• Services
• Appointments
• Privacy Pledge

• Donations
• Volunteers
• Publicity

• About Us
• Contact Us

• Health Facts
• Health Links

DIABETES

• Depends on age, symptoms

• Type I vs. Type II
• Type I is autoimmune disease (destruction of pancreatic B cells, which make insulin—which is needed for muscle/adipose glucose uptake); hence insulin-dependent; often presents in childhood or adolescence
• Type II is due to insulin-resistance (pancreas may be compensating by making MORE insulin, but may not be ENOUGH); insulin is not first-line drug, but may be required if insulin production drops

• Association with obesity, HTN, high cholesterol, family history
• Ask related questions

• Symptoms of hyperglycemia:  Increased urination, increased thirst, increased appetite (but weight loss for Type I; Type II patient is usually obese)

• Check fasting blood sugar (glucose)
• Normal:  70-100 mg/dL
• Pre-Diabetes: 100-125
• Diabetes:  >126 on more than one test

• Complications depend on how long they had it
• Macrovascular: cardiovascular events (coronary artery disease,  MI), cerebrovascular accidents, peripheral vascular disease
• Chest pain—may not have any! (“silent MI”); be sure to ask about sympathetic symptoms (sweating, tachycardia)
• Stroke risk (asymptomatic OR headache, blindness, difficulty in speaking, sensory deficit, motor deficit, etc.)
• Microvascular:
• Retinopathy (Visual changes?  Blurring of vision, floaters, blindness)
• Renal function impairment (nephropathy); (edema? microalbuminuria? HTN)
• Neuropathy
• Tingling, numbness, decreased sensation in distal extremities? (feet, fingers)
• Ask about foot care (combo of nerve problems—loss of sensation—and infection risk); want to avoid amputation!
• Gastroparesis: Intractable nausea and vomiting, Dyspepsia (indigestion); bloating/discomfort after eating?
• Orthostatic hypotension (feeling of dizziness, fainting when changes position from sitting to standing)
• Infection
• Increased risk (susceptibility to infections like TB, skin, pneumonia, etc.)
• Can also worsen DM
• Poor wound healing
• Urinary tract infections (symptoms: dysuria, frequency, urgency, dribbling, incontinence, retention)

MANAGEMENT:

MEDEM ( Monitoring, Education, Diet, Exercise, Medication)

1. Monitoring (HbA1c of 7% or lower, self monitoring of blood glucose, urine glucose & ketone)
2. Education (role of educator?)
3. Dietary modification (caloric restriction for obese patients, role of educator?)
4. Exercise (benefits in DM patients)

MEDICATIONS

• Need to check LFTs, electrolytes (BMP)
• Glyburide, glipizide: can cause weight gain (and hence noncompliance), hypoglycemia
• Metformin – ideal for obese patients (no weight gain side effect); risk of lactic acidosis, GI intolerance
• Insulin – NOT GIVEN AT PFC - risk of hypoglycemia ( patients’ compliance is critical)
• Hypoglycemia symptoms:  faint, dizziness, sweating, hunger, trembling, blurred vision, anxiety, confusion, unconscious

      - Baby Aspirin is proven of benefit in secondary prevention of MI & stroke in DM patients

 

• Hypertension = high blood pressure

• Classification (systolic/diastolic):
• Normal: < 120/80
• Prehypertension: 120-139 / 80-89
• HYPERTENSION:  >140/90
• Stage 1: 140-159 / 90-99
• Stage 2: >160 / >100

• EXCEPTION:  > 130/80 mmHg is HTN in people with diabetes and chronic kidney disease.

• Two types of hypertension :
• Essential (primary) HTN – high blood pressure with an unidentified cause
• Secondary HTN - high blood pressure with an identifiable cause

• One high blood pressure reading is not enough to diagnose HTN; need 2-3 times (2 or more abnormal readings)

• Hypertension may be asymptomatic!

• Symptoms:  headache, dizziness, other signs and symptoms if it is secondary HTN
• Complications: hypertensive heart disease, risk of : stroke, retinopathy, nephropathy
• Shortness of breath?
• Recent chest pain?
• Cough?  (heart failure)
• Edema? (swelling of ankles, legs?)

