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Rosen's Chapter 126
Diabetes Mellitus and Disorders of Glucose Homeostasis
140
Medical
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10/31/2013
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Term
the most common endocrine disease
 Definition
Diabetes mellitus
Term
the predominant metabolic fuel used by the central nervous system
 Definition
plasma glucose
Term
The CNS cannot synthesize _____, store more than a _____ minutes' supply, or _____ glucose from the circulation.
 Definition
glucose, few, concentrate
Term
Glucose is derived from what three sources?
 Definition
intestinal absorption, gluconeogenesis, glycogenolysis
Term
the breakdown of glycogen
 Definition
glycogenolysis
Term
the formation of glucose from precursors, including lactate, pyruvate, amino acids, and glycerol
 Definition
gluconeogenesis
Term
glucose taken by _____ evokes more insulin release than _____ glucose does
 Definition
mouth; parenteral
Term
insulin is rapidly degraded through the _____ and _____
 Definition
liver and kidneys
Term
The half-life of insulin in the circulation
 Definition
3 to 10 minutes
Term
the major anabolic hormone pertinent to the diabetic disorder
 Definition
insulin
Term
the major catabolic hormone in disordered glucose homeostasis
 Definition
glucagon
Term
only the liver and kidneys contain _____ , the enzyme necessary for the release of glucose into the circulation
 Definition
glucose-6-phosphatase
Term
The _____ is essentially the sole source of endogenous glucose production.
 Definition
liver
Term
_____ gluconeogenesis and glucose release contribute substantially to the systemic glucose pool only during prolonged _____.
 Definition
Renal; starvation
Term
The _____ does not require insulin for glucose to cross the cell membrane.
 Definition
hepatocyte
Term
Insulin inhibits hepatic _____ and _____.
 Definition
gluconeogenesis and glycogenolysis
Term
Muscle can store and use _____, primarily through glycolysis to _____, which is reduced to _____ or transaminated to form _____.
 Definition
glucose; pyruvate; lactate; alanine
Term
Lactate released from _____ is transported to the _____, where it serves as a gluconeogenic precursor.
 Definition
muscle; liver
Term
During fasting, muscle can reduce its _____ uptake, oxidize _____ _____ for its energy needs, and, through _____, mobilize amino acids for transport to the liver as gluconeogenic precursors.
 Definition
glucose; fatty acids; proteolysis
Term
Adipose tissue can use glucose for _____ _____ synthesis for oxidation to form _____.
 Definition
fatty acids; triglycerides
Term
Glucose regulatory hormones include _____, _____, _____, _____, and _____ _____.
 Definition
insulin, glucagon, epinephrine, cortisol, and growth hormone.
Term
When glucose is not transported into the cells because of either a lack of food intake or a lack of insulin, the body perceives a “fasting state” and releases _____.
 Definition
glucagon
Term
Glucagon is secreted from the _____ _____ of the pancreatic islets into the _____ portal circulation.
 Definition
alpha cells; hepatic
Term
Whereas insulin is an _____ agent that reduces blood glucose concentration, glucagon is a _____ agent that increases blood glucose concentration.
 Definition
anabolic; catabolic
Term
Glucagon is released in response to hypoglycemia as well as to
 Definition
stress, trauma, infection, exercise, and starvation.
Term
Glucagon increases hepatic glucose production within _____.
 Definition
minutes
Term
_____ acts within minutes and produces a transient increase in glucose production but continues to support glucose production at approximately basal levels thereafter.
 Definition
Epinephrine
Term
The American Diabetes Association (ADA) defines four major types of diabetes mellitus:
 Definition
type 1 diabetes mellitus, type 2 diabetes mellitus, gestational diabetes, and diabetes due to secondary disease processes or drugs.
Term
the preferred confirmatory test for diabetes
 Definition
hgb A1C
Term
An HbA 1c value above _____ is now considered diagnostic of diabetes.
 Definition
6.5%
Term
The use of _____ _____ _____ concentration may help identify patients at risk for diabetes
 Definition
fasting plasma glucose
Term
_____ _____ _____ is characterized by abrupt failure of production of insulin with a tendency to _____ even in the basal state.
 Definition
Type 1 diabetes; ketosis
Term
From _____ to _____% of patients with type 1 diabetes demonstrate evidence of one or more _____ implicated in the cell-mediated autoimmune destruction of the beta cells of the pancreas.
