Admission order記得要開finger sugar: AC,PC,3pm,9pm
DM diet分為1200kcal,1500kcal,1800kcal
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IBW算法: 女 IBW=(BH-70)X0.6 男 IBW=(BH-80)X0.7 |
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BW>IBW(減肥餐) |
20Kcal IBW/day |
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BW-IBW |
30Kcal IBW/day |
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BW<IBW(增重餐) |
40Kcal IBW/day |
ab:
大部分該驗的急診都驗完了,CBC/DC, U/A, sediment, BUN, Cr, Na, K, GOT/GPT
HbA1c: if 2~3個月沒測了，可以follow一下，評估過去兩三個月血糖控制情形
Lipid profile(HDL,TG,cholesterol) + LDL
視情況排Fundoscopy, Dupplex
@DM病人要評估有沒有三小micovascular disease:
Retinopathy: 可以問病人有沒有看門診紀錄眼科門診追蹤,或打過雷射
或者看一下”檢查”報告有沒有fundoscopy
病歷總覽的眼科門診紀錄
Nephropathy: 可以看一下U/A的protein量有positive就是有啦! 再來可以留24hr
Urine驗microalbumin判斷DM nephropathy stage?
Stage 1 Hyperfiltration
Stage 2 Silent
Stage 3 Microalbuminuria
Stage 4 Macroalbuminuria/Overt proteinuria
Stage 5 ESRD
Neuropathy: 問病人腳會不會麻,痛,有多久了
DM foot進來的通常都有
@要評估有沒有三大macrovascular disease:
CVA /AMI(心): 有胸悶的症狀要小心，晚上值班常常遇到，胸悶加冒冷汗快做EKG
Stroke(腦)
PAOD(周邊): 腳的pulse要會摸--->摸不太到可以排Dupplex檢查leg血流
Microvascular disease:
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Diabetic retinopathy: |
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Non-proliferative (background) |
Microaneurysms, dot and blot haemorrhages, hard exudates |
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Pre-proliferative |
Soft exudates(retinal infarcts), intraretinal microvascular abnormalities(IRMAs) |
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Proliferative |
Formation of new vessels (neovascularization) |
Everyone with type 2 diabetes should have their eyes fully examined annually.
Once retinopathy is present, examination should be performed every 6-12 months or more often if indicated.
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Diabetic nephropathy: |
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Hyperfiltration (at diagnosis) |
Hyperfuntion and hypertrophy |
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Silent stage (first 5yr) |
Thickened GBM, expanded mesangium |
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Microalbuminuria (6-15yr) |
30-300 mg/day |
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Macroalbuminuria (15-25yr) |
300mg/day |
irreversible |
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ESRD(25-30ry) |
GFR<15 |
Evidence base that diabetic nephropathy may be ameliorated through use of the following measures:
1. Control of hypertension. ACEI have renal protective effect and should be used when
microalbuminuria is present. Target goal: BP 130/80 mmHg.
2. ARB for Type 2 DM, ACEI for Type 1 DM will prolong the progression of proteinuria
3. Control blood glucose level.，lowering the HbA1C to below 7% through intensive management.
4. Early detection and treatment of urinary tract infections.
5. Avoidance of nephrotoxic agents (radiographic dyes, tetracyclines and aminoglycosides).
6. There is some evidence that a low-protein diet may be beneficial.(0.6-0.8/kg/day)
Diabetic neuropathy: (Peripheral, ANS)
Neuropathy is one of the most common diabetic complications, and is present in about 30-40% of patients with diabetes. The most common form of neuropathy is a bilateral peripheral neuropathy of a “glove and stocking” distribution, commencing in the lower limbs. Loss of pain and temperature sensation is a major contributory factor to the development of neuropathic ulceration and joint destruction. The presentation of neuropathy vary from pain, and paraesthesia through to numbness.
