Case Discussion

Diabetes Mellitus & Hypertension

DR. A. MERITON STANLY

PROFESSOR
 Objectives

❖ Discuss the importance of “Chief complaints” as

given by patient.

❖ Discuss the role of history of presenting symptoms

in diagnosis.

❖ Describe the prevention & control of diabetes and

Hypertension.
 Diabetes Mellitus
Problem Statement
Increasing prevalence of diabetes in developing countries is
closely associated with industrialization and socio economic
development.

Prevalence :
Worldwide: 8.5 %
Eastern Mediterranean Region : 11%
Western Pacific Regions: 9%
Region of Americas :11%
INDIA : 8 -10 %
Diabetes Mellitus
Diabetes Mellitus
 Diabetes Mellitus

EPIDEMIOLOGY-Agent factors
Insulin deficiency reduced utilization of glucose
Hyperglycemia Glucosuria .

1. Pancreatic disorders
2. Defective insulin formation
3. Destruction of beta cells
4. Impaired insulin receptors – impaired utilization
5. Genetic defects
6. Auto-immunity
 Diabetes Mellitus
EPIDEMIOLOGY- Host factors
1. Age : Type 2 DM – middle age, with age increasing prevalence.

2. Sex: South East Asia - men

3. Genetic factors: type 2 DM

4. Genetic markers: type 1 DM- HLA B8 , HLA B15, DR3 & DR4

5. Obesity

6. Auto Immunity
 Diabetes Mellitus
EPIDEMIOLOGY- Environmental factors
6. Viral infections: Mumps, Rubella, Coxsackie B4 viruses –

7. Chemical agents: alloxan, Streptozotocin, Valcor-rodenticide.

8. Stress : stress situations

9. Other factors: social class. 50 years ago – higher class,

Now – lower class people also affected because of lifestyle
factors.
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Clinical classification
1.Insulin Dependent Diabetes Mellitus
( IDDM, Type I) – most severe form of disease.

2.Non Insulin Dependent Diabetes Mellitus (NIDDM, Type II)

3.Impaired glucose tolerance – intermediate state between DM

and normality.

4. Gestational Diabetes Mellitus (GDM) – diabetes diagnosed

for the first time in pregnancy
.
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Clinical classification
1.Insulin Dependent Diabetes Mellitus
( IDDM, Type I) ONSET – abrupt, less than 30 years
Immune-destruction of the pancreatic beta cells.
TREATMENT – Insulin

2.Non Insulin Dependent Diabetes Mellitus (NIDDM, Type II)

Discovered by chance.
ONSET – gradual, middle aged and elderly.

.
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Screening for diabetes

1.Urine examination for glucose

2.Blood sugar testing

Fasting, Post-prandial or Random blood sugar estimation.
Standard oral glucose test (GTT) remains the cornerstone of
diagnosis of diabetes.
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Target Population for screening

✓Those in the age group 40 and over.

✓Those with a family h/o diabetes.

✓Obese persons

✓Women who show excess weight gain during

pregnancy.

✓Women who have had a baby weighing >4.5 kg

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 Hypertension Definition

SYSTOLIC PRESSURE EQUAL TO OR GREATER

THAN 140mm Hg AND/OR DIASTOLIC PRESSURE
EQUAL TO OR GREATER THAN 90 mm Hg.
Classification of HT by blood Pressure
CATEGORY SBP DBP

(i) NORMAL < 130 < 85

(ii) HIGH NORMAL 130 - 139 85 – 90

(iii) HYPERTENSION

MILD– STAGE I 140 – 159 90 -99

MODERATE – 160 – 179 100 -109

STAGE II

SEVERE – STAGE III > 180 >110

 Classification

PRIMARY OR ESSENTIAL HYPERTENSION:

The causes are generally unknown and most prevalent form of
hypertension accounting for 90% of all cases of hypertension.

SECONDARY HYPERTENSION:
Some other disease process or abnormality involved in its
causation.(diseases of kidney, adrenal gland tumours, narrowing
of aorta and toxemia of pregnancy)
Hypertension Prevalence in India

male female
(per 1000) (per 1000)

urban 59.9 69.9

rural 35.5 35.9

Classification of HT by Organ Damage

STAGE I – no manifestations of organic change

STAGE II
LVH
Generalized & focal narrowing of retinal arterioles
Microalbuminuria
Proteinuria & plasma creatinine 1.2 -2 mg/dl
Atherosclerotic plaque in Aorta, carotid, iliac or femoral
arteries by USG/ Radiological evidence
Classification of HT by Organ Damage

