4-30
Patient Education
General: DM is almost always a permanent condition, but careful self-management offers long-term benefit in
minimizing occurrence and severity of microvascular complications.
Activity: Stable patients benefit from 40 to 60 minutes of moderate aerobic exercise daily. Walking 2-3 miles
daily is usually well tolerated in the absence of foot lesions.
Diet: Limit intake of simple sugars in favor of complex carbohydrates. Obese patients should receive a
total calorie prescription with a goal of long-term weight reduction; 1500-1800 calories a day are usually
sufficient.
Prevention and Hygiene: Patients should return for a urinary dipstick test bid until urinary glucose and
ketones are negative or trace.
No Improvement/Deterioration: Patients should be referred for definitive medical care.
Follow-up Actions
Return evaluation: Daily to twice weekly initially, as dictated by severity of hyperglycemia and ketonuria.
Evacuation Consultation Criteria: Immediately evacuate all severely hyperglycemic, severely ketonuric or
pregnant patients. All other patients with diabetes mellitus should be evacuated at the earliest availability.
Endocrine: Hypoglycemia
Col Stephen Brietzke, USAF, MCIntroduction: Hypoglycemia is an abnormally low blood glucose level. Normal body function depends
glucose, the primary energy source for most cells. Metabolism of glucose is mediated by glucagon and
epinephrine (which stimulate the liver to change stored glucagon into glucose for use as an energy source)
and by cortisol and growth hormones. Insulin does the opposite, promoting removal of excess blood glucose
for storage of in the liver as glycogen. Hypoglycemia is caused by an imbalance between insulin and
glucagon, epinephrine, cortisol and growth hormone.
Subjective: Symptoms
Abrupt decline in mental status function, level of consciousness, amnesia, bizarre behavior, hemiparesis, poor
coordination, double or blurred vision. Anxiety, generalized sweating, and tremor may occur prior to other
neurologic symptoms.
Focused History: Quality: Do you feel shaky or nervous? (suggests adrenergic nervous system response to
hypoglycemia) Do you have a craving for sugar or foods? (appetite stimulated by falling blood glucose level)
Are you having difficulty thinking clearly? (CNS dysfunction results from significant hypoglycemia) Duration:
When did your symptoms begin? Has it ever happened before? (True hypoglycemia begins abruptly, and can
recur in similar circumstances over time.) Alleviating or Aggravating Factors: When was your last meal?
Were you more active today than usual? (Decreased food intake or unaccustomed exercise are common
precipitants of hypoglycemic attacks.) Do you have diabetes? Are you taking insulin or pills to control your
diabetes? (Most patients with hypoglycemia are receiving drug treatment for diabetes mellitus.) How long
after eating did your symptoms improve? (Hypoglycemia reverses rapidly with ingestion of carbohydrate.)
Objective: Signs
Using Basic Tools: Notoriously non-specific symptoms that resolve WITHIN MINUTES after giving IV or oral
glucose. Vital Signs: Tachycardia, hypertension, tachypnea
Inspection: Diaphoresis, dilated pupils, confusional or psychotic state, drowsy or comatose, ataxic gait, coma,
generalized seizure
Auscultation: Aortic or pulmonic flow murmurs
Palpation: Left- or right-sided facial/upper extremity/lower extremity weakness or paralysis; decreased visual
acuity or visual fields
Percussion: Brisk deep tendon reflexes
Using Advanced Tools: Lab: Glucose and ketones on urine dipstick.