A CASE OF PRIMARY PULMONARY HYPERTENSION

 34 Y WOMAN

SYMPTOMS 

DYSPNEA ON EXERTION

CHEST PAIN 

LOWER LIMB EDEMAFATIGUE

LETHARGY

SIGNS

LOUD SPLIT S2

SYSTOLIC EJECTION MURMER

SIGNS LEADS TO PULMONARY HYPERTENSION

CXR SHOWS ENLARGED CENTRAL PULMONARY ARTERIES 

RR 25/MIN

HR 105

Diabetes Mellitus illustrated in 10 Diagrams

1- Islets of Langerhans 

Secretes Insulin from central beta cells and Glucagon from Peripheral alpha

cells

Insulin decreases blood Glucose and increases glycoloneogenisis and Glucagon do the contrary

2- Type 1 Diabetes results from attacking beta cells by T Cells

3- mechanism and Symptoms of diabetic Ketoacidosis 

4- Diagnosis of Diabetes and Laboratory  Investigations 

5- Diabetes Complications 

Type 2 Diabetes Non Insulin Dependent Signs and Symptoms

Definition and Risk Factors

Diabetes mellitus, usually just called diabetes, is a condition in which the body is unable to use glucose properly.   type 2 diabetes, is a condition caused by either the body's inability to make enough insulin, or an inability to use it by the cells to get energy 

  After a healthy person eats a meal, the body breaks it down into simpler parts for the cells to use. Many carbohydrates are broken down into a simple sugar called glucose, which is absorbed by the small intestine, where it enters the bloodstream to be transported to cells. But, glucose can't enter the cells without the help of the protein hormone responsible for helping get glucose into cells, insulin. Insulin is made in the beta cells of the pancreas and is released when blood glucose levels are high. So normally, when blood glucose levels go up, insulin is secreted, and glucose gets stashed away in the cells, where it's either used for energy or stored, usually in the form of starch or fat. This makes blood glucose levels go back down.

In type 2 diabetes, though, even though there is insulin present, and many times plenty of it, the body's cells stop reacting properly to insulin. This is called insulin resistance, the condition in which cells don't respond normally to insulin. Insulin resistance occurs when the body saturates cells with a lot of insulin for a long period of time - the cells become less sensitive to it. It's a little like what would happen if you were trapped in a room with a strong smell. After a while, the odor doesn't smell as strong.

What are some things in a person's life that might lead to insulin resistance? The list is long. However, well-known risk factors include:

Unhealthy lifestyle choices: Type 2 diabetes is caused by the things we know we shouldn't do, but do anyway. High fat, low fiber diets, lack of exercise, and smoking have all been implicated in the disease.

Physiological Problems: Unhealthy lifestyle choices lead to other risk factors. High blood pressure, low HDL (good) cholesterol, and high levels of triglycerides in the blood stream are all separate risk factors for type 2 diabetes.

Family Factors: Genetics plays a big role in your chances of becoming a type 2 diabetic, as do race and ethnicity. African Americans, Hispanic Americans, Asian Americans, and Native Americans all have a higher risk than Caucasians do.

Age: Insulin resistance tends to naturally increase as we age. People ages 45 or older have a greater risk for type 2 diabetes than younger people do. This factor is one reason why type 2 diabetes used to be called 'adult onset' diabetes. However, that term is no longer used, especially since type 2 diabetes in children is skyrocketing, mostly because of the childhood obesity epidemic.

Weight and Fat Distribution: Obesity is by far the most famous risk factor for type 2 diabetes. There is a clear correlation between the number of people who are clinically obese and the number of people who have type 2 diabetes. Furthermore, people who store fat around their abdomen (people who are 'apple shaped') tend to be diabetic more frequently than those who accumulate fat in other places.

Prediabetes: Prediabetes means that some of the criteria used to diagnose diabetes are met in a patient. We'll talk about what this means as we discuss symptoms of type 2 diabetes. As a risk factor, prediabetes is significant, increasing a person's likelihood of becoming type 2 diabetic by at least 25%.

Insulin Resistance and Symptoms

Now that we know the risk factors for type 2 diabetes, let's look at how we become insulin resistant and how this insulin resistance leads to symptoms of type 2 diabetes.

