good morning n.
Download
Skip this Video
Download Presentation
Good Morning!!

Loading in 2 Seconds...

play fullscreen
1 / 18

Good Morning!! - PowerPoint PPT Presentation


  • 106 Views
  • Uploaded on

Good Morning!!. July 9, 2012. Phone message from mom: . “JS (well known to you, healthy 7 yr old Caucasian male) has a stomach ache that started yesterday and has vomited twice today. He has also been wetting the bed for the past 5 nights – which he hasn’t done in over 3 years!”

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Good Morning!!' - brock


Download Now An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
good morning

Good Morning!!

July 9, 2012

phone message from mom
Phone message from mom:
  • “JS (well known to you, healthy 7 yr old Caucasian male) has a stomach ache that started yesterday and has vomited twice today. He has also been wetting the bed for the past 5 nights – which he hasn’t done in over 3 years!”
    • Activity level ok, a little tired
    • Emesis is non-bloody, non-bilious
    • No recent life changes/stressors
    • Hasn’t taken his temp; doesn’t think he has a fever
illness script
Illness Script
  • Predisposing Conditions
    • Age, gender, preceding events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc)
  • Pathophysiological Insult
    • What is physically happening in the body
  • Clinical Manifestations
    • Signs and symptoms that result from the pathophysiological insult
type 1 vs type 2 dm
Type 1 vs Type 2 DM**
  • Type 1
    • Absolute insulin deficiency
    • Antibodies against beta-cell antigens
    • Still the most common form in children
  • Type 2
    • Peripheral insulin resistance  hyperinsulinemia beta-cell failure  relative insulin deficiency
    • Strongly related to obesity/metabolic syndrome
    • Strong family history
    • Becoming more common in young children
type 1 dm illness script
Type 1 DM Illness Script

Predisposing Conditions

  • Onset typically in childhood
    • Peaks: 2y, 4-6y, 10-14y
  • Highest prevalence in the US: Caucasians
  • More cases present in cooler months
  • Genetic predisposition
    • Complex mode of inheritance
    • HLA region on chromosome 6 provides strongest determinant of susceptibility
    • Direct family member: 3-6% risk
    • Identical twin: 30-50% risk
type 1 dm illness script1
Type 1 DM Illness Script

Pathophysiology

  • Autoimmune destruction of the beta cells (islets) of the pancreas (T-cell mediated)
    • Environmental trigger in a genetically susceptible individual
    • Destruction is over months to years
      • >80% of beta cells must be lost before glycemic control affected
  • Permanent insulin deficiency
  • Insulin deficiency  poor peripheral glucose uptake and increased hepatic and renal glucose production hyperglycemia
  • Increase in fatty acid oxidation; protein breakdown for alternative fuel sources  ketones
type 1 dm illness script2
Type 1 DM Illness Script

Clinical Manifestations**

  • Classic Symptoms
    • Polyuria
      • Serum glucose > 180mg/dL glycosuria osmotic diuresis dehydration
    • Polydipsia
      • Stimulated by polyuria to maintain euvolemia
    • Hyperphagia and Weight loss
      • Persistent catabolic state
      • Loss of calories through ketonuria and glucosuria
  • DKA: nausea, vomiting, dehydration, lethargy
type 1 dm diagnosis
Type 1 DM Diagnosis
  • Plasma glucose >200mg/dL (2-hr postprandial)
  • Fasting glucose ≥126mg/dL
  • 2 separate occasions, or with classic symptoms
  • DKA
    • Arterial pH < 7.25
    • Serum bicarb < 15mEq/L
    • Elevated ketones in serum or urine
treatment
Treatment**

Multi-faceted

  • Insulin
    • Multiple dosing regimens
    • Goals:
      • Maintain normal glucose concentrations
      • Prevent complications
      • Watch for hypoglycemia
treatment1
Treatment**
  • Nutrition
    • 50-60% Carbohydrate
    • 15-20% Protein
    • <30% Fat
    • Nutritionist support is always encouraged
  • Exercise
  • Pscyhologic support
honeymoon period
“Honeymoon” Period**
  • Some beta cells recover with removal of the toxic effect of hyperglycemia
    • Insulin requirements decrease 1 to 3 months after diagnosis
    • Usually lasts several months
      • May be >12 months
self management
Self-management **
  • Hypoglycemia (<60mg/dL)
    • Symptoms: headache, vision changes, confusion, irritability, seizures, tremor, tachycardia, diaphoresis)
    • Mild-moderate: Ingestion of 10-15g of glucose (4oz of juice)
    • Severe: 1mg IM or SubQ glucagon
    • Patients should always carry a source of glucose
self management1
Self-management **
  • Sick days
    • Check for ketones when
      • Persistent hyperglycemia >250mg/dL
      • Illness (especially N/V)
    • Check ketones and blood glucose every 2-4 hrs
    • Do not stop insulin – even if uncertain oral intake
      • Continue basal insulin
      • May need rapid-acting at dose10-20% of daily requirement every 2-4 hours until ketones are cleared
    • Persistent vomiting or refusal/inability to take fluids or food orally REQUIRES an ER or office visit
long term complications
Long-term Complications**
  • Microvascular damage
    • Retinopathy: >5-10y duration of disease
      • First ophtho exam at 10y or 3-5y of disease
      • Yearly thereafter
    • Nephropathy
      • Annual urine microalbumin after age 10; or DM for 5yrs
      • Nephrologist for HTN, proteinuria, elevated BUN/Cr
    • Neuropathy
  • Macrovascular damage
    • Atherosclerotic vascular disease at an earlier age
      • Check fasting lipid panel at 12y or at diagnosis if +FHx
prevention of complications
Prevention of Complications**
  • Strict glucose control will prevent long term complications
    • More frequent monitoring = improved glycemic control
      • Before meals, at bedtime, overnight
    • HgA1C: Goal 7.5% to 8.5%
      • Improvement of1% (mean glucose concentration of 30-35mg/dL) decreases the risk of long-term complications by 20-50%
comorbidities of type 1 dm
Comorbidities of Type 1 DM**
  • Autoimmune disorders
    • Thyroid dysfunction
      • Check TSH every 1-2y
    • Adrenal hypofunction
    • Celiac disease
      • Screened at least once and any time poor growth or GI symptoms occur
  • Growth Disturbance
    • Poor diabetic control can lead to decreased growth velocity, delayed skeletal and sexual maturation