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Page 1: Semiology of diabetes mellitus

Semiology of Diabetes Mellitus

Daniel Fernando Isuhuaylas Aguirre

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What is Diabetes?

• Diabetes is a group of metabolic diseasescharacterized by hyperglycemia resulting fromdefects in insulin secretion, insulin action, orboth.

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Pathogenic processes involved

HYPERGLYCEMIA

Autoimmune destruction of the

β-cells of the pancreas (resistance

to insulin action)

Deficient action of insulin on target

tissues.

Inadequate insulin secretion and/or diminished tissue

responses to insulin.

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β – Cell dysfunction and IR

β – Cell

dysfunction

INSULIN

RESISTANCE

Glucose

Uptake

Blood glucose FFA

Glucose

Production

insulin secretion

Lipolysis

Factors

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Symptoms

• Acute, life-threatening Hyperglycemia with ketoacidosis or the nonketotic

hyperosmolar syndrome.

Polyuria Blurred vision

PolyphagiaWeight loss

Polydipsia

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Long-term complications

Hypertension and abnormalities of

lipoprotein metabolism

Atheroscleroticcardiovascular,

peripheralarterial, and

cerebrovascular disease.

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Long-term complications

• Loss of vision

Retinopathy

• Renal Failure

Nephropathy

• Risk of foot ulcers, amputations, and Charcot joints

Peripheral neuropathy

• Gastrointestinal, genitourinary, and cardiovascular symptoms and sexual dysfunction

Autonomic neuropathy

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Criteria for the diagnosis of diabetes

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Natural progressionNormal IGT DM2

Fasting plasma glucose Insulin Sensitivity Insulin Secretion

Insulin sensitivity

Normal insulin secretion

Normoglycemia

Hyperglicemia

β-cell failure

Insulin resistance

DM2 + Long-termcomplications

insulin resistance

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Long-term complications

• Macroangiopathy

• Microangiopathy

• Neuropathy

CVD

Cerebrovascular Disease

Vascular disease of the lower limbs

Symmetric sensory polyneuropathy

Mononeuropathy

Autonomic neuropathy

Retinopathy

Nephropathy

• Diabetic Foot

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Long-term complications

• biochemicalalterations

• functional alterationsREVERSIBLE

STAGE

• Structural alterationsIRREVERSIBLE STAGES

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Diabetic Nephropathy

GENETICS HYPERGLYCEMIA

Diabetic Nephropathy

DIABETES MELLITUS

THICKENING CAPILLARY

BASAL GLOMERULAR

EXPANSION OF THE

MATRIX

↑ PRESSURE

MEMBRANE

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Stages

• Hyperfiltration and renal hypertrophy

• Normoalbuminuria

• Incipient diabetic nephropathy:microalbuminuria

• Clinical Diabetic Nephropathy: Proteinuria

• End Stage Renal Disease

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Diabetic RetinopathyFUNCTIONAL AND

MORPHOLOGICALNS

HEMODYNAMIC ALTERATIO

HYPERGLYCEMIA

LOST PERICYTES

VASODILATION OF CAPILLARIES

BASAL MEMBRANE ALTERATION

LOSS OF ENDOTHELIAL

acellular capillaries

Hypoxia

↑VPF VEGF

Neoformation CAPILLARIES

RD NO PROLIFERATIVE

RD PRE PROLIFERATIVE

RD PROLIFERATIVE

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DIABETIC RETINOPATHY

PROLIFERATIVE

NO PROLIFERATIVE LIGHT NO PROLIFERATIVE

NO PROLIFERATIVE

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Diabetic Neuropathy

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DISTAL AND SYMMETRIC PERIPHERAL NEUROPATHY

Symptoms

• Asymptomatic

• Numbness

• Paresthesias

• Hyperesthesia

• Pain

Signs

• ↓ Sensitivity

• Weakness

• Atrophy

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Mononeuropathy

NERVIO FEMORAL AMIOTROFIA

PARES CRANEANOS

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Autonomic Neuropathy

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Diabetic Foot

• In patients with peripheral neuropathyincidence annual foot injuries is 7.2%.

• The etiology, 60% of injuries are neuropathic,30% are neuro-ischemic and ischemic 10%.

• Injuries are related to patient age, theglycemic control and age of the disease.

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Diabetic FootDiabetic Foot

Ulceration in the foot.

Micro trauma

Developing new lines of force

Change in foot pressure areas

Peripheral neuropathy

Loss of sensation Muscle atrophy

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Diabetic Foot

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Diabetic Foot

• Risk Factors– Decrease or abolition of aquiliano reflex. – Decrease or abolition of vibratory sensation. – Orthopedic disorders:

• Hammer toes. • Hallux valgus. • Calluses • Atrophy of foot muscles themselves. • Pes cavus with deformed anterior arch.

– Decrease or abolition of tibial and dorsalis pedispulses.

– History of previous ulcer.

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Clinical Examinatios

• Coloration: – Rubicund in neuropathy, venous engorgement. – Pale in ischemia.

• Temperature: – Hot in neuropathy. – Cold in ischemia.

• Skin alterations– Dry skin. – Presence of calluses.

• Others– Limitation of joint mobility. – Atrophy of intrinsic foot muscles.– Examination of reflexes, pulse, vibration sensitivity.

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References

• Diagnosis and Classification of Diabetes Mellitus.American Diabetes Association. Diabetes Care, Volume33, Supplement 1, January 2014.Care.diabetesjournals.org

• Standards of Medical Care in Diabetes. AmericanDiabetes Association. Diabetes Care, Volume 33,Supplement 2, January 2014. Care.diabetesjournals.org

• Foot Care. Canadian Diabetes Association ClinicalPractice Guidelines Expert Committee Keith BoweringMD, FRCPC, FACP John M. Embil MD, FRCPC, FACP.March 2014.

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Instrumentation

• Fingerboard 128 mHz

• Semmens Weinstein monofilament 10 g

• Radiographs of both feet with support, frontand profile

• Doppler

• Arteriography prior to surgery

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Thank you for your attention