Diabetes mellitus

A lot of people have diabetes and they live a long life with it. Diabetes can develop at any
age, but risk increases up to age 40. After age 30 it more commonly affects women than
men. Diabetes has been known for several thousand years. When untreated, people with
diabetes could urinate frequently and copiously, therefore the Greeks named it siphon,
and later mellitus, meaning sweet. At that time, the diagnosis was made by tasting the
urine, which was sweet. The sweetness is caused by the presence of glucose in the urine.
Its presence is useful in making the difference between two forms of diabetes: mellitus
and insipidus. Insulin is the lack hormone in diabetes, which in normal, is produced by
islets of Langerhans. Until the 20th century, diabetes was a common cause of death. Since
1921, new knowledge and techniques made it possible to do more for diabetics. Dr. Elliot
Joslin of Boston made a revolution in matter of diabetes. He realized that the diabetes
patient needed to have understanding of his disease so that he could take care of himself.
The patient and his family have to be well informed about the disease in order to make
day to day decisions about managing it.
Characteristics. The main problem in diabetes is the bodys inability of metabolize
glucose, which is a crucial process in ensuring the bodys cells with energy. Glucose is
stored under normal conditions in the form of glycogen and reconverted into glucose
when it is needed. The insufficiency of insulin leads to bodys inability to metabolize
glucose, which results in an abnormal accumulation of glucose in the bloodstream. The
failure is similar to starvation. The diabetic eats food but cannot use the energy,
therefore, in order to obtain energy, the people has to metabolize the stored fat. This
results in loss of weight. A by product of fat metabolism is ketone bodies which may
produce diabetic acidosis.
Excess urine production: as glucose accumulates above normal levels in the diabetics
bloodstream, it is filtered by kidneys and remains in the urine. The excessive urine is
produced in order to eliminate the excess of glucose in the blood.
In diabetes, the glucose, protein, fat metabolism are affected, which produce changes in
the nerves, muscles, eyes, kidneys, blood vessels. This disease may be mild, moderate
and severe, and nobody knows the exact causes. Diabetes worse in the presence of
illness, hyperfunctioning diseases, stress and during pregnancy.
The diagnosis of diabetes is an easy one, especially in children, the symptoms are
evident: rapid weigh loss, extreme hunger, general weakness, frequent and copious
urination, excessive thirst. Finding glucose in the urine along with increased levels of
glucose in the blood generally confirms the diagnosis. Moreover, an adult of diabetes may
not have an evident set of symptoms for months, years. He may just have fatigue, or
skins infections. A woman may have a genital itch (prurit).
The diet is a major part of the treatment. The patient should reduce the calories in the
food. Diet is the only treatment needed by many adult diabetics, especially those who are
obese [obiz]. Usually, the obese people are more likely to develop diabetes, and it is
important for obese people to weight before they become diabetics. Each diabetics diet
has to be individualized, and should conform to the patients needs, ethnic pattern and
customs. Some nonobese diabetics, have to eliminate sugar, soft drinks , alcohol, from
their diet. Children must be helped to understand that they should avoid eating foods

containing concentrated sugar. Some people may use diet guides, which indicate number
of calories and amount of protein, fat, carbohydrate.
Until recent years, insulin was prepared in the US from beef or pork pancreas. Nowadays,
the insulin drug is manufactured synthetically[ sinthetikli] using a duplicate of human
genes. Insulin has to be given my injection, usually subcutaneous injections, because the
insulin may be destroyed by gastric secretions, if taken orally. Insulin infected once a day
should mimic normal insulin action, which is the purpose of the intermediate and longaction insulins. Other people require two or more injections. The usual time taking is
before breakfast and should be the same time every day. Second injections is at supper
time. The basic insulin dose is established according to the severity of the disease.. most
diabitics take 10-40units per day.
Most diabetics self inject their insulin and the site of injection should be changed
everyday.
Insulin shock. The injected insulin much be matched
to the amount of blood sugar. If there is too much insulin, too much exercise, or too little
ingested carbohydrate, the blood sugar level rapidly falls, a condition known
hypoglycemia[ haipoglaisimi] and the brain is deprived of energy. It occurs at the time of
the insulins peak activity, resulting in insulin shock. The first sing is mild hunger, then
quick sweating, palpitation, shallow breathing, mental confusion, loss of consciousness. In
this case, the patient should be offered sugar, or intravenous glucose. Diabetes who use
insulin should always have a lump of sugar in order to avoid the insulin reaction.
Repeated and prolonged episodes of insulin reaction may be damaging to the brain.
Development of a pump for infusion of insulin into the bodys bloodstream is a method of
treating diabetics with keto-acidosis. In this method, a reduced amout of hypoglycemia
has been reported. It includes a reservoir for insulin, a pump, and a power pack
containing batteries. This method meets the physiological needs of the body. Oral
hypoglycemic drugs are useful in controlling mild diabetes that develops in people over
45. In order this method to work, some of the islets cells must be capable to produce
insulin, because the drugs stimulate their activity. The dose varies from 1-8 pills taken
before meals and throughout the day.
Prolonged
hyperglycemia , caused by excess of sugar, from insufficient insulin activity, can cause
diabetic coma. It involves the increased amount of ketone bodies as a by product of fat
metabolism- a chemical imbalance in the blood. If we find a diabetic in coma, and we
dont know the cause, we should treat him with sugar and it will give an insulin reaction.
Diabetic acidosis occurs due to: the patient didnt take the insulin for some days, take too
little, overeate or underexercise. The treatment involves taking rapid-acting insulin every
3-4 hours.
Diabetes requires a good control, which means feeling well with small amount of sugar, or
no sugar in the urine. The patients should take personal glucose tests, to control their
urine daily, namely, in the beginning of the day. The tests offer information about the
efficiency of their diet and exercise and insulin activity.
Once the patient
has made crucial adjustments, related to his diet, insulin intake, and planned his daily
activity, he is on his way to a normal life. However, there may be obstacles, like the
acceptance, initial depression, maintaining the schedule in parties and during traveling.
Also, the familys lifestyle should be changed entirely.
Juvenile[ djuvenail]
insulin dependent diabetes. Boys and girls develop diabetes in equal numbers, the
onset is about 8years, or may be discovered in the first hours/days of life. But more often
appears at puberty. In this case, the insulin therapy is required. The children must avoid
icecream, concentrated carbohydrates, restricted animal fat. Should prevail fruits,