The mechanism for insulin resistance is very complex. A person might not be insulin resistant in some tissues, like liver tissue, but be resistant in others, like adipose (fat) tissue. In fact, while scientists are fairly sure of the correlation between insulin resistance and obesity, they're faced with a 'chicken or the egg' problem; that is, it's not clear if insulin resistance causes obesity or the other way around.

What they do know is that when a combination of risk factors makes a person insulin resistant, the hormone loses its effectiveness, and muscle, fat, and liver cells don't take up glucose. In response, the body makes even more insulin in an effort to drop blood glucose levels - and it works...at first. Eventually, though, even this increase in insulin doesn't do anything, and so the pancreas' beta cells make even more. The cycle continues with blood glucose levels increasing and the beta cells making more insulin to compensate... until eventually, the beta cell function starts to decline, leaving just high concentrations of glucose in the blood.

This high concentration of glucose in the blood is called hyperglycemia, and it is probably the most well-known symptom of diabetes. This makes sense: if insulin isn't able to help glucose get into cells, then it's going to remain in high levels in the bloodstream. In a normal person, fasting blood glucose levels are usually around 100mg/dL. In a prediabetic person, it ranges from 100 mg/dL to about 125 mg/dL, and in a diabetic person, it's 126 mg/dL or more.

In the early stages of type 2 diabetes, hyperglycemia often appears with another 'hyper' symptom: hyperinsulinemia, a high concentration of insulin in the blood. Hyperinsulinemia starts to disappear when beta cell function declines.

Before we leave blood parameters that mark type 2 diabetes, let's talk about one more: Hba1c. This is a measure of glycosylated hemoglobin, basically, how much glucose is attached to the hemoglobin present in red blood cells. The longer a person is in a state of hyperglycemia, the higher their Hba1c. In a normal person, it's less than 5.7%. It's elevated in prediabetes, up to 6.4%, and high in diabetics, where it's over 6.5%.

Type 2 diabetes also usually appears with what medical professionals sometimes call the 'three Ps': polyphagia, a frequent feeling of being hungry; polydipsia, drinking frequently to try and quench a constant feeling of thirst, and polyuria, a frequent need to urinate. You should notice that the word 'frequently' appears in all three definitions, as does the Greek root 'poly.' 'Poly' means 'frequently.' Other symptoms include blurred vision, glucose in the urine, fatigue, and the inability to heal cuts and infections quickly. Prediabetics also experience some of these symptoms.

All of the symptoms make sense when you use an 'if/then' type of logic. If cells aren't able to use glucose, then it's going to trigger the body's hunger response and also make you feel tired and energy-deprived. If there is a high concentration of glucose in the blood, then the kidney won't be able to absorb it all, and some will spill into the urine. If there is a high concentration of glucose in the urine, then more water will move into the urine through osmosis, creating a large urine output. If a lot of water is lost through a high volume of urine, then the body will activate the thirst response. If there is an elevated level of blood glucose, then the circulatory system will react to this constant saturation by becoming compromised, leading to symptoms like poor wound healing and elevated levels of Hba1c.

Prognosis and Treatment

Both the prognosis and treatment of type 2 diabetes are very variable and focus on managing blood sugar. Patients must monitor their blood glucose daily using a blood glucose monitor and also regularly have a doctor check their Hba1c. These two things together tell both doctors and patients how 'in control' a person is, that is, how close blood glucose is to normal.

In some cases, lifestyle changes like increasing exercise, eating a low salt/low refined sugar/high fiber diet, and quitting smoking will be enough to keep blood glucose levels within a proper range. In some cases, medication that either improves insulin sensitivity or lowers blood glucose need to be taken. In more extreme cases, insulin itself will need to be administered through injection.

Patients who don't commit to lifestyle changes that help keep their blood glucose under tight control face a number of problems, many of which end in 'pathy,' which means 'disease of.' Chronic hyperglycemia can lead to retinopathy (eye damage), nephropathy (kidney damage) and neuropathy (nerve damage). Furthermore, the damage to the cardiovascular system can lead to maladies like a compromised immune system and stroke.