• STAGE III
◼ HEART: angina pectoris, MI and Heart failure

◼ BRAIN: stroke, TIA, hypertensive encephalopathy

◼ OPTIC FUNDI: retinal hemorrhages and exudates with or

without papilledema

◼ KIDNEY: plasma creatinine > 2mg/dl, Renal failure

◼ VESSELS: dissecting aneurysm, symptomatic arterial

occlusive disease.
 Rule of halves
1. Whole community
2. Normotensive subjects
3. Hypertensive subjects
4. Undiagnosed
5. Diagnosed
6. Diagnosed but
untreated
2 442 7. Diagnosed and treated
8. Inadequately treated
7 9. Adequately treated
Tracking of Blood Pressure
 Tracking of Blood Pressure

TRACKING IS A PHENOMENON OF PERSISTENCE OF RANK ORDER

OF BLOOD PRESSURE.

Low BP levels tend to remain low and high levels tend to become
higher as individuals grow older.

Identifying children and adolescents “at risk” of developing

hypertension at a future date.
 Measuring BP
❖ Patient seated quietly for atleast 5 minutes in a chair,
with feet on the floor and arm supported at heart level.

❖ An appropriate-sized cuff ( cuff bladder encircling atleast

80% of the arm)

❖ Take atleast 2-3 measurements.

 Measuring BP

❖ The pressure at which the sounds are first heard is

taken to indicate the systolic blood pressure.(phase 1 )

❖ Near the diastolic pressure the sounds first become

muffled (phase 4) and then disappear (phase 5 )

❖ Diastolic Blood pressure is the point of disappearance of

the sounds (phase 5)
 Measuring BP

The sources of errors in the recording of blood pressure

❖ Observer errors

❖ Instrumental errors

❖ Subject errors
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❖ Patient name

❖ Age

❖ Sex

❖ Address

❖ Occupation
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Signs & Symptoms of Diabetes
1)
2)

3)
4)
5)
6)
7)
8)
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Signs & Symptoms of Hypertension

1) Severe headaches.
2) Nosebleed.
3) Fatigue or confusion.
4) Vision problems.
5) Chest pain.
6) Irregular heartbeat.
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History taking
❖ Chief complaints/presenting symptoms

❖ History of presenting symptoms for Diabetes - classical

symptoms : Polyuria , Polydipsia, Polyphagia, Weight loss.
Other symptoms blurred vision, frequent infections , tingling
and numbness in lower limbs.
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History taking
❖ History of presenting symptoms for
Hypertension: Severe headache, Nasal
bleeding, Fatigue or confusion, giddiness,
nausea, vomiting, sudden loss of vision
problems, Chest pain, Irregular heartbeat.
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History taking
❖ Personal History – Bowel and bladder habits,
smoking , Alcohol , sleep pattern.

❖ Past History : Diabetes, Tuberculosis, Asthma.

❖ Treatment History: Any drug allergy, Surgery if any,

any hospitalization details as inpatient.

❖ Family History: Any chronic illness.

❖ Diet History: Veg / Non-veg.

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Details of the Family

❖ Education

❖ Occupation

❖ Type of family

❖ Per capita family monthly income

❖ Socio –Economic Class

❖ Any other details regarding the family

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Environmental Information
❖ House Details- Type, No.of rooms, lighting, ventilation,
kitchen details, overcrowding ,set back

❖ Water Supply

❖ Waste Disposal

❖ Sanitary Facilities

❖ Pet animals if any

❖ Mosquitoes / Fly nuisance

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Clinical Examination

❖ General examination

❖ System examination

❖ Local examination

❖ Provisional Diagnosis

❖ Investigations, Diagnosis ,Treatment & Prevention

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Clinical Examination
❖ General examination
Body build, Consciousness, Pallor, Icterus,
Clubbing, Cyanosis, Lymph nodes if any, Edema,
Vital signs-temperature, pulse, RR ,BP ,Height,
Weight, BMI.
 Indices of Obesity
(i) Body Mass Index(QUETELET’S index) =WEIGHT(Kg)/ HEIGHT2 (m)

(ii) Ponderal index = height (cm) / cube root of body weight( kg)

(iii) Brocca index= height in cm minus 100

(iv) Lorentz’s formula

( height in cm minus 100) minus {ht(cm-150)/ 2 or 4}

(v) Corpulence index = actual weight / desirable weight.

THIS SHOULD NOT EXCEED 1.2
 <16.00 GRADE III THINNESS UNDERWEIGHT

16.0 - 16.99 GRADE II THINNESS UNDERWEIGHT

17.0 - 18.49 GRADE I THINNESS UNDERWEIGHT

18.5 - 24.99 NORMAL RANGE

25.0 - 29.99 GRADE I OVERWEIGHT PRE- OBESE

30- 34.99 - OBESE –I

30.0 - 39.99 GRADE II OVERWEIGHT
35 - 39.99 - OBESE- II

>40 GRADE III OVERWEIGHT OBESE CLASS III

 Indices of Obesity
SKIN FOLD THICKNESS
4 sites measurement – mid- triceps, biceps, subscapular &
suprailiac region.
sum of them should be < 40mm in boys & < 50mm in girls.

