Unit 3 Objectives
By the end of this module participants will be able
to:

Discuss the clinical manifestations of diabetes
with peculiarities of Type 1 and Type 2 DM
Describe the initial approach in the work up of a
newly diagnose diabetic patient.
Explain the different complications of diabetes.
Discuss acute complications of DM and their
management.

Case 1.

A 24 yrs male patient presented with history of polyuria, polydypsia of 2 weeks duration, he gives history of weight loss of 3 kgs. On arrival the doctor in the medical OPD evaluated him and ordered an urgent Blood sugar and Urine analysis. The result appeared after 30 minutes
showed Random blood sugar of 287 mg/dl and Urine
sugar of 2 +, no ketonuria.
Question 1.
- What is the diagnosis of the patient?
- What additional information do you like to know?
- What additional tests do you want to do?

Case 1 Ans.
• Type 1 diabetes mellitus
• Detailed history and physical exam
• Baseline Lab tests

Case 2.
• A 47 yrs old male patient presented with history of profound weakness, fatigue, weight loss of 2 months duration. He developed cough, running nose, sneezing and headache of 2 days duration for this he visited a private clinic in early morning.
• His physical examination was non revealing except he had runny
nose and nasal congestion.
• The lab result revealed, normal CBC, FBS 178 mg/dl.
 Questions

What is the diagnosis of this patient?
How do you confirm the diagnosis?
What additional information do you want to know?

Case 2. Ans.

1. Type 2 diabetes mellitus with URTI
2. Repeat FBS, HbA1c, RBS.
3. Additional history, physical exam and Baseline lab tests

Clinical Manifestations of Diabetes Mellitus

Clinical Manifestations of Diabetes
Mellitus

Most Type 1 diabetes mellitus and few type 2
diabetic patients usually present with
– Increased thirst and Polydypsia
– Polyuria and nocturia
– Polyphagia
– Unexplained weight loss and
– muscle wasting
– Extreme fatigue

Clinical Manifestations of DM….

About half of type 2 diabetes patients may
remain asymptomatic or might have non
-specific symptoms
More than 50% of type two diabetic patients are
undiagnosed.
Some type 2 DM patients can present with
chronic complications of diabetes mellitus.

Clinical Manifestations of DM….
Other features of DM are:

Blurred vision,
Recurrent skin infections,
Recurrent itching of the vulva,
Abnormal sensory/ motor neurologic findings
on extremities,
Foot abnormalities (various deformities,
ulcers, and ischemia) could be presenting
signs.
Symptoms and Signs of Acute complications

Complications of Diabetes
Diabetes or its treatment can cause acute
complications or long term complications
a) Acute
b) Chronic

a) Acute Complications of DM
1. Diabetic Ketoacidosis (DKA)
2. Hyperglycemic Hyperosmolar State (HHS)
3. Hypoglycemia – Complication Of Treatment

Initial Evaluation of DM

Aims of initial evaluation
– Classify the diabetes
–Detect the presence of diabetes
complications
–Review previous treatment and glycemic
control in patients with established diabetes
–Assist in formulating a management plan
– Provide basis for continuing care

Comprehensive diabetes evaluation
• MEDICAL HISTORY
– Age and characteristic of onset of diabetes (e.g. DKA,
asymptomatic lab finding)
– Eating (dietary) patterns, physical activity habits,
nutritional status, and weight history; in children and adolescents Growth & Development)
– History of associated conditions like hypertension
– History of diabetes related complications
• Acute: DKA, Hypoglycemia, HHS
• Chronic:
– Macro vascular: CHD, CVD,PAD
– Micro vascular: retinopathy, Nephropathy, neuropathy (sensory, including history of foot lesions, autonomic, including sexual dysfunction and
gastro-paresis)
– Other: Psychosocial problems, dental disease

PHYSICAL EXAMINATION
• Height, weight and BMI, waist circumference
• Blood pressure determination, including orthostatic measurements when indicated
• CVS
• Thyroid palpation(Type 1 DM)
• Skin examination for Acanthosis nigricans, infections
• Neurologic exam
• Fundoscopic examination
• Comprehensive foot exam

Also Read Nyaata Yeroo Soomaa Afuura Namaa Sassaabu - Teemira

Waist Circumference
• Normal
– Males – <94 cm
– Females – <80 cm
• Measure midway between lower costal margin & iliac crest

Comprehensive foot examination
– Inspection
– Palpation of dorsalis pedis and posterior tibial
pulses
– Presence/ absence of patellar and Achilles
reflexes
– Determination of proprioception, vibration and
monofilament sensation

Use the 60 second screening tool for Diabetes foot

Laboratory evaluation
– For making diagnosis
• FBS
• RBG
• HgA1C
– Other lab evaluations
• Liver function tests
• Serum Creatinine
• Fasting lipid profiles
• Urine analysis= Protienuria, ketonuria, glucosuria,
infection
• TSH in Type 1 DM, in patients with Dyslipidemia, or
women over age 50Yrs

Referral for initial care management
Diabetic patients may need evaluation and care by different health professionals.
• Eye care professional for annual dilated eye exam.
• Family planning for women of reproductive age.
• Preconception care for women
• Dentist for comprehensive dental and
periodontal examination.
• Mental health professional, if indicated.