In some cases, when hyperglycemia is extreme, the body, unable to use glucose, turns to breaking down fat stores, releasing ketone bodies at a high rate into the blood. This condition can be fatal if the blood becomes too acidic. This is called ketoacidosis.Type

Disorders of Pancreas Signs and Symptoms

Pancreas Secrets 2 hormones 

Insulin and Glucagon 

Any problem in Glucagon secretion will be reflected on insulin Secretion and sensitivity of cells towards insulin 

Blood Glucose or sugar has to be carried inside body cells with the help of insulin 

With increase of blood Glucose level there is increase in Insulin Secretion in normal body also the cells needs normal Glucose level in blood between 70 and 130 ml/dl

If there is high Glucose level in the blood and no insulin reaction Glucose will be excreted through Kidneys to Urine and Water follows Glucose outside the body leads to dehydration

Diabetes Mellitus

Is defined as a condition in which the pancreas does not produce enough Insulin or cells do not respond to the insulin that is produced resulting in high blood Sugar 

To check for diabetes simply analysis of Glucose in Urine 

When Cells due to diabetes can not engulf Glucose 

Fats and Proteins in cells are used to generate energy 

So a Person With Diabetes will experience sense of Hunger

So Symptoms of Diabetes 

- Polyuria

- Polydipsia

- Polyphagia

Types of Diabetes 

- Type 1 Insulin Dependent Diabetes or Juvenile Diabetes 

- Type 2 non Insulin Dependent Diabetes or Adult Onset Diabetes

- Gestational Diabetes as In Pregnancy body secrets a number of hormones interfere with Glucose Metabolism 

Type 1 Diabetes in Brief Definition Risk Factors

Definition and Risk Factors

 Diabetes mellitus type 1, more commonly known as type 1 diabetes, is an autoimmune disease of the pancreas that results in a lack of insulin.

Let's break that down. An autoimmune disease is caused by the response of an overactive immune system. Just like an overactive imagination can see a shadow and think it's the boogeyman, an overactive immune system can mistake a part of its own body for a pathogen and attack it. In the case of type 1 diabetes, the immune system attacks beta cells, which are cells in the pancreas located in the islets of Langerhans.

Beta cells are important because they produce insulin, the protein hormone required to get glucose, or sugar, into your body's cells. A reduced number of beta cells equals a reduced amount of insulin. When your body is insulin-deficient, you begin to experience the symptoms of type 1 diabetes.

Scientists have isolated several possibilities as to why this autoimmune response takes place, including:

• Genetics - activation of several genes is one possibility as to why someone gets type 1 diabetes
• Environmental factors, such as where you live (for some reason, people living further from the equator tend to be more afflicted)
• Dietary factors, such as low vitamin D intake
• And even viral attack

...but there are no definite answers.

Symptoms

Loss of one of the hormones responsible for regulating glucose levels in the body has a profound effect. Let's take a look at some of the symptoms of type 1 diabetes and why they occur.

Don't be intimidated by the new words in this lesson - they share a lot of common roots. Learn the roots, and you will be able to learn the new words without memorizing them. As an example, poly means many or much. You'll notice that root in a few of the terms we'll be using. Other examples are glu or gly for glucose and uri for urine.

Hyperglycemia, or high concentration of glucose in the blood, is the most well-known symptom of diabetes. Since insulin's job is to help glucose get into cells from the bloodstream, it makes sense that a lack of insulin means that a lot of glucose is going to stay in the bloodstream. Normal fasting glucose is about 100 mg/dL. An elevated value of over 125 mg/dL indicates hyperglycemia.

Polyphagia (literally 'very much eating'), or increased hunger, when coupled with weight loss, is another common symptom of type 1 diabetes. If glucose is unable to get into cells, it can't be metabolized to create the energy necessary for cells to function. In a way, the body's cells are starving to death in a sea of glucose. Since the body senses that energy is low, it triggers the hunger response, causing cravings for food, especially sugary carbohydrates.

The presence of glucose in urine, or glycosuria, is not normal. During the process of filtration in a healthy body, the kidneys are able to reabsorb all of the glucose that passes through them. However, if blood glucose levels are over about 170 mg/dL, the kidneys' reabsorption mechanism becomes overwhelmed by the amount of glucose, and some passes into the urine. Glycosuria is often detected by a qualitative commercial dipstick test, where a change in color indicates how much glucose is present.