• Associations:  high cholesterol, diabetes

MANAGEMENT

• Life style modification (low salt diet, cessation of smoking, reduce body weight if overweight, moderation of alcohol intake, etc;)
• Benefits of diet and exercise (avoid adding salt, soy sauce, canned foods, TV dinners...)
• Medication compliance – Because hypertension is often asymptomatic, and even if blood pressure is normal on medications, patient still has “hypertension”
• Medication overdose may result in hypotension or fainting
• ALWAYS CHECK BLOOD PRESSURE IN EVERY VISIT AND RECOMMEND PATIENTS TO CHECK BLOOD PRESSURE AT HOME AND NOTE DOWN

• MEDICATIONS used in PFC & SIDE EFFECTS
• Diuretics (HCTZ, furosemide):  electrolyte imbalances (muscle cramp, weakness, abdominal cramp ); decreased potassium, sodium, and chloride
• Beta-blockers(drugs with the ending: “-lol”) : heart failure, AV block, depression, Raynaud’s phenomenon, hyperlipidemia; contraindicated if asthma or chronic obstructive pulmonary disease (COPD) due to bronchoconstriction in non-selective beta blockers
• Calcium channel blocker (verapermil): edema, constipation, nausea, headache, etc.
• ACE inhibitors (drugs with the ending: “-pril”):  angioneurotic edema, hypotension, rash, dry cough (may lead to non-compliance!!)
• Good for patients with both diabetes and HTN b/c diabetes often has renal complications
• Also:  Angiotensin receptor blockers (ending with: “-sartan”)

 

• May be asymptomatic, but the potential consequences are SERIOUS
• One of the major risk factors for heart disease
• Atherosclerosis: cholesterol plaques build up on walls of arteries; “hardening of arteries”; vessel narrowing (think clogged pipe) and slowed/blocked blood flow
• Stroke (Transient ischemic attack; ischemic vs. hemorrhagic stroke)
• Symptoms depend on location of blockage or hemorrhage in brain
• Blurred vision, headache, limb weakness (esp. one-sided), sensory (tingling, numbness), neck stiffness
• Thrombolytics used in infarct stroke (need to refer the patient out!)
• Ischemic heart disease, HEART ATTACK
• Hypertension

• Need to distinguish between total, LDL, and HDL
• Total cholesterol: ideally <200; >240 is high
• LDL = “bad cholesterol” (ideally <100; >160 is high)
• HDL = “good cholesterol” (ideally >60; <40 is low)

• Major risk factors that affect LDL:
• Cigarette smoking
• High blood pressure
• Low HDL cholesterol
• Family history of early heart disease (father or brother < 55; mother or sister <65)
• Age (men >45 years; women >55)
• Obesity, Sedentary lifestyle

 

• DIABETIC PATIENTS: must control LDL to <100, because 2X risk of heart disease

MANAGEMENT

• Lifestyle modifications first: Diet, weight loss, increase physical activity

MEDICATIONS

• Cholesterol is made in the liver so before starting meds, need to get baseline liver function tests (LFTs), and follow LFTs once on meds

• Statins (eg. Atorvastatin = Lipitor)
• Statins are competitive inhibitors of HMG CoA reductase (part of cholesterol synthesis pathway) and dramatically reduce LDL cholesterol levels!!
• SIDE EFFECTS:
• mild elevation of serum aminotransferases (check LFTs); patients with pre-existing liver disease may have more severe reactions
• severe muscle pain (TOXICITY)
• AVOID drugs or foods (eg. grapefruit) that inhibit cytochrome P450 activity b/c that is how these drugs are metabolized
• TERATOGENIC

• Bile acid-binding resins (eg. cholestyramine)
• Prevent absorption of dietary cholesterol and reduce reabsorption of bile acids secreted in the liver thus diverting hepatic cholesterol to synthesizing new bile acids and increasing synthesis of LDL receptors (which increases removal of LDL from the blood)
• SIDE EFFECTS:  bloating, constipation, unpleasant gritty taste; impaired absorption of certain vitamins (eg. Vitamin K, dietary folates) and drugs (eg. digitalis, thiazides, warfarin, statins)

• Fibric acid derivatives (eg. gemfibrozil)
• Ligands for PPAR-alpha protein, a receptor that regulates transcription of genes involved in lipid metabolism
• Reduce serum triglycerides; modest reduction of cholesterol
• SIDE EFFECTS:  Nausea, skin rashes, risk of cholesterol gallstones (caution with patients with prior history)
• WARNING:  DO NOT combine with statins! (myopathy risk)

