Pathology - Exam 3

Skin

Every 26-28 days

• protection
• environmental barrier
• metabolism
• sensation
• thermoregulation
• sensory reception

• epidermis
• --stratum corneum
• --stratum lucidium
• --stratum granulosum
• --stratum spinosm
• --stratum basal (germinativum)
• dermis
• subcutaneous tissue (hypodermis)
• deeper tissue

• stratum corneum
• stratum lucidium
• stratum granulosum
• stratum spinosm
• stratum basal (germinativum)

• stratisfied squamous epithelial
• avascular
• 0.06-0.6mm thick
• thickest on the palms and soles of feet

• "horny" outermost layer
• 20-30 cells thick
• thickest in the palms and soles of feet
• callus forms from pressure

• clear layer of dead flattened keritinocytes
• thicker and most prominent in hands and feet

• forms waterproof layer
• --prevents water loss
• langerhans help with immune system

• "spiny" appearance due to kerotin fibers
• progressive maturation and migration of germinal cells

• aka: germinativum
• single undulating layer of columnar and cuboidal cells
• undulations produce fingerprints
• provides germinal kerotinocytes for regeneration of epidermis
• melonin produced here

• Melanocytes: pigment, UV protection
• Merkel cells: light touch, mechanoreceptors
• Langerhan Cells: fight infection, decrease as we age, risk of skin cancer increases, dendritic cells

• hair follicles (soft keratin)
• sebaceous glands (lubrication)
• sudoriferous glands (sweat)

• Part of the epidermis
• acellular
• attaches stratum basale to dermis
• scaffolding for epidermis
• filters substances and moving between dermis and epidermis
• semipermeable - nutrients from dermis
• blisters occur here due to friction between basement membrane and papillary dermis
• anchors epithelial to loose tissue

• vascularized
• --capillary beds
• --rosy/pink color
• lymphatic system
• --returns water, proteins, other substances to the blood
• high water content
• 2.0-4.0mm thick

• nutritional support to epidermis
• houses epidermal cells and growth factors for epidermal replication and dermal repair after trauma
• thermoregulation through control of skin blood flow
• contains immune cells
• --defense against foreign invaders
• sensory assist to epidermis for info on environment

• fibroblasts (collagen/elastin) flexability
• microphages
• --modulate lymphocyte function and promote growth
• WBC
• mast cells - histamines

• hair follicles
• erector pilae muscles
• sweat glands
• sebaceous glands
• pacinean corpuscle and free nerve endings (vibration and pressure)
• nails

• aka - hypodermis
• highly vascularized
• more moist
• adipose tissue
• --shiny whitish yellow in color
• if cut -> see blood
• stores energy and vitamins A D E and K
• cushioning over bony prominences
• deeper lymphatic vessels here
• fascia
• --fibrous white connective tissue
• --seperate structures facilitating movement

• muscle: bloody red is normal
• tendons: white regularly arranged fibers
• ligaments: white regularly arranged fibers
• joint capsule: white irregularly arranged fibers
• bone: milky white, hard when probed

• wounds caused by shearing, friction, and mild burn
• healing occurs by regeneration of epithelial cells on wound surface an migration of epidermal cells across the surface
• affects epidermis layer only
• skin remains intact
• examples - blisters, 1st degree burns

• effects epidermis and part of the dermis
• accessory structures are spared (hairs and glands stay in tact)
• heals similarly to superficial thickness wounds
• eschar may form
• --dessicated necrotic tissue
• --black color
• examples - road rash, deeper burns

• effects epidermis, dermis, and into subcutaneous tissue
• muscle, tendon, and bone can be involved

• normal skin has elastic, tensile and viscous properties
• much of elasticity comes from viscous elements (viscoelastic)
• tendons are very stiff and elongate very little
• --due to parallel arrangement of thick collagen
• --due to different proportions of glycosaminoglycans
• turgor
• --ability of skin to recoil when pinched
• --decreases with dehydration

superficial and partial thickness wounds

• Inflammation
• Proliferation
• Maturation/Remodeling

• "exudative" phase for homeostasis and fight infection
• platelet aggregation
• --forms plug to stop bleeding
• coagulation and fibrin formation
• --controls bleeding
• neutrophils, macrophages, and mast cells
• --assist with destruction and removal of bacteria and cellular debris
• --secrete inflammatory mediators
• --phagocytosis and proteolysis