Polyuria and polydipsia are the increased need to urinate and increased need to drink, respectively. High concentrations of the solute glucose in a diabetic's urine cause water to leave blood plasma and enter the urine through osmosis. This leads to polyuria (literally 'much urine') and results in a frequent need to urinate. In order to make up for this loss of water from the blood, the body's thirst response is triggered, causing polydipsia, the need to drink frequently.

Diagnosis

It's vital to note that no one standalone symptom or value can lead to a definitive diagnosis of type 1 diabetes. Let's look at the things we just discussed and how they might lead a medical professional to suspect a case of type 1 diabetes.

• Age: Usually the autoimmune response responsible for beta cell destruction takes place early in childhood or early adulthood, which is why it used to be called juvenile diabetes. However, type 1 diabetes can also develop in adults, so this term is no longer used.
• Hyperglycemia coupled with frequent hunger (polyphagia), frequent thirst (polydipsia), and frequent urination (polyuria)
• Polyphagia
• Polydipsia
• Polyuria
• Autoantibodies for beta islet cells

If these things are all concurrent, a patient should be tested for the presence of autoantibodies, chemical markers that show the immune system has attacked the islet beta cells in order to distinguish between type 1 and type 2 diabetes. Because type 1 diabetes is not caused by unhealthy lifestyle choices and obesity, it is much less common than type 2 diabetes.

Prognosis and Treatment

There is no cure for type 1 diabetes, but patients can live long and fairly normal lives if they manage it correctly. Patients must monitor their blood glucose using a meter and, based on their blood glucose levels, administer injections of insulin, either through a syringe or pump. They must also carefully monitor their diet and exercise. Beta cell transplants are being researched as an effective cure but are still in the trial stages.

Poorly managed diabetes can be fatal both in the short- and long-term. Too much insulin can lead to a very low blood glucose level, hypoglycemia. Sometimes called insulin shock, the symptoms of hypoglycemia include weakness, sweating, and mental confusion. Hypoglycemia can generally be treated by eating sugary food or drink, or, in some cases, administration of glucagon, the hormone responsible for releasing glucose stored in the cells into the blood.

Chronic hyperglycemia, on the other hand, occurs when patients do not take enough insulin. This can lead to many different conditions, many of which have the root -path, which means disease or suffering. Among these are neuropathy (damage to the nerves), nephropathy (kidney damage, including eventual kidney failure), retinopathy (eye damage) and cataract, foot problems, and poor wound healing.

In some cases, when hyperglycemia is extreme, the body, unable to use glucose, turns to breaking down fat stores, releasing ketone bodies at a high rate into the blood. This condition can be fatal if the blood becomes too acidic. This is called ketoacidosis and is discussed in detail in another lesson.

An Introduction to Hormones and Endocrine Glands

Hormones

What are hormones? You have most likely heard of hormones at some point in your lifetime and may think you know what they do. Well, the truth of the matter is that hormones and their function within the endocrine system are extremely complex. There are multiple glands throughout the body, and each gland produces specific hormones designed to carry out certain functions. The whole process is actually quite amazing! It also has the potential to be very overwhelming at times. Never fear, because you are about to learn a general overview of this highly important system.

What Are Hormones?

Hormones are actually tiny chemical messengers located inside of your body. They are unable to be seen with the human eye and travel throughout the internal superhighway - otherwise known as the bloodstream - to all of your body's organs and tissues. Different hormones perform specific roles inside of your body. Some of these hormones work quickly to start or stop a process, and some will continually work over the course of a long period of time to perform their necessary jobs. Some of these jobs include the body's growth and development, metabolism (or production of energy), sexual function and reproduction.

The Endocrine Glands

The endocrine glands are a highly specialized group of cells responsible for making hormones. These glands are located throughout your entire body. Each gland plays a specific role in the production of a particular hormone or group of hormones needed to carry out the necessary duties required by your body to help the body remain in a state of homeostasis, or continual balance. The body requires a continual state of balance in order to function at its maximum level of efficiency. If, for any reason, your body is ever found to be outside of homeostatic balance, there could be significant negative results if the body is not repaired within a certain period of time.

For example, if a person is exposed to cold weather for an extended period of time, the body's internal temperature begins to fall. The body's temperature must remain within a certain range in order for the continual balance of homeostasis to occur and ensure all organs and systems are functioning properly. In order to remain in homeostatic balance, certain hormones are sent to specific cells and tissues to trigger a sensation which generates heat within the body and causes you to experience things such as shivering and the chattering of your teeth. These indications remind you that it is time to find a warmer location so your body may begin working to restore its internal temperature back to the range needed for proper body functions to occur. If the body temperature continues to fall, and you are unable to find a way to generate the heat required to reverse this problem, organs and systems will slowly begin to fail.