• Due to reflux of acid into esophagus
• Predominant symptom is “heart burn”
• Other atypical symptoms: cough, asthma, hoarseness, chest pain, oral ulcers, hiccups, dental erosion
• Warning symptoms: dysphagia (difficulty in swallowing), early satiety, weight loss, bleeding
• Diagnosis is mostly done with therapeutic trial of PPI (proton pump inhibitor)

MANAGEMENT:

• Lifestyle modifications: eating small meals, refraining from eating 2-3 hours before lying down, decreasing fat intake, chocolate, coffee, cola, alcohol and smoking cessation

MEDICATIONS:

• H2 blockers: drugs that end with “-tidine” (e.g. cimetidine, ranitidine, famotidine)
• PPI (proton pump inhibitors): drugst that end with “-zole” group (eg. omeprazole)
• Common side effects: diarrhea, headache, abdominal pain

• Hepatitis is a serious infection of the liver caused by different viruses (A, B, and C). 
• Vaccines are available for Hepatitis A and Hepatitis B, but there is NO CURE for hepatitis.
• Hepatitis B and hepatitis C are silent killers

• Hepatitis A (HAV): 
• Prevention is key:  Hepatitis A vaccines are available (2 shots)
• Mode of transmission:  Fecal-oral transmission (restaurants—workers who don’t wash hands, or contaminated raw foods)
• Symptoms:  Acutely ill, but rarely fatal (jaundice—yellow!!)

• Hepatitis B (HBV):
• Prevention is key:  3-shot hepatitis B vaccine confers life-long protection against HBV (World Health Organization calls it the world’s first “anti-cancer vaccine”)
• Modes of transmission:  blood (eg. during childbirth from mother-to-child, wound-to-wound contact, resusing or sharing needles for tattoes, piercings, acupuncture or IV drug use, sharing razors or toothbrushes contaminated by blood, blood transfusions); sexual contact
• Hepatitis B is NOT transmitted through sharing food, water, or utensils, nor is it spread through tears, sweat, urine, coughing, sneezing, kissing, or breastfeeding
• Alarming facts: 

            HBV is a global epidemic
            Despite there being a vaccine, HBV still kills up to 1 million people
            worldwide
            About 370 million individuals in the world live with chronic HBV
            HBV is 100X more infectious than HIV
            As many as 1 in 10 foreign-born Asians are chronically infected with HBV
            As many as 2 out of 3 chronically infected persons are unaware of their
            infection
            Without appropriate monitoring or treatment, 1 in 4 will die from liver
            cancer or liver failure.
            Every 30-45 seconds, one person dies from this vaccine-preventable
            disease

• Symptoms:  Often asymptomatic until too late.  By the symptoms such as abdominal pain, abdominal distension, or jaundice, it is often too late for treatment to be effective.  Chronic infection with hepatitis B can lead to premature death from liver scarring (cirrhosis), liver failure, or liver cancer. 
• Early detection of liver cancer is important:

            Liver cancer is a silent killer because patients typically show no
            symptoms until the end stages of the disease.
            Asians who are chronically infected by HBV at birth or during childhood
            may develop liver cancer as early as their teens
            If diagnosed late, liver cancer is one of the most difficult cancers to treat.
            Early detection and screening can lead to successful surgical removal
            and long-term survival.

• 3 classifications for HBV infection:
• Acute hepatitis B resulting in liver failure
• Acute hepatitis B with full recovery and development of immunity
• Chronic hepatitis B (lifelong infection)
• still test positive for Hep B after 6 months
• ¼ chance of developing liver failure or liver cancer
• may not have symptoms until too late; need regular screenings
• HBV Screening is important:

            Many chronically infected persons show no outward signs of HBV
            infection, therefore screening for HBV is necessary to:

• Identify individuals who have chronic HBV infection so they can receive appropriate medical management
• Identify those who are unprotected so they can be vaccinated
• Interpretation of screening results:

            Hepatitis B surface antigen (HBsAg):  If a patient remains HBsAg-
            positive for more than 6 months, they have chronic HBV infection.
            Hepatitis B surface antibody (anti-HBs):  The anti-HBs test will tell if your
            patient is protected against HBV.  Anti-HBs can be produced in response
            to vaccination or recovery from an acute hepatitis B infection.

