MINISTRY OF HEALTH PROTECTION OF UKRAINE Vynnitsa national medical university named after M.I.Pyrogov
«CONFIRM» on methodical meeting of endocrinology department A chief of endocrinology department, prof. Vlasenko M.V. ______“_31_”_august___ 2012 y
METHODOLOGICAL RECOMMENDATIONS FOR INDEPENDENT WORK OF STUDENTS BY PREPARATION FOR PRACTICAL CLASSES
Scientific discipline Internal medicine Мodule № 3 Current practice of internal medicine substantial module №4 Keeping patients in the Endocrinology Clinic Topic Management the patient with chronic complications of a diabetes. Course 6 Faculty Medical № 1
Vynnitsa – 2012 Subject: Management of chronic complications of diabetes Actuality. Chronic vascular and neurological complications of diabetes is the cause of disability and early mortality of patients. In the pathogenesis of chronic complications leading role allocating chronic hyperglycemia, oxidative stress, hlikuvannyu protein activation poliolovoho stress hlikuvannyu protein activation poliolovoho way exchange of glucose, protein kinase C dysfunction epithelium, lipid metabolism, insulin resistance and others. To improve the quality of treatment is to achieve targets of no more than carbohydrate and lipid metabolism and blood pressure: fasting glycemia 5.0 - 7.2 mmol postprandialna glycemia -
4. Diabetic neuropathy, classification, diagnosis and treatment 5. Diabetic foot: classification, diagnosis, treatment 6. Principles of treatment of pregnant women, patients with diabetes mellitus 7. Characteristics of emergency and planned surgical procedures in patients with diabetes 8. Mode of insulin therapy: traditional and intensified 9. Complications of insulin therapy: hypoglycemic states Somodzhi syndrome, allergy, lipodystrophy, insulin resistance, insulin edema.
The student should be able to: 1. Quiz and fiziakalne patients with diabetes 2. Measure and assess capillary blood glucose 3. Assess the level of HbA1c, LDL, HDL 4. Measure and evaluate SC 5. Make plan to test a patient with chronic diabetes complications justify the use of basic diagnostic testing, to determine the indications for their conduct 6. Based on analysis of laboratory and instrumental tests to substantiate the diagnosis and the development of diabetes and its complications 7. Purpose of treatment and diabetes vahitnistnosti 8. Assign the appropriate treatment of diabetes who need surgery 9. Demonstrate knowledge of principles of moral and ethical medical specialist Classes are held in the form of students within the work of students within small teams at the bedside of a patient with diabetes according to the curriculum "Internal Medicine".
Timing practice (5,5 hrs.): 1. Morning medical conference - 30 min.; 2. Supervision of patients in the department - 2hod.; 3. Clinical analysis of medical history (seminar) - 1,5 hour.; 4. Independent work (study of literature, articles from the past 2 years, design blog, solving problems with step 2) - 1.5 hours.
Minutes examination, diagnosis, treatment and prevention
PART OF MANAGEMENT TO ACTION Welcome Pryvitaytesya and by introducing the patient Getting Collect passport data of the patient (P, IB, sex, age, residence, place of employment and profession) Complaints of the patient at the time of examination blurred vision, swelling of the face, extremities, increased blood pressure, pain in the legs, forming ulcers on feet Management of diabetic retinopathy Diabetic retinopathy - retinal vascular microangiopathy in diabetes mellitus, which leads to the terminal stadiyiyi complete loss of vision. Classification Neproliferatyvna Preproliferatyvna Proliferative Makulopatiya Plan examination required ophthalmic diagnostic methods: - Definition of visual acuity (vizometriya) and visual fields (perimetry); - Measurement of intraocular pressure (tonometry); - Lens biomicroscopy and vitreous body using slitlamp; - Ophthalmoscopy with expansion of the pupil. Additional ophthalmic diagnostic methods: - Photography vessels of retina with Fundus Camera; - Fluorescent angiography of retinal vessels; - Electrophysiological methods for determining the functional state of the optic nerve and retina; - Ultrasound in the presence of significant pomutnit in the lens and vitreous body; - Honioskopiya (review angle anterior chamber of the eye). Treatment of AD is performed endocrinologist and eye: 1. Compensation of carbohydrate metabolism (HbA1c <7,0%). Degree of compensation between glycemia and the development of AD there is a clear dependence. 2. Use of medical and preventive purposes angioprotektors deemed ineffective in proliferative stage of DR, especially against poor compensation of carbohydrate metabolism. At the stage of DR neproliferatyvniy angioprotektors mikroanevryzm used to treat spasms and vessels of retina. 3. The most effective method for treatment and prevention of blindness DR currently is laser photocoagulation: local, focal, panretynalna. 4. Laser-and kriokoahulyatsiya (projected ciliary body). 5. Vitrectomy with endolazerkoahulyatsiyeyu.