The endocrine glands and their related organs operate like small factories. They produce and store the gland-specific hormones until the time comes for those hormones to be released to a particular site in the body. The specific endocrine gland will receive a message from the pituitary gland, which is also known as the master gland, stating how much hormone is needed and where this hormone is to travel. The hormone then begins its journey through the superhighway of the bloodstream and continues along this path until it reaches the targeted tissues or cells. These tissues and cells will contain receptors located along their outside walls to serve as binding sites for the attachment of the hormone. Once the hormone has attached to one of the binding sites, the hormone is now in a position to carry out its specific role in helping maintain your body's homeostatic balance.

Location of the Endocrine Glands

When we visualize the human body, starting with the head, we can locate the pituitary gland and pineal gland inside of the brain. The pituitary gland is normally found inside of the skull, just above the nasal passages. It is considered the master gland because of its responsibility to ensure the timely production and delivery of every hormone in the body. Its assistant, the hypothalamus, while not officially considered a major endocrine gland, serves an essential role in helping with the delivery of messages to and from each respective endocrine gland throughout the body. This relationship controls the amount of hormone secreted from various glands during a particular period of time. The hypothalamus is actually located quite close to the pituitary, sitting directly above the brain stem. The pineal gland is a small, pea-sized gland located towards the back portion of the brain and is responsible for your body's circadian rhythm, or internal clock.

The thyroid and parathyroid glands are located at the base of your neck. The parathyroid glands are actually directly behind the thyroid glands, but both of these glands together resemble a bowtie-shape. The thyroid gland's main function is to control your body's metabolism, while the parathyroid glands play a large role in the distribution of calcium and phosphate throughout the body.

The pancreas lies directly behind the stomach and is responsible for the production of insulin and glucagon. Both insulin and glucagon are important in helping maintain the correct level of glucose in your body throughout the day, especially before and after you eat. The adrenal glands resemble witches' hats and sit on top of each kidney. They are responsible for the fight-or-flight reflex your body enters when faced with a challenging or frightening situation. They also play a large role in the anti-inflammatory response as well as the regulation of salt and water balance within your body.

In males, the testes are located outside of the pelvic cavity and are responsible for the production of male sex organs and secondary sexual characteristics, such as extra muscle development, lowering of the voice and increased body hair. In females, the ovaries are located inside of the pelvic cavity on either side of the uterus and are responsible for the production of eggs, which are needed for reproduction. Also, the ovaries are responsible for female secondary sex characteristics, such as breast enlargement and changes in the physical shape of a woman's body.

Diabetic KetoAcidosis in Brief

Definition

Diabetic ketoacidosis, sometimes abbreviated as DKA, is a condition in which a high amount of acid in the body is caused by a high concentration of ketone bodies. That definition might sound complicated, but it's really not. Acidosis itself is the state of too many hydrogen ions, and therefore too much acid, in the blood. A pH in the blood leaving the heart of 7.35 or less indicates acidosis. Ketones are the biochemicals produced when fat is broken down and used for energy. While a healthy body makes a very low level of ketones and is able to use them for energy, when ketone levels become too high, they make the body's fluids very acidic.

Cause

Let's talk about the three Ws of ketoacidosis: who, when, and why. Type one diabetics are the group at the greatest risk for ketoacidosis, although the condition can occur in other groups of people, such as alcoholics. Ketoacidosis usually occurs in type one diabetics either before diagnosis or when they are subjected to a metabolic stress, such as a severe infection. Although it is possible for type two diabetics to develop ketoacidosis, it doesn't happen as frequently.

To understand why diabetic ketoacidosis occurs, let's quickly review what causes diabetes. Diabetics suffer from a lack of insulin, the protein hormone responsible for enabling glucose to get into cells. This inability to get glucose into cells means that the body is forced to turn elsewhere to get energy, and that source is fat.