• swelling (tumor)
• redness (rubor)
• warmth (calor)
• pain (dolar)
• decrease in function (functio laesa)

• begins as early as 48 hours
• angiogenesis
• --sprouting of capillaries
• --tiny red dots in wound bed
• granulation tissue
• --tissue fills wounds
• --temporary matrix of vascular connective tissue formation (laid down by fibroblasts)
• --red, beefy, shiny, granular beds
• --very fragile
• --if trauma -> may cause bleeding
• wound contraction
• --decrease in size of wound
• --actin-rich myofibroblasts pull wound margins together
• epithelialization
• --keratinocytes migrate across wound
• --slowed by debris
• --clean/moist facilitates movement
• needs warm environments with high oxygen and nutriant demands

• "differentiation" phase
• maturation of collage, scar formation, and epithelialization
• rosy, pink scar
• remodeling of collagen fibers as they thicken, reorganize and mature
• --scar color similar to surrounding tissues
• 9 days - 2 years after injury
• tissue strength - 15-20% initially, 80% of original when healed

• Primary Intention
• Secondary Intention
• Teritiary Intention

• primary closure
• uses sutures, staples, adhesives
• minimal inflammatory phase
• fastest closure
• proliferation is epithelialization

• secondary closure
• allow wounds to heal on own
• used for wounds with tissue loss, irregular edges, tissue necrosis, high microbial count, or presence of debris
• increased healing time
• granulation has to be generated to close
• increased healing time
• increased scarring

• delayed primary closure
• leaving wound open until closing is prudent
• wound is not allowed to granulate
• closure of wound after time to start healing
• combo of primary and secondary
• needs cleansing of wound prior to closure

• mechanism
• location
• dimensions
• temperature
• dehydration
• necrotic tissue
• infection
• medications
• circulation
• sensation
• mechanical stress
• foreign body
• age
• nutrition
• comorbidities
• compliance

• age
• chronic disease
• perfusion and oxygenation
• neurologically impaired skin

• medications
• nutrition
• irradiation and chemo
• psychophysiological stress
• behavior/lifestyle
• infection
• necrotic tissue

• local ischemia
• inappropriate wound care
• trauma
• cross-contamination/infection
• sheer injuries

• decreased immune system
• --decreased inflammatory response
• --delays angiogenesis
• dermal and epidermal atrophy
• --increased risk of skin tears
• decreased collagen synthesis
• decreased dermal vascularity (decreased nutrition)
• decreased oil and sweat activity decreased barrier

• malnourished: increased wound complications
• water: vital to wound healing
• protein: risk of protein depletion
• carbs: provide energy for repair and regeneration
• vitamins: needed to build new tissue and aid in immune function
• fats: essential fuel and vitamin transport

• disease processes that affect tissue perfusion affect wound healing (PVD, anemia, COPD)
• immunocompromised patients
• --ineffective immune system increases infection risk (HIV/AIDS, steroids, chemo)
• activity limitations
• --increased risk of skin breakdowns and delayed repairs

as temperature decreases, speed of healing decreases

• history
• systems review
• tests and measures
• --anthropometric
• --cognition
• --assistive/adaptive decives
• --gait, locomotion, balance
• --ROM, MMT, posture
• document

• clues concerning the cause of the wound and prognosis for healing
• color
• odor
• drainage
• shape
• surrounding skin color

strong indication for vascular supply

• indicates infection
• clean wounds have no smell
• sweet (fruity)
• --suggests psudeomonas
• foul (fecal smell)
• --gram negative bacteria

• thick, creamy drainage indicates infection
• amount
• type - serous (clear), sanguinous (pinkish)
• color

• melanin and hemoglobin
• --primary determinates of skin color
• palor suggests arterial insufficiency
• purplish hue
• --due to desaturated hemoglobin
• --severe arterial insufficiency
• --severe CHF or pulmonary disease
• redish
• --inflammation
• --infection
• heavy pigmented skin
• --hyperemia produces violet/eggplant color
• look at nail beds and lips
• trophic changes
• --indicators of poor arterial circulation
• --dry, scaly, leathery skin
• --brittle nails
• --hair loss (epidermal appendage)

• slough: yellow or white strings or thick clumps
• granulation: pink or beefy red tissue, shiny, moist, granular appearance
• epithelial: new pink or shiny tissue, grows in from edges
• necrotic: eschar, black , firmly adheres to the wound bed
• closed/resurfaced: wound completely covered

