DIABETES MELITUS I TYPE IDDM II TYPE NIDDM

DIABETES MELITUS I TYPE IDDM II TYPE NIDDM Insulin-Dependent Non-Insulin-Dependent

IDDM RISK FACTORS Ø virus infection Ø affecting of the toxic substances Ø burdened heredity Ø autoimmune infringements

NIDDM RISK FACTORS Ø Ø Ø obesity atherosclerosis unbalanced feeding burdened heredity pancreas diseases

carbohydrate metabolism protein metabolism DIABETES MELITUS fat metabolism water-salt metabolism

carbohydrate metabolism q hyperglycaemia, glucosuria protein metabolism q trophic ulcers q slow healing of wounds q decreased immune response

fat metabolism q wasting of the patient q atherosclerosis q fat infiltration of the liver q diabetic coma water-salt metabolism q polyuria q loss of sodium and potassium

COMPLAINTS q excessive thirst - polydipsia q increased urination - polyuria q skin itching q increased appetite - bulimia q wasting q weakness q decreased work capacity

INSPECTION Common condition Skin dry, rough, easily scaling, covered with traces of scratching Tongue furuncles, exematous and ulcerous lesions rubeosis xanthosis Diabetic soles Insulin lipodystrophy

Diabetes mellitus complications diabetic coma acute hypoglycaemic coma chronic inflammation foci late microangiopathy macroangiopathy neuropathy affection other organs and system

Respiratory v bronchitis v pneumonia v pulmonary tuberculosis organs Cardiovascular system atherosclerosis of various arteries: v angina pectoris v myocardium infarction v ganfrene of the feet

Muscles and bones v muscular atrophy v osteoporosis Gastro-intestinal tract and liver § paradontosis and pyorrhoea § hypo- or achlorhydria § fat dystrophy of the liver

nephropathy q hypertension q pyelonephritis Kidney q q polyneuritis q retinopathy: Nervous system exudate in the retina, haemorrhages and pigment abnormality in the yellow sport q cataract Eyes

DIABETIC COMA Precomatose state Depression Coma excessive thirst polyuria loss of appetite epigastric pain dyspepsia headache strong nervous excitement: - insomnia - restlessness - clonic convulsion

Deep coma v patient is motionless v face may be pink or pallid v skin is dry v muscle tone and tendon reflex decrease v pathological reflexes sometimes develop v eyeball tone decreases they are soft to the touch v pupils are narrow

v Kussmaul's respiration v patient's breath smells of acetone (odour of rotten apples) v pulse is low and fast v arterial pressure falls v hypothermia v oliguria and sometimes anuria develops v blood sugar markedly increases v ketonuria and glucosuria

Hypoglycaemic coma develops rapidly Coma is preceded by üsudden feeling of hunger üweakness üsweating ütremor in the entire body üpsychic and motor excitement

Comatose state v pallor and moist skin v increased muscular tone and tendon reflexes v convulsion v firm eyeballs v dilated pupils v sugar and acetone are absent in the urine v blood sugar is low Urgent help hypertonic solution of glucose (40 ml 40% sol)

DIABETES DIAGNOSTICS sugar in the blood on an empty stomach 3, 3 – 5, 5 mmol/l glycemia on an empty stomach 6, 1 – 6, 9 mmol/l glucose tolerance tests

Health sugar in the blood on an empty stomach lesser 5, 6 mmol/l Glycemia disturbances on an empty stomach sugar in the blood on an empty stomach >5, 6 but <6, 1 mmol/l glucose tolerance tests lesser 7, 8 mmol/l Disturbances glucose tolerance tests >7, 8 but <11, 1 mmol/l

Diabetes mellitus sugar in the blood on an empty stomach > 6, 1 mmol/l glucose tolerance tests > 11, 1 mmol/l v insulin 3 – 25 mk. ED/ml v C-peptide 50 – 550 ng/ml

v insulin antibodies v Hb. Alc 4, 8 – 6% Diabetes control q glycemic profile q sugar and ketone bodies in the urine q Hb. Alc

DIFFUSE TOXIC GOITRE thyrotoxicosis Basedow disease

REASONS • psychic trauma • infection • dysfunction of the pituitary • familiar factors Main signs of the disease • heart affection (palpitation, arrhythmias) • enlargement of the thyroid gland • dysfunction of the nervous system • ocular signs • digestion disorders

