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SESSION

Khawaja Yunus Ali Medical College Hospital

Dept. of Medicine
Unit- II
Presentation
Investigation
Diagnosis
Features of the metabolic syndrome:

 Type 2 diabetes or impaired glucose tolerance

 Central (visceral ) obesity
 Hypertension
 Elevated triglycerides Low HDL cholesterol;
 Microalbuminuria
 Hyperinsulinaemia
 Increased fibrinogen
 Elevated plasma uric acid
Clinical presentation of DM:
Asymptomatic
Typical / Classical symptoms
Atypical/unusual symptoms
With micro/macroangiopathy
 COMPARATIVE CLINICAL FEATURES OF TYPE 1 AND
TYPE 2 DIABETES
Type 1 Type 2

Age at onset <30 yrs >30 yrs

Duration of symptoms Weeks Months to Year

Body weight Normal or low Obese

Genetic correlation less,HLA linked more

Insulin reserve Absent / low Normal / high

Ketonuria Yes No

Rapid death without insulin Yes No

Auto antibodies Yes No

Acute complication DKA HONK

Family history of diabetes Uncommon Yes

 APPROACH TO THE PATIENT
History should be taken with special emphasis
on DM-relevant aspects such as :
weight,
family history of DM
risk factors for cardiovascular disease,
Past illness.
Exercise.
Smoking.
Alcohol.
PHYSICAL EXAMINATION

1. Weight or body mass index

2. Blood pressure
3. Peripheral pulses
4. Foot examination
5. Lower extremities
6. Vibratory sensation
7. Insulin injection sites.
8. Retinal examination
9. Teeth and gums should also be examined.
Thirst,
Dry mouth
Polyuria
Nocturia
Tiredness, fatigue
Recent change in weight
Blurring of vision
Nausea, headache
Hyperphagia;
Mood change, irritability, difficulty in
concentrating, apathy
 PHYSICAL SIGNS
Type 2 diabetes
The physical signs in patients with type 2 diabetes at
diagnosis depend on the mode of presentation.
More than 70% are overweight, and obesity may be
central (truncal or abdominal).
Hypertension is present in at least 50% of patients with
type 2 diabetes.
Although hyperlipidemia is also common, skin lesions
such as xanthelasma and eruptive xanthomas are rare.
Classical type 2 diabetes is increasingly recognised in
obese sedentary young people, including children.
 EXAMINATION OF THE HANDS

Limited joint mobility ( 'cheiroarthropathy') may be present; this is
the inability to extend (to 180°) the metacarpophalangeal or
interphalangeal joints of at least one finger bilaterally. The effect
can be demonstrated in the 'prayer sign'. It causes painless
stiffness in the hands, and occasionally affects the wrists and
shoulders.

Dupuytren's contracture : common in diabetes and may include
nodules or thickening of the skin and knuckle pads.

Carpal tunnel syndrome : common in diabetes and presents
with wrist pain radiating into the hand.

Trigger finger (flexor tenosynovitis)

Muscle-wasting/sensory changes may be present as features of
a peripheral sensorimotor neuropathy, although this is more
common in the lower limbs.
 Stress hyperglycemia

In some people, an abnormal result is observed

under conditions which impose a burden on the
pancreatic β cells, e.g.
during pregnancy,
infection,
myocardial infarction or other severe stress,
During treatment with diabetogenic drugs such
as corticosteroids.
 This 'stress hyperglycemia' usually
disappears after the acute illness has resolved,
but blood glucose should be remeasured.
 Renal glycosuria
 The greatest disadvantage of using urinary
glucose, as a diagnostic or screening procedure is
the individual variation in renal threshold for
glucose.

 The most common cause of glycosuria is a low

renal threshold, which is common during
pregnancy and in young people.

 Renal glycosuria is a benign condition unrelated

to diabetes.
 Alimentary glycosuria

A rapid but transitory rise of blood glucose follows a
meal and the concentration exceeds the normal renal
threshold; during this time glucose will be present in
the urine. This is described as alimentary glycosuria.