• Available hepatitis B vaccines:
• Engerix-B
• Recombivax HB
• MANAGEMENT OF PATIENTS WITH CHRONIC HBV:
• Help your patients understand their hepatitis B status by making sure the test results and letters are clear.  Give your patients HBV informational brochures that are culturally and linguistically appropriate.
• Screen patients regularly for liver damage and cancer:  People with chronic HBV infection can live completely normal lives as long as they are screened regularly for liver damage and cancer. 
• Give the hepatitis A vaccine to reduce the risk of further liver damage
• Tell your patients to avoid regular alcohol consumption to help protect their liver
• Test and vaccinate patient’s close contacts (family, significant others)
• Educate patients on how to minimize the risk of infecting others
• Give HBV treatment with anti-viral medications if necessary
• There are currently 4 FDA-approved medications to treat chronic HBV:

The following oral antivirals inhibit replication of HBV:
Lamivudine (Epivir-HBV, approved 1998)
Adefovir (Hepsera, approved 2002)
Entecavir (Baraclude, approved 2005)
Telbivudine (Tyzeka, approved 2006)
Common side-effects include:  The main adverse outcome is drug-resistent mutant viruses.  Side effects are uncommon and usually mild (weakness, headache, fatigue, diarrhea, and stomach pain).  Adefovir has potential renal toxicity, though it is uncommon.

• Hepatitis C (HCV):
• Mode of transmission:  blood (IV drug use, childbirth, razors, toothbrush); sexual transmission UNLIKELY
• May be co-infected with Hep B
• NO vaccine
• Most people are asymptomatic
• Most likely to become chronic if infected and lead to liver cancer

 

• Types:
• Age-related
• Proteins of the lens clump together over time and start to cloud the lens
• Lens may instead gradually change to a yellowish/brownish color
• Lens clouding/coloration reduces light that may reach the retina
• Congenital
• Present at birth or early in development
• May be so small that they do not affect vision
• May call for removal
• Traumatic
• Develop after an injury
• Common in athletes
• Secondary
• Can form after surgery or as a result of other conditions
• Sometimes linked to diabetes or steroid use steroid use
• Radiation
• Develop after exposure to some types of radiation

• Target groups:
• Elderly (age-related)
• Diabetics, smokers, alcohol users, those exposed to UV radiation (other types)

• Symptoms:
• Cloudy/blurry vision
• Discoloration
• Glare
• Poor night vision
• Double vision or multiple images in one eye
• Frequent need for prescription changes in eyeglasses or contact lenses

 

• Treatment:
• For early cataracts, new eyeglasses, brighter lighting, anti-glare sunglasses, or magnifying lenses may help
• For mature cataracts, surgery is the only effective treatment
• Phacoemulsification:
• Small corneal incision
• Ultrasonic probe used to soften and break up cataractous lens
• Lens removed by suction
• Extracapsular surgery:
• Longer corneal incision
• Cataractous lens removed in one piece
• In both cases, the natural lens is replaced with an artificial, intraocular lens (IOL) that becomes a permanent part of the eye.
• Protecting your vision from cataract
• Wear sunglasses to block UV sunlight
• Eat green leafy vegetables, fruit, and other foods with antioxidants
• If over 60 years of age, have an comprehensive eye exam every two years

• Caused by a build up of pressure inside the eye that may damage the optic nerve and other parts of the eye; peripheral vision is affected first

• Most common form of glaucoma is open-angle glaucoma

• Target groups:
• African and African-Americans over the age of 40
• Anyone over the age of 60
• People with a family history of glaucoma

• Symptoms:
• No pain
• Decreased peripheral vision

• Detection:
• Visual acuity test—measures distance vision
• Visual field test—measures peripheral vision
• Dilated eye exam—to examine retina and optic nerve
• Tonometry—use of an instrument that measures intraocular pressure
• Pachymetry—use of ultrasonic waves to measure corneal thickness

• Treatment and/or Management:
• Early diagnosis is crucial!
• Eye-drops or pills -- aim to either slow the production of fluid from the eye or lower the pressure inside the eye by helping fluid drain
• Laser trabeculoplasty – laser surgery that makes evenly spaced burns that stretch the drainage holes in the meshwork of the eye to allow better fluid drainage
• Conventional surgery – a small piece of tissue removed to make a new opening for fluid to leave the eye

• Other types:
• Low/Normal-Tension – optic nerve damage and narrowed side vision in the absence of high intraocular pressure
• Closed-angle – fluid at the front of the eye cannot reach the angle and leave the eye. Angle is blocked by part of the iris, causing a sudden increase in IOP.
• Associated symptoms include severe pain, nausea, redness of eye, and blurred vision
• This type of glaucoma needs to be treated as an emergency, as blindness can take hold very quickly
• Congenital – birth defect involving angle of eye that obstructs normal fluid drainage
• Associated symptoms include cloudy eyes, light sensitivity, and excessive tearing
• Secondary – sometimes associated with eye surgery or advanced cataracts, eye injuries or tumors, or uveitis (eye inflammation)
• Pigmentary: pigment from iris flakes off and block the meshwork, slowing fluid drainage
• Neovascular: severe form linked to diabetes

 

• Characterized by gradual decline in sharp, central vision.