Main complaints Ø heart palpitation, arrhythmia Ø increased psychic excitability Ø increased reactivity Ø non-motivated anxiety Ø deranged sleep Ø tremor of the fingers or entire body Ø hyperhydrosis Ø subfebrile temperature Ø muscular weakness Ø frequent defaecation Ø wasting Ø discomfort of the neck region

Objective examination q special behaviour features q common inspection q neck examination q ocular symptoms q cardiovascular system examination

• Special behaviour features: • general motor restlessness • fussiness • nervousness, fidgetiness • fast change of the mood • tearfulness • hasty speech • sometimes the patient drops the subject quite unexpectedly and starts discussing another subject • Facies Basedovica

Common inspection • insufficient weight to cachexia • skin: • smooth • moist • warm to the touch • diffuse pigmentation, which however does not colour the mucosa • the pigment is sometimes deposited selectively in the skin of the eyelids • hair of the head: • thin • soft

Neck examination O- enlarged thyroid gland is seen during swallowing, but its size is not more than one falangs of the patient thumb I- the size of thyroid gland is more than one falangs of thumb II - clearly visible thickening of the neck due to goitre

Ocular symptoms • bilateral dilation of the eye slits • exophthalmus • Stellwag's sign • Graefe's sign • Kocher's sign • Mebius' sign

Cardiovascular system Ø heart palpitation, arrhythmia Ø headache increased BP toxic effect of the thyroid hormones Auscultation of the heart: üsnapping first sound ü tachycardia ü atrial fibrillation tachysystolic form

ü systolic murmur at the apex over all points increased blood flow rate low tone of the papillary musclses ü systolic pressure grows ü diastolic pressure falls ü pulse pressure increases increased 200/50 mm Hg • systolic and minute volumes • mass of the circulating blood

Digestive system Ø increased appetite Ø diarrhoea increased motor function of the intestine Ø hepatic dysfunction cirrhosis Endocrine system hypofunction diabetes mellitus amenorrhoea sex glands adrenal cortex hypoadrenocorticism

DIAGNOSTIC METHODS OF THE THYROTOXICOSIS Biochemical studies of blood increased content of protein-bound iodine Blood radioimmunoassay increase triiodothyronine – T 3 thyroxine – T 4 thyrotropic hormone-TTH

Basal metabolism increases by 50% and sometimes by 100% in norm 30% The body temperature Ultrasonography Radioisotope scanning subfebrile

Radioisotope examination Tests with I 131 Normal accumulation of the radio-active iodin in thyroid gland : after 2 h. - 7 -12% after 24 h. - 30%

Myxoedema P Y H R Y H T O M S I D I O

Primary hypothyroidism • thyroid gland anomaly • inflammatory diseases of the thyroid gland • thyroidectomy • radioactive iodine therapy Secondary hypothyroidism • congenital or got insufficiency of the thyrotropic hormone • secretion of the inactive thyrotropic hormone

HYPOTHYROIDISM arisen in childhood period cretinism

COMPLAINTS Ø apathy Ø lack of interest in the surroundings Ø impaired memory Ø decreased work capacity Ø somnolence Ø flaccidity Ø chill

Inspection The patients appearance: • the face is puffy • the skin is pallid with a yellowich hue sometimes with blush on the cheek bones • eye slits are narrowed • the neck oedematous Skin: • dry, thick, and scaling • rough and cold to the touch Hair on the head is rare; it falls off from the brous Movements are slow and speech is monotonous

Cardiovascular system § the minute blood volume decreases § the blood flow rate is slow Heart auscultation : bradycardia the heart sounds are dulled systolic pressure falls diastolic pressure remains normal pulse pressure decreases 90/70 mm Hg

• constipation • meteorism Gastro-intestinal tract hypo- and achlorhydria decreased intestinal motor function Central and peripheral nervous system: psychosis • strong severe radicular pain in the extremities • paraesthesia • cramps • shaky gait

DIAGNOSTIC METHODS OF THE HYPOTHYROIDISM Biochemical studies of blood • decreased content of protein-bound iodine Blood radioimmunoassay decrease § triiodothyronine – T 3 § thyroxine – T 4 § thyrotropic hormone

Basal metabolism decreases to 50 % in norm 30% Body temperature decreases Radioisotope examination