It may occur in
normal people
after gastric surgery, when it is caused by rapid gastric
emptying and more rapid absorption of glucose into the
circulation,
with hyperthyroidism,
peptic ulceration or
hepatic disease.
1. Urine examination:
 sugar: Benedict test
 ketone bodies: Rothera's test to detect ketonuria
 protein: Heat coagulation test

2. Blood glucose determination:

 Random blood glucose
 Fasting blood glucose
 Oral glucose tolerance test( OGTT)

3. Glycosylated Hb test:
Normal 4-6% of total Hb are glycosylated
 DIAGNOSIS OF DIABETES

Patient complains of symptoms suggesting

diabetes
Test urine for glucose and ketones
Measure random or fasting blood glucose. Diagnosis
confirmed by*:
 Fasting plasma glucose ≥7.0 mmol/l (126 mg/dl)
 Random plasma glucose ≥11.1 mmol/l (200 mg/dl)

In asymptomatic patients
two samples are required to confirm diabetes.
Documented on more than one occasion
Patient complains of symptoms suggesting diabetes:

 Test urine for glucose and ketones

 Measure random or fasting blood glucose. Diagnosis confirmed by*:

Fasting plasma glucose ≥7.0 mmol/l (126 mg/dl)

Random plasma glucose ≥11.1 mmol/l (200 mg/dl)

 Indications for oral glucose tolerance test

 Fasting plasma glucose 6.1-7.0 mmol/l (110-126 mg/dl)
 Random plasma glucose 7.8-11.0 mmol/l (140-199 mg/dl)

 * In asymptomatic patients two samples are required to confirm

diabetes.
 HbAlc is not used for diagnosis.
 OGTT

This is the standard procedure to classify a

person as a diabetic, IGT, IFG or non diabetic.

Indications for oral glucose tolerance test

Fasting plasma glucose 6.1-6.9 mmol/l (110-125 mg/dl)
Random plasma glucose 7.8-11.0 mmol/l (140-199 mg/dl)
ORAL GLUCOSE TOLERANCE TEST
(OGTT)
OGTT Procedure :
Unrestricted carbohydrate diet, at least 150 gm of CHO daily
for at least previous 3 days
Fasted overnight (8-14 hrs )
Rest before test (30 mins); 1st blood sample: Fasting blood
prior to glucose drink.
Glucose drink: 75 gram oral glucose load dissolved in a
glass of water (250-300 ml). In case of children,1.75gm/kg
body weight up to maximum 75 gm.The drink must be
completed with in 5 minutes.
2nd blood sample: 120th min after the glucose drink
 smoking; tea, physical stress is not allowed during test.
Results are for venous plasma - whole blood values are
lower.
 Interpretations:
Venous plasma mmol/l (mg/dl)

Noemal:

Fasting <6.1

2 hrs after glucose load <7.8

Impaired fasting glycaemia

Fasting ≥6.1 to <7.0

2 hrs after glucose load < 7.8

 Interpretations:
Venous plasma mmol/l (mg/dl)

Diabetes:

Fasting ≥7.0 (≥126)

2 hrs after glucose load ≥11.1 (≥200)

Impaired glucose tolerance:

Fasting < 7.0 (< 126)

2 hrs after glucose load ≥7.8 to < 11.1 (140-199)

 Glycosylated haemoglobin (HbA1 or
HbA1c) and fructosamine

Glycosylation of haemoglobin occurs as a two-step reaction,

covalent bond between the glucose molecule and the terminal
valine of the |3 chain of the haemoglobin molecule.

The rate at which this reaction occurs is related to the

prevailing glucose concentration.

Glycosylated haemoglobin is expressed as a percentage of

the normal haemoglobin (standardized range 4-6.5%).

This test provides an index of the average blood glucose

concentration over the life of the haemoglobin molecule
(approximately 6 weeks).

The figure will be misleading if the life-span of the red cell is

reduced or if an abnormal haemoglobin or thalassaemia is
present.
Glycosylated plasma proteins ('fructosamine')
may also be measured as an index of control.

Glycosylated albumin is the major

component,and fructosamine measurement
relates to glycaemic control over the preceding 2-
3 weeks.

It is useful in patients with anaemia or

haemoglobinopathy and in pregnancy (when
haemoglo bin turnover is changeable) and other
situations where changes of treatment need a
swift means of assessing progress.
Regular checks for patients with diabetes:

Checked each visit:

Review of self-monitoring results and current
treatment.
Talk about targets and change where
necessary. -
Talk about any general or specific problems.
Continued education.
Checked at least once a year:

 Biochemical assessment of metabolic control (e.g.

glycosylated Hb test).
 Measure bodyweight.
 Measure blood pressure.
 Measure plasma lipids (except in extreme old age).
 Measure visual acuity.
 Examine state of retina (ophthalmoscope or retinal photo).
 Test urine for proteinuria/microalbuminuria.
 Test blood for renal function (creatinine).
 Check condition of feet, pulses and neurology.
 Review cardiovascular risk factors.
 Review self-monitoring and injection techniques.
 Review eating habits.
THANK YOU