Keeping a patient with diabetic nephropathy Diabetic nephropathy - kidney specific vascular lesion in diabetes that is accompanied by the formation of lumpy or diffuse glomerulosclerosis, a terminal phase characterized by development of CRF. Classification of stages of development and stage of diabetic nephropathy - kidney hyperfunction Second stage - the initial structural changes in the kidney Stage III - diabetic nephropathy, which begins Stage IV - pronounced diabetic nephropathy Stage V - uremia Test Plan - research microalbuminuria (UIA) - Investigation of proteinuria (in urinalysis or urine daily) - Investigation of urine sediment (erythrocytes, leukocytes) - Research creatinine and serum urea - Research GFR Treatment The stage of microalbuminuria - an optimal compensation of carbohydrate metabolism (HbA1c <7%) - The use of ACE inhibitors or ARBs in subpresornyh doses of AT and normal doses in serednoterapevtychnyh - With increasing AT above 130/80 mmHg - Constantly; contraindications - during pregnancy - Dislipoidemia correction (if any) - Diet with moderate restriction of animal protein (not more than 1 g protein per 1 kg body weight) Stage proteinuria - an optimal compensation of carbohydrate metabolism (HbA1c <7%) - Maintaining the level of BP to 130/80 mmHg; first-line drugs of choice - ACE inhibitors or ARBs - permanently; contraindications - during pregnancy - Dislipoidemia correction (if any) - constantly - Restriction of animal protein to 0.8 grams of protein per 1 kg of body weight - permanently - Prevent the use of nephrotoxic drugs (contrast, antibiotics, nonsteroidal anti- inflammatory drugs) - Erythropoietin in renal anemia confirmation (Hb <110 g / l) Stage CRF Conservative stage - compensation of carbohydrate metabolism (HbA1c <7%) - Maintaining the level of BP to 130/80 mmHg; first choice drugs - ACE inhibitors or ARBs (with caution - if the blood creatinine level of 330 mmol / l). Recommended combination antihypertensive therapy - Restriction of animal protein to 0.8 grams of protein per 1 kg of body weight - permanently - Dislipoidemia correction (if any) - constantly - Treatment of renal anemia (erythropoietin) - at the level of Hb <110 g / l (under the control of SC, Hb, Ht, blood platelets, iron and serum ferritin) - Correction of hyperkalaemia - Correction of phosphate-calcium exchange - Enterosorption - Hemodialysis - Peritoneal dialysis - Kidney transplantation (in specialized centers) Indications for early renal replacement therapy in renal patients with diabetes mellitus with renal insufficiency - GFR <15 ml / min - Serum potassium> 6.5 mmol / l - Severe hiperhidratsiya the risk of pulmonary edema - Increase protein and energy deficiencies
Management of diabetic neuropathy Diabetic neuropathy - a set of clinical and subclinical syndromes characterized by diffuse or local lesion of peripheral and / or autonomous nerve fibers due to diabetes. Classification (formulation diagnosis) lesions of peripheral nervous system: • Diabetic polyneuropathy: sensory (symmetric), motor (symmetric); sensomotorical (symmetric) • Diabetic mononeyropatiya (isolated lesion pathways of cranial or spinal nerves) Autonomous (vegetative) neuropathy: cardiovascular shape; gastrointestinal form; urohenitaltna form; violation recognition of hypoglycemia. Diagnostic Study for the diagnosis of neuropathy in patients with type 1 diabetes conducted 1 year after the debut of diabetes in patients with diabetes mellitus type 2 - diabetes after diagnosis. The list of mandatory investigations for the diagnosis of DL: 1. Overview feet to detect dry skin, hyperkeratosis, corn, infected skin lesions, broken nail growth. 