 Definition
85; 90; autoantibodies
Term
Strong human leukocyte antigen (HLA) associations are also found in type _____ diabetes.
 Definition
1
Term
Patients with type 2 diabetes may remain asymptomatic for long periods and show _____, _____, or _____ levels of insulin because of insulin _____.
 Definition
low, normal, or elevated; resistance
Term
_____ may be related to peripheral tissue resistance to insulin because of defects in the insulin receptor.
 Definition
Hyperinsulinemia
Term
Defects in _____ glycogen synthesis have an important role in the insulin resistance that occurs in type _____.
 Definition
muscle; 2
Term
_____ _____ is characterized by an abnormal OGTT.
 Definition
Gestational diabets
Term
The clinical presentation of gestational diabetes is usually _____ _____ during pregnancy.
 Definition
nonketotic hyperglycemia
Term
One should not be complacent about the patient with IGT because the decompensation of this group into the category of diabetes mellitus is _____ to _____% per year.
 Definition
1; 5
Term
The pathogenesis of IGT/IFG is thought to be related to _____ _____.
 Definition
insulin resistance
Term
The peak age at onset of type 1 diabetes is _____ to _____ years.
 Definition
10; 14
Term
The morbidity in diabetes is related primarily to its _____ complications.
 Definition
vascular
Term
an overt sign of beta cell destruction
 Definition
hyperglycemia and ketosis
Term
The most striking feature of long-standing type 1 diabetes is the nearly total lack of insulin-secreting beta cells and insulin, with the preservation of _____-secreting alpha cells, _____-secreting delta cells, and pancreatic _____-secreting cells.
 Definition
glucagon; somatostatin; polypeptide
Term
In both types of diabetes, a variety of viruses have been implicated, most notably congenital _____, _____, and _____.
 Definition
rubella, Coxsackievirus B, and cytomegalovirus
Term
In type 1 diabets, plasma _____ levels are high but suppressible with _____.
 Definition
glucagon; insulin
Term
In type 1 diabetes, plasma insulin levels are _____ to _____.
 Definition
absent to low
Term
In type 2 diabetes, plasma insulin levels are _____ to _____.
 Definition
normal to high
Term
One of the fastest-rising subgroups of patients with type 2 diabetes is now _____ _____ and _____, who have a disease similar to that seen in older adults and thought to be due to the rise in _____ in this age group.
 Definition
young adults and children; obesity
Term
____% of type 2 diabetics are not obese.
 Definition
20
Term
As a rule, any random plasma glucose level above _____ mg/dL, HbA 1c value above _____, fasting plasma glucose concentration above _____ mg/dL, or 2-hour postload OGTT is sufficient to establish the diagnosis of diabetes.
 Definition
200; 6.5%; 126
Term
Formal OGTTs are unnecessary except during _____.
 Definition
pregnancy
Term
Given the long half-life of red blood cells, the percentage of HbA 1c is an index of glucose concentration of the preceding _____ to _____ weeks.
 Definition
6 to 8
Term
Normal values of HbA 1c are approximately _____ to _____% of total hemoglobin.
 Definition
4 to 6
Term
The ADA recommends at least _____ measurements of HbA 1c for the follow-up of all types of diabetes.
 Definition
biannual
Term
The ADA currently sets an HbA 1c value of less than _____% as a treatment goal.
 Definition
7
Term
Urine ketone dipsticks use the nitroprusside reaction, which is a good test for acetoacetate but does not measure _____,in which case the urine dipstick does not reflect the true level of _____.
 Definition
β-hydroxybutyrate; ketosis
Term
When ketones are in the form of ____, the urine ketone dipsticks may infrequently yield negative reactions in patients with significant ketosis.
 Definition
β-hydroxybutyrate
Term
May be the most dangerous acute complication of diabetes...
 Definition
hypoglycemia
Term
The most common cause of coma associated with diabetes is...
 Definition
an excess of administered insulin with respect to glucose intake.
Term
Severe hypoglycemia is usually associated with a blood glucose level below _____ to _____mg/dL and impaired cognitive function.
 Definition
40 to 50
Term
Hypoglycemia without warning symptoms, or _____ _____, is a dangerous complication of type 1 diabetes probably caused by previous exposure to low blood glucose concentrations.
