 mmol/L (approximately 200 mg/dL))
• metabolic acidosis (venous bicarbonate < 15 mmol/L and/ or venous pH < 7.3 (H+ > 50 nmol/L)).
Abdominal pain is sometimes a feature of DKA, particularly in children, and vomiting is common. Serum amylase may be elevated but rarely indicates coexisting pancreatitis. In infected patients, pyrexia may not be present initially because of vasodilatation secondary to acidosis
Investigations
The following investigations are important but should not delay the institution of intravenous fluid and insulin replacement:•Venous blood: for urea and electrolytes, glucose, bicarbonate and acid–base status