Acute complications of DM

Diabetic Ketoacidosis (DKA)
Hyperglycemic Hyperosmolar
State ( HHS)
Hypoglycemia

Case Study 3.
A 28 yrs old Type 1 Diabetic who has been on NPH
insulin 22 IU, am and 12 IU, pm, SC. developed cough,
chest pain and fever of four days duration. These
symptoms were accompanied by polyuria, polydypsia, vomiting and abdominal pain of two days duration.
• On Physical Examination: Patient has deep breathing, is
confused,
• B/P, : 80/50mmHg, pulse 124/minute,Temp.38,6oC.,
• Sunken eyes, Bronchial breath sounds in the Left lower posterior lung field.
Questions
✓ What are the Diagnoses of the patient?
✓ How do you confirm the diagnosis?

Case 3. Answers.
1. Type 1 DM, DKA, Pneumonia
2. FBS/RBS,Urine analysis ,Urine ketone/sugar,
CXR
N.B. Patient results were:
• RBS 450 mg/dl,
• Urine sugar :4+,
• Urine ketones 3+,
• CXR: Homogenous opacification in the left lower lung field

DKA & HHS
• very serious DM complications
• if untreated both are life threatening
• both are preventable
• have overlapping features
• both result from relative or absolute insulin deficiency

DIABETIC KETOACIDOSIS
Introduction:

Diabetic ketoacidosis (DKA) is a condition in
which there is severe disturbances in metabolism of carbohydrate (severe hyperglycemia), protein (Catabolism), and fat (lipolysis) that result from insulin deficiency
This state of severe hyperglycemia and ketone body production results in volume depletion, acid-base and electrolyte abnormalities.

DKA: Introduction cont.
• It often occurs in type 1 diabetes patients but may also occur in type 2 diabetes.
• DKA is a medical emergency requiring urgent
treatment as mortality ranges from 10 to 30%
in resource limited settings like Ethiopia.
• It is characterized by:
– hyperglycemia (BG>250mg/dl)
– ketosis (urine ketone >/= 2+)
– acidosis

DKA Introduction Cont.
• The precipitating factors of DKA include:
– previously undiagnosed and untreated diabetes,
– Insulin errors, omissions and non-adherence
– stress of Intercurrent illness (e.g., Pneumonia,
meningitis, UTIs, Acute Febrile Illnesses, Trauma, myocardial infarction, stroke, surgery, etc)
– Drugs e.g. steroids, cocaine
– Pregnancy
– psychological stress
– no precipitant factors could be found in up to 20-30% of cases

DKA-Clinical features:
• Clinical features may include worsening poly symptoms:
–excessive urination,
– excessive thirst and,
–excessive drinking of water
• Non specific symptoms like malaise, fatigue, nausea, vomiting,
abdominal pain (may mimic acute abdomen)
• Signs of dehydration with:
–dry skin and
–reduced skin turgor or sunken eyes
–low blood pressure and
–fast and weak pulse.

Also Read Fayyadama Yeroo Suhuurii

DKA-Clinical features…
• Signs and symptoms of acidosis and ketosis,
• deep and fast breathing, and
• ‘Fruity’ breath (smell of acetone).
• Altered level of consciousness (depressed mentation to coma)could be a feature of severe DKA.
• Symptoms of infection or other underlying condition

Laboratory
If you find such clinical features
HC
• Serum/finger prick glucose
• urine analysis – ketones , glucose, leucocytes
• Complete blood count
• pregnancy test in women of child bearing age
• others tests as per the clinical indications
In Primary and General Hospitals
• Serum electrolytes (K, Na),
• renal function,
In Tertiary Hospitals
• blood gas analysis ,
• calculation of anion gap and serum osmolality should be done.

Diagnose DKA
• Based on clinical symptoms and signs and
– RBS > 250 mg/dl
– Positive Urine ketone (2+ and above)
– Glucosuria
NB: Some patients can develop DKA even at lower
blood glucose levels e.g. Diabetic Pregnant women, partially corrected blood glucose due insufficient dose of insulin.