• shape
• edges
• temperature
• size
• volume
• limb girth

• highly regular: associated with pressure
• irregular: associated with vascular insufficiency
• extremely irregular: has "peninsulas and bays", areas of healthy skin surrounded by necrosis, associated with venous insufficiency

• attached: quicker to heal
• unattached: slower to heal
• rolled: signs of chronic wound
• callused: diabetic

• check severity of inflammatory response by temperature of surrounding skin
• increased in skin temperature due to developing cellulitis or infection
• decreased temperature caused by arterial insufficiency
• decreased temperature delays healing by reducing oxygen release

• length and width
• --tracing, photographic grid
• greatest length by greatest width method
• depth, tunneling
• --cotton tip applicator, tunneling stick
• surrounding skin errythema

fill wound with Hydrogel from a syringe

• document landmarks for reproductability
• pitting, or firm?

• palpitations
• --dorsal pedis, posterior tibial, popliteal pulses
• capillary refill
• --tests surface arterial blood flow
• -- ~30 seconds to normally return
• dependent rubor test
• --tests arterial flow
• --supine, lift leg, observe initial color, after 1 minute, observe change in color of foot. ~15-20 seconds to return. >40 seconds with insufficiency
• ankle brachial index (ABI)
• --measure BP on arm and on ankle
• --divide ankle pressure by arm pressure
• --normal indext is 1.0
• --<0.95 - narrowing
• --<0.8 - intermittent claudation

• Pattern A: prevention/risk reduction
• Pattern B : superficial skin involvement
• Pattern C: partial-thickness skin involvement
• Pattern D: full thickness skin involvement
• Pattern E: skin involvement extending into fascia, muscle, or bone, and scar formation

• works with the nervous system
• metabolism
• water and salt balance
• blood pressure
• sexual reproduction
• --differentiation
• --growth
• --coordination

• hypothalamus
• pituitary
• thyroid
• parathyroid
• adrenal
• pancrease
• repoductive glands
• pineal

• link between endocrine and nervous system
• nerve cells control pituitary gland by producing chemicals that either stimulate or supress hormone secretion

• controls other glands
• anterior lobe secretes: ACTH, TSH, GH, LH, FSH, prolactin (produced after childbirth, stimulates milk production)
• posterior lobe secretes:
• --ADH (controls body water and balance by acting on kidneys to modify urine out)
• --oxytocin (triggers contraction of uterus during labor

• regulates metabolic rate, growth and development and protein synthesis
• thyroid hormones:
• --thyroxin (T₄) - blood stream
• -- triiodothyroix (T₃) - cell functioning
• --calcitonin - stimulates calcium deposits in bone

• PTH
• increases blood levels of calcium by removal of calcium from bone to increase levels in the blood

• mineralcorticoids
• aldosterone
• --acts primarily on kidney to promote absorption of sodium and excretion of potassium
• --increase of sodium levels contribute to retention of water and increased blooe volume
• absence of aldosterone
• --sodium is excreted resulting in decrease blood volume and decreased blood pressure
• glucocorticoids
• --produced in response to stress
• cortisol
• --increase blood glucose by stimulating liver to produce glucose from stored, non-glucose sources
• --decreased swelling by inhibiting immune system response to injury or infection
• --prednisone produced from cortisol

• composed of modified neurons
• secretes hormones in response to stress
• --epinepherine (adrenaline)
• --norepinepherine (non-adrenaline)
• stimulate fight or flight response of sympathetic nervous system
• --increase HR and BP
• --dilate airways to facilitate oxygen flow to lungs

• digestive and endocrine gland
• islet or langerhans are cells that secrete
• --insulin (removal of glucose from blood to store as glycogen, promotes build up of fats and proteins and uses as energy source)
• --glucagon (increases levels of glucose in blood, released from alpha cells)
• secretes digestive enzymes into duodenum through pancreatic duct

• considered endocrine
• pear shaped
• apple shaped
• secretes hormones responsible for:
• --metabolism
• --hunger
• --vasoconstriction
• --cell growth and development

• LH from pituitary gland stimulates sex hormones
• responsible for secondary sex characteristics such as facial hair and breast development

• secretes melatonin
• light from eye stimulates gland through optic nerve
• melatonin is formed at night
• longer nights = increased levels of melatonin
• --levels vary with seasons and time of day
• melatonin helps regulate (rhythms):
• --circannual
• --arcadium

