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CONTENTS
• Objective.
• Clinical presentation.
• 1-Acute.
• 2-Sub acute.
• 3-Asymptomatic.
• 4-Severe presentation.

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 Objective
• Know the most common clinical features of
DM.
• Common complications of D.M.
• Know brief information about medical
Emergencies in D.M.
• Differences between D.M type 1,& 2 in Clinical
features.

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 Acute
• History of symptoms of 2 to 6 weeks.
• Classic triad of symptoms:
• Polyuria : due to the osmotic diuresis that results when blood
glucose levels exceed the renal threshold (180 mg/dl).
• Polydypsia (Thirst): due to the resulting loss of fluid and
electrolytes (also the patient discribe it commonly as dry
mouth).
• Excessive weight loss : due to fluid depletion and the
accelerated breakdown of fat and muscle secondary to
insulin deficiency.
• Polyphagia most common in adults.
• In young patients ketonuria.
• If these symptoms are not treated leads to ketoacidosis.
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 Sub acute
• Clinical onset may be over several months or years commonly
in adults.
• Classic traid also present.
• Lack of energy.
• Blurred vision (glucose-induced changes in refraction of eye).
• Genital candidal infections as(pruritus vulvae , balanitis).

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 SYMPTOMS OF HYPERGLYCAEMIA
• Thirst, dry mouth .
• Polyuria .
• Nocturia.
• Tiredness, fatigue .
• Recent change in weight.
• Blurring of vision.
• Pruritus vulvae, balanitis (genital candidiasis).
• Nausea; headache.
• Hyperphagia; predilection for sweet foods.
• Mood change, irritability, difficulty in concentrating, apathy .

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 Complications as the presenting
feature
■ Staphylococcal skin infections
■ Retinopathy noted during a visit to the
optician.
■ Polyneuropathy causing tingling and
numbness in the feet.
■ Sexual disturbances as erectile dysfunction.
■ Arterial disease, resulting in myocardial
infarction or peripheral gangrene.
■Nephropathy.
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 Asymptomatic
• Glucosuria which is normal in around 1% of
the population(were there is low renal
threshold).
• Increase blood glucose level more than
120mg/dl.
• Usually detected in routine visits for other
problems.

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 Severe Presentations
• It includes two types.
1.Diabetic ketoacidosis (DKA).
2.Non-Ketotic hyperosmolar coma(HHS).
3.Hypoglycemia.
• Considered as one of the medical
emergencies.

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 DKA
• Occurs most commonly in type 1 DM.
• Marked hyperglycemia , glucosuria , polyuria ,
& dehydration.
• Ketosis (β-hydroxybutyrate > acetoacetate)
• Ketonuria, & acetone smell from the mouth.
• Kussmul respiration (Detected on
examination).
• Loss of consciousness, may lead to death.

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 HHS
• Common in type 2 DM.
• Severe hyperglycemia.
• Polyuria, thirst, and altered mental state.
• Acidosis and ketosis are usually not found.
• Coma.

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 COMPARASON BETWEEN DKA &
HHS

DKA HHS
Glucose,a mmol/L (mg/dL) 13.9–33.3 (250–600) 33.3–66.6 (600–1200)
Plasma ketones ++++ + or -

Arterial pH 6.8–7.3 >7.3

Osmolality (mOsm/mL) 300–320 330–380

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 Hypoglycemia
• Blood glucose < 3.5 mmol/l (63 mg/dl).
• Usually due to treatment either insulin or oral
hypoglycemic drugs (sufonylureas).
COMMON SYMPTOMS OF HYPOGLYCAEMIA
Autonomic Neuroglycopenia Non-specific

Sweating Confusion Nausea

Trembling Drowsiness Tiredness

Pounding heart Speech difficulty Headache

Hunger Inability to concentrate

Anxiety Incoordination

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 COMPARATIVE CLINICAL FEATURES OF
TYPE 1 AND TYPE 2 DIABETES
Type 1 Type 2
Typical age at onset < 40 years > 50 years
Duration of symptoms Weeks Months to years
Body weight Normal or low Obese
Ketonuria Yes No
Rapid death without Yes No
treatment with insulin
Autoantibodies Yes No
Diabetic complications at No 25%
diagnosis
Family history of diabetes Uncommon Common
Other autoimmune disease Common Uncommon

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 I really
RESOURCES recommen
d this book
I. Kumar & Clark's Clinical
Medicine 7th ED (Saunders,
2009) [CH:19 Diabetes mellitus
and other disorders of
metabolism] Page1036.
II. ABC. OF Diabetes, 5th ED written
by Peter J Watkins, Pages 7-8 (2
Clinical presentation: why is
diabetes so often missed?)
published by BMJ(British
Medical Journal).
III. Davidson’s Principles & practice
of Medicine 19th ED. CH : 15 DM.
IV. HARRISON’S MANUAL OF
MEDICINE 17th ED CH: 24,25
Pages :100-104

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