2. Rating tendineae reflexes (knee, ahilovoho). 3. Evaluation of tactile sensitivity (monofilamentom). 4. Assessment of pain sensitivity (blunt tip needle) 5. Evaluation of temperature sensitivity. 6. Rating proprioceptive sensitivity (sensitive ataxia - instability in Romberg position) 7. Determination of vibration sensitivity (calibrated tuning fork). 8. Electromyography (EMG) - stimulation of sensory nerve ikronozhnoho (n. Suralis dextr.) And motor (n. peroneus dextr.) • action potential amplitude • M-response amplitude of the velocity of excitation 9. Detection of orthostatic hypotension (BP decrease> 30 mmHg when changing position from lying to standing) 10. Valsalva test (increase in heart rate during stress, natuzhuvanni) 11. Change of heart rate at inhalation and exhalation. Distal polyneuropathy (DPN) Sensory: Pain in the legs sharp burning or aching, aggravated alone, especially at night, numbing, paresthesia, including painful tension, tingling, lowering the threshold of tactile, pain, temperature sensitivity, joint sensation. Reduction of action potential amplitude and velocity of excitation of sensory nerve EMG. Motor: Night cramps in muscles, muscle weakness, atrophy, gait instability, decreased Achilles reflex, possible changes mikrosymptomy as pupillary reflexes, weakness of convergence, unilateral reduction rohivkovoho reflex, light ataxia. Reduction of action potential amplitude and velocity of excitation EMG motor nerves. Vegetative (autonomic) neuropathy - develops, usually in 5-10 years from the beginning of diabetes. In most patients it is asymptomatic course until the pathological changes become persistent. Autonomic neuropathy causes of motor and sensory functions of various organs and systems. The clinic depends on changes in innervation of an organ: • cardiopathy: Dizziness when standing orthostatic hypotension as a manifestation; BP decrease when getting out of bed more than 30 mm Hg, arrhythmias, regular tachycardia, tachycardia rest, negative Valsalva test or bradycardia, reducing the Valsalva ratio <0.21 (by electrocardiogram: max RR to exhale / max RR for inhalation. As he normally> 0.21), sudden death. • Bladder neuropathy: atonia it, reducing the frequency of defecation, urinary incontinence (samosporozhnyuvannya it), increasing the size of the bladder according to the U.S. • neuropathy gastric: Hastroparez - significant weight loss, feeling full stomach, nausea, vomiting, anorexia, reflux • neuropathy thick, thin, rectum, the source: their dysfunction, diarrhea, occurring after each meal or at night, constipation, diarrhea that change. • neuropathy skin: Violation of sweat - sweating after drinking peep (particularly acute) dry feet (anhidrosis) • Sometimes the first symptom of neuropathy is a perversion of taste sensitivity: reducing the sensation of sweet, salty and sour (raising the threshold of sensitivity); distorted perception of sour and salty (seen opposite), and sweet, which in small quantities is perceived as bitter, in large considered normal.