• Causes:

• Dry AMD – (90% of all cases)
• Area of the retina becomes diseased
• Slow breakdown of light-sensing cells in the macula
• Gradual loss of central vision
• Wet AMD – (10% of all cases, yet it accounts for 90% of all blindness from AMD)
• New blood vessels begin to grow and are very fragile
• Vessels break and leak fluid and blood under macula
• Rapid damage to macula as a result
• Loss of central vision in short time

• Risk factors:
• Anyone over 60 years of age
• 30% risk in people over 75 years of age
• Gender – women at greater risk than men
• Race – unlike glaucoma, whites are more at risk than blacks
• Smoking may increase risk
• Anyone with a family history of AMD is at a greater risk

• Symptoms:
• Dry AMD
• No pain
• Blurred vision
• May see blind spot in middle of visual field
• Wet AMD
• Straight line appear crooked
• Small blind in spot middle of visual field also possible

• Detection:
• Dilated eye exam
• Viewing of Amsler grid, a pattern that looks like a checkerboard

• Treatment:
• Dry AMD – no treatment (potentially certain vitamins and minerals)
• Wet AMD – laser surgery to destroy new blood vessels

 

• Diabetic Eye Disease is a group of eye problems that affect people with diabetes, to include:
• Diabetic retinopathy – damage to the blood vessel in the retina
• Cataract – see above
• Glaucoma – see above

• Diabetic retinopathy is caused by changes in blood vessels of the retina.
• Retinal blood vessels may swell and leak fluid OR
• Abnormal new blood vessels may grow on the surface of the retina

• Risk factors:
• Anyone with diabetes
• Between 40-45% of diagnosed diabetics have some form of diabetic retinopathy

• Symptoms:
• Often none in early stages
• No pain
• Blurred vision may occur when macula swells from leaking fluid (“macular edema”)
• Blocked vision due to new vessels growing onto surface of retina

• Treatment:
• Laser surgery can reduce risk of blindness by 90%
• Early detection is crucial!

• Prevention:
• Suggested that better control of blood sugar levels slows the onset and progression of retinopathy

 

• Conjunctivitis (“Pink Eye”):
• Conjunctiva (a clear membrane lining the eye and inner eyelids) becomes inflamed
• Caused by infection (bacterial, viral, or allergic), allergies, or irritation
• Allergic conjunctivitis, a common form, is usually seen seasonally as a result of grass or pollen or other allergens, and tends to produce symptoms in both eyes simultaneously
• Symptoms:
• Itchiness and tearing
• Redness
• Thick white, yellow, or green discharge
• Thinner, possibly clear discharge (viral or allergic)
• Treatment:
• Antibiotic eye drops or ointment
• Antihistamines (for allergic conjunctivitis)
• Eye cleansing

• Amblyopia (“lazy eye”):
• Characterized by one eye with weaker vision
• Caused by uneven or crossed eyes, or a difference in visual acuity between two eyes
• Symptoms:
• Frequent squinting or closing one eye to see
• Poor visual acuity
• Eye-strain
• Headaches
• Treatment: (usually needs to be started before age 5 since an amblyopic eye has problems in its connection to the brain)
• Wearing glasses to align or focus eyes
• Surgery on the eye muscles
• Eye exercises
• Wearing a patch over stronger eye
• Atropine drops in strong eye

• Myopia (“nearsightedness”):
• Affects distance vision because light entering the eye is focused in front of the retina

• Hyperopia (“farsightedness”):
• Affects near vision because the eye focuses light behind the retina

• Presbyopia:
• Affects close-up/reading vision
• Usually has its affects at around 45 years of age
• Due to the lens’ decreasing elasticity and inability to focus light properly on the retina; naturally occurs with age

Pacific Free Clinic © 2003 :: contact us :: website accessibility

Open each Saturday, 10am-2pm. We accept all patients regardless of immigration status, language, or insurance.