 Definition
hypoglycemia unawareness
Term
What is the Somogyi phenomenon?
 Definition
The phenomenon is initiated by an excessive insulin dosage, which results in an unrecognized hypoglycemic episode that usually occurs in the early morning while the patient is sleeping. The counter-regulatory hormone response produces rebound hyperglycemia , evident when the patient awakens. Often, both the patient and the physician interpret this hyperglycemia as an indication to increase the insulin dosage, which exacerbates the problem. Instead, the insulin dosage should be lowered or the timing changed.
Term
Signs and symptoms of hypoglycemia are caused by excessive secretion of _____ and _____ dysfunction.
 Definition
epinephrine; CNS
Term
If factitious hypoglycemia is suggested, testing for _____ _____ or _____ may be helpful.
 Definition
insulin autoantibodies; C peptide
Term
A patient who is surreptitiously administering exogenous insulin will have _____ levels of C peptide and _____ insulin levels.
 Definition
normal to low; markedly elevated
Term
In hypoglycemic patients with a history of alcohol abuse, _____ should be administered.
 Definition
thiamine
Term
In a child younger than 8 years, _____ or _____ should be administered instead of D50W.
 Definition
D25W or D10W
Term
The pediatric dose of dextrose for hypoglycemia is...
 Definition
0.5 to 1 gram/kg
Term
Glucagon may be given IM or Subq at a dose of...
 Definition
1 to 2 mg
Term
Glucagon's onset of action is _____, and peak response occurs in _____. It may be repeated _____.
 Definition
10 to 20 minutes; 30 to 60 minutes; as needed
Term
Glucagon is ineffective in causes of hypoglycemia in which _____ is absent, notably _____.
 Definition
glycogen; alcohol-induced hypoglycemia
Term
Sulfonylurea oral hypoglycemic agents pose special problems because the hypoglycemia they induce tends to be _____.
 Definition
prolonged and severe.
Term
Patients with an overdose of sulfonylurea hypoglycemic agents should have a minimum observation period of _____ if _____.
 Definition
24 hours; hypoglycemia is recurrent in the ED after management of the initial episode
Term
Patients at risk for hypoglycemia from oral sulfonylureas include...
 Definition
patients with impaired renal function, pediatric patients, and patients who are naïve to hypoglycemic agents.
Term
A patient with hypoglycemia from sulfonylureas, in addition to standard glucose replacement, frequently requires treatment with an agent to inhibit further insulin release, such as _____.
 Definition
octreotide
Term
Octreotide is a _____ analogue.
 Definition
somatostatin
Term
Typical adult doses of octreotide have ranged from _____ intravenously or subcutaneously every _____.
 Definition
50 to 100 mcg; 12 hours
Term
Type 1 diabetic patients with brief episodes of hypoglycemia uncomplicated by other disease may be discharged from the ED if...
 Definition
a cause of the hypoglycemia can be identified and corrected by instruction or medication.
Term
Patients who are discharged should receive _____ for ongoing evaluation.
 Definition
short-term follow-up
Term
Hypoglycemia in the nondiabetic patient may be classified as _____ or _____.
 Definition
postprandial or fasting
Term
The most common cause of postprandial hypoglycemia is _____, such as that seen in patients who have undergone _____, _____, _____, or _____
 Definition
alimentary hyperinsulinism; gastrectomy, gastrojejunostomy, pyloroplasty, or vagotomy.
Term
_____ _____ is caused when there is an imbalance between glucose production and use.
 Definition
Fasting hypoglycemia
Term
7 causes of overuse of glucose...
 Definition
insulinoma, exogenous insulin, sulfonylureas, drugs, endotoxic shock, extrapancreatic tumors, and a variety of enzyme deficiencies
Term
The _____ produced by hyperglycemia and dehydration is the most important determinant of the patient's _____.
 Definition
hyperosmolarity; mental status
Term
In 95% of patients with DKA, the total sodium level is...
 Definition
normal or low.
Term
In DKA, _____, _____, and _____ deficits are usually marked, however, the initial reported values may be _____.
 Definition
higher than actual body stores
Term
Cells unable to utilize glucose decrease _____ _____ uptake and accelerate _____, releasing large amounts of _____ _____ to the _____.