Central neuropathy • Tserebrastenichnyy syndrome: state of neurosis, sleep disturbance, concentration, memory, apathy, depression, depression by type astheno-hypochondriac syndrome obesyvno-fobichnyy syndrome, etc. • encephalopathy: persistent organic cerebral pathology with appropriate clinical signs and changes in neurological status. • discirculatory disorders of vascular origin: dizziness, tinnitus, mental instability, fluctuations mnesis violations dysforychni disorders violation rate of mental activity. Treatment
1. Compensation diabetes (NvA1s <7,0%). 2. Pharmacotherapy (in accordance with the recommendations of other medical specialties): 1. ά-lipoic (tioktova) acid 2. Complex B vitamins 3. Cymptomatychna therapy pain syndrome and the court (hababentyn, nonsteroidal antiinflammatory drugs, analgesics, tricyclic antidepressants, carbamazepine, anticonvulsant). 4. Angioprotective tools 5. Metabolic Therapy 6. Sulfur-containing compounds (Sodium Thiosulfate) 7. When used in autonomic disorders symptomatic medications series, which are directed to refund the lost functions of the authority: • Increase in neuromuscular conductivity: antyholinesterazni drugs • The analysis was hypotension to maintain a constant blood volume in upright position 1. To increase the bcc: o A high position of the head and upper body during sleep o Eat - 5-6 times a day o Use of kitchen salt 4.3 g / day of liquid - up to 2,5-3 l / day o tight bandaging legs, pelvic girdle, abdomen, stockings o Physical activity with isotonic loads o Prevent long stay in bed 2. Increased activity of the sympathetic nervous system: o mineralocorticoid hormone Prevention of diabetic foot syndrome o Support long-term stable compensation of carbohydrate metabolism (HbA1C <7%) o Training patients to look after their feet o Early identification of patients who are at risk of diabetic foot syndrome o Wearing orthopedic shoes o the Office of the diabetic foot (frequency determined individually, depending on the combination of risk factors and severity of condition) o ά-adrenomimetykiv o Reduced vasodilatation: NPZS, β-blockers a. Bladder neuropathy o Increase reduce detrusor - cholinergic drugs o Improving the sphincter - α-adrenomimetykiv o Electrostimulation pelvic girdle muscles b. Neuropathy GIT o Eat, easily digested (restriction of fat, fiber) o Acceptance of laxatives (for constipation) o Holinomimetyky o Electrostimulation spinal roots o Antyholinesterazni drugs
3. Physiotheraty 4. LFK Indications for admission to the Endocrinology department: • Pain syndrome of lower extremity neuropathy. • To improve treatment of the expressed forms of neuropathy, particularly autonomic
Criteria of treatment efficacy absence of clinical manifestations of neuropathy
Clinical supervision: Survey: Length of Hospitalization Research specialists Frequency Neuroscientist defined all kinds of sensitivity (tactile, vibration, pain, temperature, proprioceptive), tendineae reflexes. 2 times a year Dovichnna Conducting orthostatic tests (endocrinologist) 1 city per year Valsalva test (by ECG) 1 city per year Analysis of heart rate variability 1 year on year Cardiologist, gastroenterologist, urologist When needed
Management of diabetic foot
Diabetic foot syndrome (SDS) combines pathological changes of the peripheral nervous system, blood and microcirculation, osteo-articular apparatus of the foot and directly threatens the development of necrotic ulcer and gangrene of the foot processes.
Classification (formulation of diagnosis) • neuropathic form: o peredvyrazkovi changes and foot ulcer o osteoartropathy diabetic (Charcot joint) • Neuro-ischemic form • Coronary form Diagnosis required methods o Family history o Overview of lower extremity o Evaluation of neurological status o Assessment of arterial blood flow o Radiography feet and ankle joints in two projections o Bacteriological study of wound exudate Anamnesis
Neuropathic neuropathic FORM FORM Long flow of DM and / or Naya ing a history of trophic ulcers of the feet, amputations long course of diabetes and / or a history of trophic ulcers of the feet, amputations Abuse of alcohol abuse smoking Overview of lower extremity Neuropathic forms of ischemic FORM Skin suh , Areas of hyperkeratosis in areas of excessive pressure on the foot Skin color pale or tsianotychnyy, skin atrophy, often - crack
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