vegetables, eggs supply the growing organism with nutriets, peanut butter, whole grains
and honey instead of sugar.
Pregnancy is special for a diabetic woman and her unborn child. But with good
management during diabetics pregnancy, the baby has an excellent chance of being
normal and healthy. Therefore the diabetic mother need to be tested more often by the
obstetrician, controlling the urine glucose and blood glucose levels.
**Diabetes is usually compared to aging, due to a loss of elasticity in the cells of the
blood vessels, kidneys, eyes, nerve tissues. The nerve-tissue changes may cause a
reduced sensation to touch and pain, loss of motor function. The eye-ground changes can
cause loss of vision. The changes of kidneys affect the filtration functions, loss of protein
from the blood into the urine, development of high pressure. Medicine can reduce the
effects but cannot cure them. The prevention is possible, and good diabetic control
contributes to a delay in development of the complications. The vascular changes make
the feet vulnerable[valnerbl] to infections that can result in gangrene [gngrin] and
amputation. Daily care is the best remedy. Toenails cut only by podiatrist[pdaitrist].
Prevention is useful in diabetes. Avoiding the risk factos, especially if your parents,or
relatives developed diabetes. A laboratory test, called a glucose tolerance test, may
identify a person who is prediabetic. Having urine tests once a year, to determine the
presence of sugar. The todays diabetic patients have a better chance for better life than
those from the last generation. Detection and prevention are the steps to a healthy life.
Rheumatic fever
One of the major rheumatic manifestations is arthritis, which is the painful inflammation
of the joints, especially the larger joints are involved (ankles, knees, hips, elbows,
shoulders). Rarely only one joint is affected. The inflammation may last a day or two. In
most cases the joint is swollen and tender to touch, may be hot and red. Active and
passive motion is painful. The patients temperature is elevated, a moderate leukocytosis
is present and the erythrocyte sedimentation rate is increased. Occasionally, the small
joints of the fingers are involved. It was observed that most patients with polyarthritis
have a degree of cardiac involvement even if a clinical evidence is absent. Therefore, it is
necessary to have electrocardiograms during an attack of polyarthritis. In this patients,
there may be present a prolongation of the conduction time.
Chore is the disorder of the central nervous system characterized by emotional instability,
purposeless movements, muscular weakness. It usually occurs between the age of sevenfourteen, with the peak incidence at the age of eight years. Chorea is rare after puberty
and never occurs after the age of twenty years. The onset it gradual. The mother may
observe that the child becomes suddenly nervous, tends to drop things and stumbles.
Often writing difficulties are reported, the speech is affected and the purposeless
movements of legs and arms. The emotional instability is the first indication that chores is
developing, and more often, only one side of the body is involved. The muscular
weakness is so marked that the child is unable to walk, talk or sit up, or the movements
may become violent. The symptoms of chorea dont occur at same time with arthritis.
Patients with chore do not have fever, leukocytosis or rapid erythrocyte sedimentation
rate. There are no changes in the spinal fluid. The presence of fever and increased
sedimentation rate indicates cardiac involvement.
The medical interview