As anyone who exercises or eats a low-calorie diet knows, fat metabolism is completely normal. Liver cells break down fatty acids in a process called beta-oxidation. The product of beta-oxidation is acetyl-CoA. Normally, acetyl-CoA moves on to the Krebs (or citric acid) cycle, where it's turned into energy. However, there is a limit to how much acetyl-CoA the Krebs cycle can handle. If this limit is exceeded, then the leftover acetyl-CoA is turned into one of three ketones.

Think of a crowd of people waiting to get on an escalator. If the escalator is consistently full, then some people may get tired of waiting and take the stairs. This is a little like what happens in people who have uncontrolled diabetes. Since the body can't use glucose for energy, the body is forced to break down a lot of fat. A lot of beta-oxidation means a lot of acetyl-CoA, and a lot of acetyl-CoA means the production of ketones.

Again, production of some ketones by the body is normal. Ketones can be used by the heart, the brain, and the liver for fuel. Furthermore, people who eat a diet that is extremely low in carbohydrates or do a lot of endurance exercise make more ketones than these organs can use and sometimes enter into ketosis, the state of elevated ketone levels in the body. These individuals will show the presence of ketones in the blood, or ketonemia, as well as a presence of ketones in the urine, or ketonuria. It is only when the number of ketones in the blood is high enough to cause a drop in blood pH that ketoacidosis occurs.

Symptoms and Treatment

The symptoms of ketoacidosis we're about to discuss and their causes all make a lot of sense if you think about them as being connected rather than as separate, sort of like small roads that connect to one another, eventually leading to a superhighway. Also, pay close attention to the repeated use of scientific roots like 'uri-' and 'poly.' They mean the same thing every time you see them.

The first signs of ketoacidosis are also the signs of uncontrolled diabetes. As we said earlier, a lack of insulin means that glucose isn't going to be able to get into cells. Instead, it causes a high concentration of glucose in the bloodstream, or hyperglycemia. Normally, as blood passes through the kidneys, the kidney recovers all of the glucose present. In a state of hyperglycemia, though, the kidneys aren't able to absorb it all, and some will spill into the urine. This presence of glucose in urine is called glycosuria, and it causes a whole host of other problems.

Glucose in the urine causes water to move from blood plasma into urine via osmosis. All of this water movement creates a high volume of dilute urine, or polyuria. In order to make up for the loss of water in the blood plasma, the body's thirst mechanism kicks in, causing a frequent need to drink, or polydipsia.

Meanwhile, the body is burning fat to prevent itself from starving to death, and there is too much acetyl-CoA for the Krebs cycle to handle, producing so many ketones that ketonemia and ketonuria are present. These cause even more loss of water to the urine in the same way that hyperglycemia and glycosuria cause water loss. It's no surprise that a major symptom of DKA is dehydration. Dehydration also means loss of the sodium and potassium ions crucial for the nervous system function. These lead to heart arrhythmias like tachycardia (fast heart rate). Dehydration also leads to tissue shrinking and a very low blood pressure (hypotension) - and possibly brain swelling. Even worse, people in DKA suffer from nausea and vomiting and even more fluid loss.

As the ketones travel through the blood, they start to fall apart biochemically. This causes two symptoms. First, some of the ketones degrade into acetone. As blood passes through the lungs, acetone diffuses into the alveolar sacs and is exhaled. Acetone, which is present in some nail polish removers, smells fruity or chemical. This smell, which is also present in the urine, is a classic symptom of DKA.

The second consequence of severe ketonemia is the loss of hydrogen ions from the ketones. Once the body's natural buffering system is overwhelmed, these hydrogen ions cause a drop in pH and acidosis. Acidosis can be mild (7.25 to 7.30 on the pH scale), moderate (7.00 to 7.25), or severe (below 7.00). In an effort to rid the body of excess acid, the body will sometimes start Kussmaul breathing, a form of hyperventilation consisting of increasingly quick and deep breaths trying to expel as much carbon dioxide, which is also acidic, as possible.

Logically, the treatment of this condition leads to doing two things: relieving the most dangerous and immediate symptom and treating the root cause. The former is done by providing hydrating fluids, usually an IV drip that is isotonic with the blood, while carefully monitoring sodium and potassium ions. The latter is solved by insulin injection, sometimes, again, by IV. Finally, if the episode of DKA was initiated by infection, then that should be treated with antibiotics. Lack of treatment of DKA will lead to coma and/or death.