• more prevalent in women than in men
• most disorders prepresent hypofunction of gland secondary to:
• --defects in development
• --enzyme deficiencies
• --autoimmune destruction
• --decrease hormone stimulation
• --infection, neoplasia, hemorrage, or infarction

• thyroid disease
• parathyroid disease
• acromegaly (GH - pituitary)
• diabetes (pancreas)
• cushings syndrome (Cortisol - adrenal)

• acromegaly
• myxedema
• diabetes mellatus
• hyperparathyroidism
• hyperthyroidism
• gout
• hormone imbalance
• --menopause
• --pregnancy
• --oral contraceptives

• chondrocalcinosis
• --deposits of calcium salts in joint cartilage
• --5-10% have underlyng endocrine or metabolic disease
• ->hyperparathyroidism
• ->hypothyroidism
• ->acromegaly

• within anterior pituitary gland
• growth hormone deficiency
• --short stature
• --delayed grouth and puberty
• --adrenocorticol insufficiency
• --hypothyroidism
• --gonadal failure
• --neurologic signs if caused by tumore
• dwarfism
• treatment
• --lifetime hormone replacement

• result from the posterior pituitary gland
• diabetes insipidus -> RARE
• --lack of secretion of vasopressin antidiuretic (ADH)
• --water not reabsorbed in kidneys
• --dehydration
• --excretion of large amounts of dilute urine
• --expect patient to be fatigued and irritable due to nocturia

• symptoms:
• polyuria
• polydipsea
• nocturia
• dehydration
• imbalance of water
• treatment:
• hydration and replacement of ADH

• acromegaly (adults)
• abnormal enlargement of skeleton due to hypersecretion of GH
• clinical signs and symptoms
• --enlargemnet of face, hands, and feet
• associated musculoskeletal signs
• --carpal tunnel, hand pain and stiffness, back pain (thoracic and/or lumbar)
• giantism (Childhood)
• overgrowth of long bones
• grows past growth plate
• timely diagnosis is key
• treatment
• drug therapy
• removal of tumor (if present)

• goiter
• thyroiditis
• hyperthyroidism
• hypothyroidism
• hyperparathyroidism
• hypoparathyroidism

• enlargement of the thyroid gland due to iodine, deficient diet, inflammation or tumor
• pressure on trachea and esophagus causes difficultly breathing and swallowing
• may or may not be regional
• surgery if affecting trachea

• inflammation of thyroid due to infection or autoimmune process
• Hashimoto Thyroiditis is most common form
• --early disease hyperfunction
• --late disease hypofunction
• treatment:
• long term hormone therapy

• Thyrotoxicosis
• execessive secretion of thyroid hormone
• causes general increase in body metabolism
• Graves Disease (most common)
• gerneralized enlargement of gland
• protruding eye (exopthalamus)
• heat intolerance
• weight loss
• sweating
• diarrhea

• tachycardia
• hyperactive reflexes
• increased
• sweating
• heat intolerance
• fatiguetremors
• purple anterior tibia
• nervousness
• polyuria
• weakness/atrophy
• increased appetite
• dyspnea
• tachypnea
• weight loss

• insufficient production of thyroid hormone
• generalized depression of body metabolism
• untreated congenital hypothyroidism in infants was called Cretinism (now: neonatal hypothyroidism)
• mostly 30-60 years old, 50% in families, 95% impaired

• proximal muscle weakness
• slowed speeched and mental function
• carpal tunnel
• muscle and joint edema
• bradycardia
• CHF
• respitory muscle weakness
• poor wound healing
• myxedema

ongoing synthetic hormones

• CTs may develop before other signs
• proximal muscle weakness
• myalgias and trigger points
• muscle and joint edema
• back pain

• usualled caused by tumor
• causes release of calcium by bone and accumulation of calcium in the blood stream
• excessive calcium leads to bone damage, hypercalcemia, kidney damange

• bone demineralisation and bone pain
• proximal muscle weakness and fatigability
• GI problems and pancreatitis
• slow mental ability, personality changes
• concurrent illness and surgery can induce acute arthritic episodes
• --condrocalcinos and calcified tendinitis

