Let’s talk about the types of diabetes - type
I, type II.
Type I completely deficient of insulin.
There are a couple of things here that I need
to bring to your attention when I talked to
you about pathogenesis, but for right now,
stick with me here when I tell you with type
I, IDDM, insulin dependent diabetes mellitus.
Obviously, this patient is young and by young,
look at the first…
second column, excuse me, and you notice that
it’s a age range of less than 30.
So, when I say young, hmm, be careful.
You’re reading this stem of a question or
you’re reading the chart with chief complaint
and your patient doesn’t have to be two,
three or five years of age.
They could be up until 25.
So, even at the age of 25, you can have a
patient that develops type I diabetes.
Do not just think that just because insulin
is not present that it only occurred in a
child that was four or five years old and
that’s where students and doctors tend to
get this confused.
You can still have a type I diabetic who develops
it at the age in their 20’s regularly.
Now, there is a genetic component that’s
extremely important for you to pay attention
to and 20 to 50 percent twin concordance,
so quite a bit of association within twins
and there is a HLA link.
Now, with the type I diabetic, these individuals
are not obese, none of these younger patients
and they most likely are already on insulin.
If they never had insulin to begin with, how
in the world could oral hypoglycemic drugs
If there’s no insulin in the pancreas, now
how can you give drugs to release the insulin
that isn’t even present to begin with?
You have to give a pump and so, therefore,
you call type I diabetics insulin dependent.
The acute complications… okay, here once
again, try not to memorize, use the physio
and biochemistry as the foundation so that
you can understand the complications please.
The acute complication in type I… if the
pump isn’t working, if the patient, for
whatever reason, is not compliant with insulin,
this goes back to understanding that insulin
normally breaks down your carbohydrate so
you have your glycolysis.
Insulin is going to build up your fat, right,
that’s lipogenesis, but if you don’t have
insulin, what’s going to happen to fat?
You break it down resulting in diabetic ketoacidosis.
How do you know that?
What’s your breathing pattern in a patient
that has uncontrolled type I diabetes… whooh,
whooh, whooh, whooh, whooh.
What’s going on?
DKA has kicked in, metabolic acidosis, the
patient is then compensating by breathing
faster and faster and faster and that breath
smells oh so good, ha-ha.
Now, that’s a problem, we’re talking about
kussmaul’s breathing, aren’t we?
Because the respiratory rate is increased
due to compensation of this metabolic acidosis.
Obviously, hypoglycemia will be an acute complication.
Chronic complication will share pretty much
the same set of chronic complications that
you would expect to see with type II diabetic,
but everything is accelerated.
So, uncontrolled type I diabetes chronically
diabetic retinopathy, diabetic, diabetic nephropathy,
diabetic neuropathy, macrovascular; under
macrovascular will be atherosclerosis.
Type II diabetic… a type II diabetic is
non-insulin diabetes mellitus… insulin resistance.
This patient usually will be obese and so,
therefore, if the insulin receptors aren’t
working, they’re offering resistance.
How in the world can you take up the glucose?
Here, the genetic… the genetic component
60 to 90 percent with twin concordance and
there is an incredible correlation with your
Family history is huge for type II diabetes,
Acute complication, well, you’re paying
attention to first non-ketotic hyperosmolar
In a type II diabetic, there is every possibility
that your patient might have residual insulin
in the pancreas.
Therefore, what’s your first step of management
in type II diabetes?
First step of management avoid medicine, ha.
Actually, conduct yourself in a disciplined
manner, what does that mean?
Exercise, diet, that’s your first step of
Do not choose drugs first, if you find lifestyle
modification as being an extra choice.
Either when the question upon real life, tell
your patient why go on drugs when you can…
when you have the power to take care of this
Lose weight, exercise, watch your diet, all
these may even correct type II diabetes.
Now, if that doesn’t work then you start
becoming more and more aggressive.
So, non-ketotic hyperosmolar coma would mean
that an acute complication in which you would
have too much glucose in your circulation.
If you’re thinking about DKA in type II,
it just means that your patient here is heavily,
heavily stressed, heavily.
But, DKA is much more common in type I than
Could you find DKA in type II?
Yes, you can, but it would have to be under
Now, in the United States, you’ve heard
of dialysis clinics and there are thousands
upon thousands of them.
Every single dialysis clinic is filled to
capacity, that’s why they keep building
This is not good news.
Maybe you’re a nephrologist, but that’s
kind of a sick story, right?
Because then you’re guaranteed business,
Anyhow, a nephrologist is completely happy
with these dialysis clinics because they’re
filled, filled, filled, filled.
Type II diabetic over tens and decades of
years will go on to diabetic nephropathy,
the most common cause of diabetic, excuse
me, chronic renal failure will be because
of diabetic nephropathy in the US.
In addition, one of the most common causes
of blindness in the US is diabetic retinopathy.
And remember with the eyes with diabetes,
it could be either retina and once you have
retinopathy, gone is the vision and what if
you take a look at the lens of your patient
with diabetic and it looks cloudy… that’s
cataract, right, cataract.
So, when you get into complications, we’ll
talk about the eyes, we’ll talk about the
kidney and we’ll talk about the nerves.
What about the nerves?
What are you worried about in diabetic?
You’re always checking the bottom of the
foot, right, bottom of the foot and what might
Ulcers and with that ulcer, what are you worried
How come the patient isn’t telling you,
“My goodness, I have a huge gouge, a wound
in the bottom of the foot.”
Because your patient can’t feel the pain
due to neuropathy.
So, you’re paying attention to ulcer why?
Because it may undergo an infection, may then
go gangrene and even to this day, a common
cause of amputation is due to diabetes, isn’t
Because you have poor wound healing and you
also have neuropathy.
Macrovascular disease… atherosclerosis,
pretty big deal with type II diabetes.
In type I, take a look, chronic complications
in type I and type II pretty much the same.
In type I, it’s a lot more accelerated;
in type II, you’re talking about decades
and decades and decades in which you go on
into certain damages.
Now that you have an overview, let’s get
Other entities include gestational diabetes
which we’ll talk about in female reproductive
Diabetes associated with pancreatic damage,
chronic pancreatitis, hemochromatosis, cystic
If you have a patient that is drinking alcohol,
“Ouch Doc, aw, it hurts in my stomach.”
Where else does it hurt?
“Oh, it seems to hurt in my back too.”
If alcohol causes complete destruction of
pancreas may that result in hyperglycemia…
yes; hemochromatosis, what does that mean?
Iron overload, iron killing the pancreas,
iron accumulating on your skin.
What colour is that?
So, you have bronze diabetes, you’ve heard
Cystic fibrosis, it is one of the most common
genetic abnormality in the US in the Caucasian
Cystic fibrosis causes pancreatitis.
All of these are differentials for hyperglycemia,
beyond diabetes mellitus type I and type II.
Glucocorticoids… now, this should make perfect
What kind of effect does cortisol have on
So, therefore, anytime that you have a patient
that’s diabetic, you want to think once,
twice, three times before you prescribe prednisone
because otherwise you are exacerbating the
Pay attention to your patient.