Internal Medicine

P1: RLJ/OZN P2: KUF

0521779407-D-01 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:41

Diabetes Mellitus, Type 1 473

■Dysphagia, early satiety, bloating, nausea/vomiting, diarrhea, con-

stipation

■Impotence, incontinence

■Claudication

■Foot ulcers

■Microaneurysms, hemorrhages, exudates, cotton wool spots, new

vessels

■Loss of sensation, proprioception, temperature discrimination,

absent ankle jerks

■Hammerhead deformity of toes, calluses, ulcers

■Miosis, diminished pupillary dilation

■Resting tachycardia, postural hypotension

■Necrobiosis lipoidicum diabeticorum

■Diminished/absent pulses in lower extremities

tests

Laboratory

■Basic blood studies:

➣Established disease: elevated glucose, HgbA1c, creatinine, dys-

lipidemia

➣Ketoacidosis: elevated glucose, electrolyte abnormalities, aci-

demia, reduced bicarbonate, positive ketones

■Basic urine studies:

➣Established disease: albuminuria

➣Ketoacidosis: glycosuria, ketonuria

■Specific diagnostic tests

➣Anti-GAD (glutamic acid decarboxylase), anti-insulin, anti-islet

cell antibodies, C-peptide

differential diagnosis

■Type 2 diabetes mellitus

■Diabetic ketoacidosis; alcoholic ketoacidosis; anion gap acidosis;

methanol, ethylene glycol, salicylate overdose, uremia, lactic aci-

dosis

management

What to Do First

■Diabetic ketoacidosis:

➣Start hydration and insulin

➣Search for precipitating factor: omission of insulin most com-

mon, infection, MI, stroke