WAIST CIRCUMFERENCE & WAIST-HIP RATIO (WHR)

Midpoint between lower border of rib cage and the iliac crest.
Waist circumference >102 cm(men) & >88 cm(women) results in
increased risk of metabolic complications.

WHR >1 in men and >0.85 in women indicates abnormal fat

accumulation.
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Clinical Examination
❖ Examination of skin:
Colour, texture, turgor, dry skin or not, Calluses , heel
fissures or cracks of skin due to reduced sweating in
autonomic neuropathy

❖ Examination of Nails :
Atrophy, dystropic, hypertrophy, paronychia,ingrown toe
nails, onchomycosis, interdigital lesions & fungal
infections, ulcer if any
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System Examination
Cardiovascular system: Apical Impulse, Heart rate.
Heart sounds & Murmur if any by auscultation

Respiratory system
Inspection- Position of trachea, Chest wall movements
Palpation-confirming inspection findings
Percussion-Resonant in all sides
Auscultation- NVBS
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System Examination
❖ Abdominal examination

Inspection (distension , scars ,symmetrical

movements with respiration)

Palpation(tender or not, liver and spleen examination)

Percussion- Dullness

Auscultation-Bowel sounds.
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System Examination
❖ Central Nervous System

Higher mental functions, motor examination,

sensory loss if any.
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Clinical Examination
❖ Provisional Diagnosis

❖ Investigations

❖ Final Diagnosis

❖ Treatment & Prevention

❖ Summary & Discussion

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• PRIMARY PREVENTION
1. NUTRITION
a) Salt intake < 5g/day
b) Avoiding high alcohol intake
c) 20- 30% fat intake, limiting saturated fat to 10%
2. WEIGHT REDUCTION
3. PROMOTION OF EXERCISES
4. BEHAVIOURIAL CHANGES
5. HEALTH EDUCATION
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SECONDARY PREVENTION - DIABETES
Diet alone: frequent, small balanced meals.

Diet & oral hypoglycemic drugs

Diet & insulin

Estimation of Glycosylated haemoglobin (HbA1c) at half yearly

intervals which provides a long term index of glucose control.

Self Care
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SECONDARY PREVENTION-HYPERTENSION
Treatment
Aim is to obtain a BP below 140/90 and ideally a BP
of 120/80mm Hg.
Mild hypertension should also be treated.

CONTROL OF HYPERTENSION IS IMPORTANT AS IT

HAS SHOWN TO REDUCE THE INCIDENCE OF STROKE
AND OTHER COMPLICATIONS
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Anti-Hypertensive Drugs
1.Diuretics
i) Thiazides
ii) Potassium sparing diuretics
2.ACE Inhibitors (Angiotensin Converting Enzyme)
3. Angiotensin 1 Receptor Blockers
4.Beta Blockers
5.Calcium Channel Antagonists
6.Centrally acting anti-hypertensive drugs
7.Vasodilators
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SECONDARY PREVENTION
Diet alone: frequent, small balanced meals.

Diet & oral hypoglycemic drugs

Diet & insulin

Estimation of Glycosylated haemoglobin (HbA1c) at half yearly

intervals which provides a long term index of glucose control.

Self Care
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SECONDARY PREVENTION
Self Care
a) Adherence to healthy diet
b) Adherence to drugs/ insulin
c) Sugar examination – blood/urine
d) Maintain body weight
e) Attend periodic check-ups including eye examination
f) Recognise symptoms of glycosuria and hypoglycemia
g) Feet examination
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TERTIARY PREVENTION
❖ Minimising the complications –
Retinopathy,Neuropathy,Nephropathy , Stroke &
Heart diseases
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A 46-year-old businessman (body mass index - 32 kg/m 2) with
type 2 diabetes mellitus (T2DM) of 8 years duration presented with
poor glycemic control (HbA1c - 9.4%)and having hypertension for
past 6 years. His BP was 150/100 mm of Hg. He underwent laser
treatment in both eyes for blood vessel leakage in retina.

He is on metformin 500mg once daily in morning and T.

Gilbenclamide 5mg once daily in afternoon and having erroneus diet
pattern with sedentary lifestyle. He is taking Amlodipine 2.5mg daily
in morning.

He wants advice on which anti-hypertensive & oral hypoglycemic

drug would be best suited in his case that may provide better blood
pressure & glycemic control,weight loss and Heart protection.
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Thank You