The medical interview is the most important tool of the physician. It is done more often
than anything in the physicians professional life. The functions of the medical interview
are: to gather and to communicate information, to develop and maintain a therapeutic
relationship. Each function requires a specific behavior and a separate set of skills.
Collecting information is the base function of the medical interview. Whether this
information is physiological or biological, appropriate collection skills can increase the
efficiency of the information that is collected. The main steps of the conversation
between patient and physician is to gather information and determine [dtrmin] the
nature of the problem. The required skills are: open-ended question (tell me about..) ,
facilitation (help the patient to continue, encourage), direction(want to know more about
it), , summarizing and checking the worries.
A therapeutic relationship means a relationship that promotes care, cooperation, healing.
The good interaction between patient and physician, gives the patient freedom to talk
openly and in more detail about his/her feelings. The interviewing techniques such as
reflection, legitimation, support, respect, partnership, empathy, positive regard,
avoidance of shame and humiliation and nonverbal skills contribute to interview
efficiency. In order to maintain a good relationship, the physician needs to handle the
patients emotions. The physician should be attentive and aware of whether the emotions
become evident and when they have to be but they are not. Also the physician must
involve the patient in making decisions. This fact would make the patient more
responsible for his/her health and may improve the biological outcome. Patients who are
understood by their physicians are satisfied and feel better, and the physician is satisfied
in turn. The physician should establish baseline knowledge and attributions by asking the
patient to tell what he/she knows about his/her disease. Also he should avoid complex
medical terminology, and check the patients understanding and attention by asking him
to summarize the information. In this way, the patients will better understand the nature
of their illness, the diagnostic procedures, and the treatment. The information provided
by physician should be brief and concrete. The patient may be anxious and therefore,
may not be able to understand the physicians message. in this way, the physician must
follow some points (to the structural elements of the interview): optimizing the
environement, opening, preparing to listen, greeting, the introduction, identification of
the barriers of communication, survey the problems, negotiate the problems, establish a
narrative thread, developing the life context of the patient and illness.
1. Optimizing the environment by removing the environments barriers, eliminating the
distractions, ensuring privacy, making eye contact. Also, having nice telephone operators.
2. an open attitude, which means being ready to listen, to gather information, to be
attentive and generate hypotheses [haipotheziz]
3. preparing to listen involves focusing, leaving behind other worries, thoughts, being
centered upon the patients problems.
4. greeting the patient, that gives a positive note to the conversation and set the initial
tone for the interview. From the greeting, the patient may understand how is the doctors
mood, if he/she knows the patient.
5. in the introduction phase the patient and physician discuss the expectations, why they
are there, what their expectation are, the limits. The social talk may occur. The physician
must show care. Today many patients have bad experiences with doctors, therefore the
patient may be fearful or angry and may be inclined to show these feelings. in this

situation the doctor may say I see you are in pain. May I help make you feel
comfortable? it is a way to obtain the patients belief that you care and interested in his
needs.
6. identification and elimination of the barriers to communication. Unless it is done, the
interview is worthless, the physician is wasting time and obtaining bad information.
Physical barriers: deafness, severe pain; cognitive-depression, hallucinations, anger;
cultural- language, health belief, fears of deportation.
7. survey and analyze all the problems. The physician should identify the chief complaint,
therefore he might ask what brings you today in? and keep asking in order to find the
real problem and cause. The most significant problem to the physician came up third
because patients often complain about what embarrasses and frightens them the last.
8. negotiate a priority problem with the patient. it is important because the patient may
complain for back pain, but in the opinion of the physician, the most serious problem is
bloody sputum[ bladi spiutm]. For this, the physician needs to explain the patient the
causes of his decision. The physician states his her reasons and the patient does the
same, and then the physician and patient decide together. The best way is to ask the
patient to tell the story of his symptoms from the beginning; this establishes a narrative
thread. In this way the physician and patient cooperate and try to solve the problem
together.
9. the narrative thread is helpful in finding out information about patients life context and
illness.
So firstly, the physician must show interest, secondly, demonstrate respect, sensitivity,
kindness and concern. Third, to listen actively, which means not only hearing but also
observe the things that are not said- the emotions, things that embarrass the patient,
when he changes the subject.
The end of the visit is also important. At this stage, the physician and the patient discuss
about the diagnostic procedures and therapeutic options. The most important, the
physician should allow the patient to review in his/her own words what has happened and
what will happen.
Osteoarthritis.
OA is the most common type of arthritis, occurring in 10% of population all around the
world. It is the disease of cartilages, they become eroded [iroudid] and thinned as the
disease developes. The disease moves slowly from one joint to other. A great impact has
the weight, because the disease affects especially the joints of the legs, and it is the main
cause of disability in elderly people.
1.

2.
3.
4.
5.

Age. OA doesnt affect only elderly people but can occur in young people too. It has
been shown that the cartilage in older people is biochemically different in those with
OA.
Mechanical factors. Damage to the joints, such as trauma and fractures through the
articular surfaces, surgical meniscectomy.
Genetic factors. Predisposition to OA
Obesity. It is more common in obese people
Biochemical abnormalities. OA is increased in patients with metabolic and hormonal
changes, for example in acromegaly

6.

Diet

Changes in articular cartilage occur first in OA. There is loss of proteoglycans which form
the ground substance and increased cellular [seliul] proliferation. This leads to
development of cracks and fissures. Collagen fibrils which are parallel in normal
cartilages, are disarranaged in OA. Cartilage is lost from the articular surface and as a
result the synovial tissues become thicker. There is an increased activity and remodeling
of subchondral bone. The surface of the joints become mineralized and hard. Bone cysts
are formed, which are areas of porosis which are seen on X ray. OA begins at about
50years. It is twice more common in women than men, however, it is uncommon in black
population. It usually affects the knees.