 Definition
amino acids; proteolysis; amino acids; liver
Term
Adipose tissue in the patient with DKA fails to clear the circulation of _____.
 Definition
lipids
Term
Insulin deficiency results in activation of a hormone-sensitive lipase that increases circulating _____.
 Definition
free fatty acid (FFA) levels
Term
Long-chain FFAs, now circulating in abundance as a result of insulin deficiency, are partially oxidized and converted in the _____ to _____ and _____.
 Definition
liver; acetoacetate and β-hydroxybutyrate
Term
The alteration of liver metabolism to oxidize FFAs to _____ rather than the normal process of re-esterification to _____ appears to correlate _____ with the altered glucagon/insulin ratio in the portal blood.
 Definition
ketones; triglycerides; directly
Term
Despite the increased pathologic _____-mediated production of ketones, the body acts as it does in any form of starvation to decrease the peripheral tissue's use of _____ as fuel.
 Definition
glucagon; ketones
Term
The combination of increased ketone production with decreased ketone use leads to _____.
 Definition
ketoacidosis
Term
The degree of ketosis has been related to the magnitude of release of the 5 counter-regulatory hormones...
 Definition
epinephrine, glucagon, cortisol, and somatostatin
Term
_____ is elevated fourfold to fivefold in DKA and is the most influential ketogenic hormone.
 Definition
Glucagon
Term
_____ is believed to affect ketogenesis by reducing the concentration of malonyl coenzyme A and by inhibiting _____.
 Definition
Glucagon; glycolysis
Term
The acidotic patient attempts to increase lung ventilation to rid the body of excess acid with _____ respiration, using _____ up in the process.
 Definition
Kussmaul's; bicarbonate
Term
_____ has been reported in diabetic patients vomiting for several days and in some with severe dehydration and hyperventilation.
 Definition
Ketoalkalosis
Term
The finding of alkalemia should prompt the consideration of _____ _____, in which this finding is much more common.
 Definition
alcoholic ketoacidosis
Term
Approximately _____% of all episodes of DKA occur in patients whose diabetes was previously undiagnosed.
 Definition
25%
Term
Approximately half of patients with DKA, especially children, complain of _____ _____.
 Definition
abdominal pain
Term
In _____ with DKA, abdominal pain more often signifies true abdominal disease.
 Definition
adults
Term
An elevated _____ is rarely caused by DKA itself and suggests the presence of infection.
 Definition
temperature
Term
Serum ketones are present in _____ and absent in _____.
 Definition
DKA; HHS
Term
A bicarbonate < ____ indicates DKA, while a bicarbonate > ____ indicates HHS.
 Definition
10; 15
Term
If there is concern for the adequacy of respiratory compensation or concern for a mixed acid-base disorder (such as concomitant metabolic alkalosis from vomiting that may confuse the clinical picture), an _____ sample should be obtained.
 Definition
ABG
Term
euglycemic DKA (blood glucose ≤ _____mg/dL) has been reported in up to _____% of patients.
 Definition
300; 18
Term
Rarely, a well-hydrated patient with DKA may have a pure _____ _____ with no anion gap.
 Definition
hyperchloremic acidosis
Term
Metabolic acidosis with an anion gap is primarily the result of elevated plasma levels of _____ and _____, although lactate, FFAs, phosphates, volume depletion, and several medications also contribute to this condition.
 Definition
acetoacetate and β-hydroxybutyrate
Term
Decisions about volume replacement need to be made irrespective of whether an _____ is noted on blood chemistry testing.
 Definition
azotemia
Term
The serum sodium value is often misleading in DKA and is often low in the presence of significant dehydration because it is strongly affected by...
 Definition
hyperglycemia, hypertriglyceridemia, salt-poor fluid intake, increased gastrointestinal and renal losses, and insensible loss.
Term
_____ is common in DKA because of impaired lipoprotein lipase activity and hepatic overproduction of _____ _____.
 Definition
Hypertriglyceridemia; very-low-density lipoproteins
Term
In the absence of marked lipidemia, the true value of sodium may be approximated by adding _____ to _____mEq/L to the sodium value on the laboratory report for every _____mg/dL glucose above the norm.