Management of DKA and HHS
(See Algorithm III)
1. Attention to ABC immediately on arrival !!!
2. Fluid deficit in HHS is up 10 liters or more
in DKA often 3 to 5 liters
Type of fluid to administer:
– start with N/S
– once BG ≤ 250 mg/dl change IV fluid to 5 %
dextrose in water(5 % D/W)

Management of DKA/HHS……

initial fast hydration (1-2 lit. in the 1st hr) then based on response
follow – hydration status
UOP & electrolytes
avoid fluid overload
Generally replace 50% of total deficit in 8 hrs, the rest in 16 hr

Management of DKA/HHS…
3. Insulin
• IV infusion of regular insulin is the standard treatment
– doses: 0.1 Units/kg/hr with initial bolus of 0.1-0.15Units/kg
– let 50 ml fluid through the line before starting infusion
• However if insulin pump is not available the following is preferred:
– IV 0.1u/kg stat+
– 0.1 Units/kg IV Q 1hr or subcutaneously every 1-2 hours
• Postpone insulin Rx if patient is hypotensive or severely hypokalemic until this is corrected

Management of DKA/HHS…
Goal: blood glucose should decrease by 50-75mg/dl/hr
• If target not achieved increase the hourly insulin dose by 50%
• If blood glucose falls below 250mg/dl shift to 5% D/W
• decrease hourly insulin dose by 50% when blood
glucose<200 mg/dl
• Continue infusion till ketone clears
• Keep BG between 150 & 200 mg/dl
• When ketone clears shift to standing NPH Insulin S.C with
additional hourly Regular insulin based on Blood glucose for 2 hrs.

Case Study 4
• A 67 yrs. old male patient from Adama , Known case of diabetes mellitus for the last 25 yrs. on Glibenclamide of 5mg Bid, presented with history of pain and Ulceration of Rt. foot of one month duration. These symptoms were accompanied by polyuria, polydypsia, generalized weakness and vomiting.
• On Examination patient was comatose, BP: 90/60
mmHg, temp, 36.8oc, ulcerated rt. Foot, with purulent discharge.
• His RBS was > 600 mg/dl.
Question
• What are the specific diagnoses of this patient?
• How do you manage this patient?

Case 4. Answers
Diagnosis
1. Type 2 diabetes mellitus
2. Diabetic Foot infection
3. Hyperglycemic Hyperosmolar State (HHS)
Management
– See Algorithm 3 for HHS
– Diabetic foot infection—refer Module 4

Hyperglycemic Hyperosmolar State (HHS)
• It is less common than DKA, but results in more death than DKA because it mainly affects the elderly and those with co – morbidity.
• Occurs in type 2 diabetes mellitus
• it progress is relatively slow
• major features are
– severe hyperglycemia (often>600mg/dl)
– profound dehydration

Also Read Unit 5 - Management of Type 1 Diabetes Mellitus

Management of HHS
(See Algorithm no. III)
• Management of HHS is similar to the
management of DKA
• but fluid replacement is usually much higher
(up to 8- 10 liters)
• Criteria to document improvement
– Hydration status improves
– Mental status clears
– Blood glucose < 200mg/dl

Case Study 5
A 75 yrs. Old , Known case of Type 2 diabetes
patient, who has been taking, Glibenclamide 10
mg BID, recently he developed decreased appetite because of lower abdominal pain, he suddenly developed profound weakness, palpitation, sweating and became unconscious.
Questions
 What is the most likely diagnosis of this
patient?
 What will you do for the patient?
 How do you confirm the diagnosis?

Case 5 Answers
1. Hypoglycemia
2. Patient is unconscious so give 50 ml of 40%
glucose IV, repeat same dose if no response in 15 min. If still the blood glucose is low start 10% D/W at 100ml/hr. Refer to higher level.
3. His Random Blood Glucose was 42 mg/dl

Hypoglycemia
• Hypoglycemia occurs in most patients with type 1
diabetes and some type 2 diabetics.
• Hypoglycemia can cause serious morbidity; if severe
and prolonged, it can be fatal.
• Most common risk factors for hypoglycemia are

• fasting or missed meals
• insufficient meals
• overdose of hypoglycemic agents or insulin
• exercise
• chronic kidney disease,
• hepatic disease
• Adrenal insufficiency
• other drugs and alcohol consumption

Clinical Manifestations of Hypoglycemia
Autonomic manifestations(“You are hungry”)

Anxiety
Tremulousness
palpitations
sweating
Hunger, and
Paresthesias
Neuroglucopenic manifestations (“Your nerves are hungry”)
headache
Extreme Fatigue
Confusion
Seizure
drowsiness
lethargy and coma

Hypoglycemia cont.
• Diagnosis of hypoglycemia in diabetic patient
is based on
 clinical manifestations
 blood sugar values ≤ 70 mg/dl
Rapid response to Glucose Treatment

Management of hypoglycemia
(See Algorithm No. IV)
Principles of treatment:
• Hypoglycemia is a medical emergency
• do not wait for confirmation if test is not
readily available
• change in mental status in a diabetic is
considered to indicate hypoglycemia until roven otherwise !!!

RX of Hypoglycemia
If patient can take by mouth:
– hard candy, glucose tablets or other sources of fast
absorbable carbohydrate
N.B.
Forceful attempt to give glucose by mouth in a stuporous or disoriented individual is difficult and may prove harmful – avoid this !!

Hypoglycemia…
More severe hypoglycemia or patient unable to
take by mouth:
• Where available administer 0.5 –1mg glucagon IM
• administer 40 or 50% dextrose IV followed by a
maintenance dextrose in water infusion
Remember!!
• Sufficient amount and durations of Rx
• Rx should be followed by regular feeding
• avoid or treat causes when possible