 Definition
1.3 to 1.6; 100
Term
Dehydration produces hemoconcentration, which contributes to normal or high initial serum _____, _____, and _____ readings in DKA, even with profound total body deficits.
 Definition
potassium, magnesium, and phosphorus
Term
The effect of acidosis on the serum potassium determination can be corrected by subtracting _____mEq/L from the laboratory potassium value for every _____ decrease in pH noted in the arterial blood gas analysis.
 Definition
0.6; 0.1
Term
Leukocytosis more closely reflects the degree of _____ than the presence of infection. Only the elevation of _____ _____ has been demonstrated to indicate the presence of infection, with a sensitivity of _____% and a specificity of 80% from a single small retrospective study.
 Definition
ketosis; band neutrophils; 100
Term
_____ should be the blood test of choice if pancreatitis is a concern.
 Definition
Lipase
Term
Alcoholics, especially those who have recently abstained from drinking, with Kussmaul's respiration, a fruity odor to the breath, and acidemic arterial blood gas values may have _____ _____.
 Definition
alcoholic ketoacidosis
Term
Alcoholic ketoacidosis patients may be _____glycemic or _____glycemic, and a large part of their acidosis is often caused by the unmeasured _____ _____.
 Definition
euglycemic or hypoglycemic; β-hydroxybutyric acid
Term
Alcoholic ketoacidosis accounts for approximately _____% of all cases of ketoacidosis.
 Definition
20
Term
_____ can also develop with fasting in the _____ trimester of pregnancy and in nursing mothers who do not eat.
 Definition
Ketoacidosis; third
Term
The presence of DKA should not exclude investigation for other causes of anion gap metabolic acidosis, such as _____, _____, or _____ _____ .
 Definition
sepsis, poisoning, or lactic acidosis
Term
The comatose patient, especially if vomiting, requires intubation. Once the patient is intubated, maintain _____ to prevent worsening acidosis.
 Definition
hyperventilation
Term
The current therapy of choice as recommended by the ADA is regular insulin infused at _____ unit/kg/hr.
 Definition
0.1
Term
In children with DKA, controversy exists about the dosing and administration of fluids and insulin because of concerns related to the risk of inducing _____ _____.
 Definition
cerebral edema
Term
The incidence of cerebral edema in children with DKA is _____%.
 Definition
1
Term
DKA-related cerebral edema is virtually unheard of in children older than _____ years.
 Definition
5
Term
When the blood glucose concentration has dropped to _____ to _____mg/dL, add dextrose to the intravenous fluids to prevent iatrogenic _____ and _____ _____.
 Definition
250 to 300; hypoglycemia and cerebral edema
Term
In patients with _____ DKA, add dextrose to the intravenous fluids at the start of insulin therapy.
 Definition
euglycemic
Term
NS solution at _____ mL/kg during the first hour is the usual fluid resuscitation therapy for a child to achieve a urine output of _____.
 Definition
20; 1 to 2 mL/kg/hr
Term
If the patient is in hypovolemic shock, administer normal saline (NS) as rapidly as possible in the adult or in boluses of 20 mL/kg in the child until a systolic pressure of _____ mm Hg is obtained.
 Definition
80
Term
Whereas fluid administration decreases serum glucose concen­tration and improves acidosis, the underlying insulin deficiency in DKA still requires administration of insulin for correction of _____.
 Definition
ketoacidosis
Term
_____ decreases after fluid infusion alone. Increased perfusion improves tissue oxygenation, thus diminishing the formation of _____. Increased renal perfusion promotes renal _____ _____ loss.
 Definition
Acidosis; lactate; hydrogen ion
Term
Potassium levels often plummet with correction of _____ and administration of _____.
 Definition
acidosis; insulin
Term
In patients with low serum potassium concentration at presentation, intravenous administration of potassium in concentrations of _____ is required.
 Definition
20 to 40 mEq/L
Term
If the measured serum phosphorus is low, it should be replaced with _____ _____.
 Definition
potassium phosphates
Term
Magnesium deficiency is a common problem in patients with _____ without _____ _____.
 Definition
DKA; renal disease
Term
Magnesium deficiency may exacerbate _____ and _____ _____, promote _____ and _____, or induce fatal cardiac dysrhythmia.
 Definition
vomiting and mental changes; hypokalemia and hypocalcemia
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