• usually back accidental removal of the parathyroid gland, but sometimes genetic disease, tumor/trauma
• muscles weakness and pain
• thinning hair
• brittle nails
• hypocalcemia leading to muscle spasms, parethesias, tetany, and cardiac arrythmias
• actue episodes can be life theratening and treated with calcium replacement
• can be idiopathic - children 9x>adults, women 2x > men
• treatment: pharmacologic management

• hypofunction (Addisons disease)
• hyperfunction (Cushings)

• surgery
• pregnancy
• trauma
• infection
• salt loss from profuse diaphoresis
• treated by administering exogeneous cortisol
• fatal if not treated

• hyperfunction of the adrenal gland
• hypercortisolism from over secretion of ACTH from the pituitary

• hyperfunction of the adrenal gland
• hypercortisolism from adrenal oversecretion or excessive corticosteroid meds
• corticosteroid administration must be stopped gradually so normal adrenal function can resume

• abnormal fat distribution
• moon shaped face
• "buffalo hump"
• enlarged supraclavicular pads
• protuberant abdomen with purple striae

• Brown: specialized tissue for thermoregulation "baby fat"
• White: storage of triglycerols as long-term reservoir of energy

secretes proteins which have important roles in fat metabolism, feeding behavior, hemostasis, vascular tone, energy balance and insulin sensitivity

• good adipokines: leptin and adiponectin
• bad adipokines: tumor necrosis factor, resistin, interleukin-6, IL-8, acylation-stimulation protein, and angiotension and plasma activator inhibitor

• colon cancer
• pancreatic cancer
• non-hodgkins lymphoma
• uterine cancer
• breast cancer (after 65 years)
• prostate cancer
• greater risk for cancer
• --worst outcome - recurrance, malignancy and lifespan

• excessive white adipose tissure
• visceral and hepatic fat are key
• subcutaneous fat (little insulin resistance)

• fat that accumulates around organs
• intra abdominal deposits
• --omental fat
• --intrahepatic fat

• persistnt elevation in blood glucose caused by a relative or absolute deficiency in insulin production by the beta cells of the pancreas (in the presence or absence of insulin resistance)
•  

• 6th leading cause of death
• changes life expectancy 5-10 years
• vascular disease 2x to 4x
• nontraumatic amputation
• nerve damage in 60-70%
• blindness
• kidney failure
• kills 1 in every 3 minutes

• Alpha Cells
• glucagon
• --acts on liver to release glucagon
• --increase blood sugar
• Beta Cells
• insulin (decrease blood sugar)
• Delta Cells
• somatostatin
• --stops glucagon and GH
• --decrease blood sugar

• after intake of food, blood glucose increases
• beta cells release insulin
• insulin transports glucose
• cascade leads to decreased blood glucose
• homeostasis restored

• hypoglycemi
• decreased blood glucose
• alpha cells release glucagon
• stimulated liver to release glucose
• increases blood glucose and homeostasis restored

• about 10% of all cases
• cell-mediated autoimmune destruction of beta cells
• --usually leading to absolute insulin deficiency
• --insulin dependent
• requires injection
• onset before age 30
• beody weight at onset is normal or thin
• Management
• --diet
• --exercise
• --insulin
• Cause
• --envirnomental exposure
• --genetic mutation

• about 90% of all cases
• onset usually after age 35
• insulin production may be below or above normal
• ineffective insulin action at cellular level
• 20-30% require insulin injections
• body weight at onset:
• obese in 80%
• diabesity - obesity dependent DM in children
• Management
• diet
• exercise
• oral hypoglycemic agents
• insulin
• Other Characteristics:
• insidious
• obesity or weight gain
• related to other IRS signs (hyperlipidemia, acanthosis nigricans)
• older (increased obesity =decreased age, fatter and younger)
• ethnic links
• family Hx
• no ketones

• impaired insulin secretion = insulin deficiency
• increased hepatic glucose production
• carbohydrate absorption
• decreased glucose uptake = insulin resistance

• test a fasting plasma glucose in:
• all adults over age 45 years (repeat every 3 years)
• particularly those with BMI >25
• younger adults if BMI >25 and one or more risk factors

• prediabetes
• primary relative with diabetes
• high-risk ethinic group
• previous gestational diabetes

• fasting plasma glucose:
• <70: hypoglycemic
• <100: good
• 100-126: prediabetic
• >126: diabetic

• measures percentage of glycated hemoglobin or HbA1c, in blood
• how dody handles sugar
• look back over time
• ~120 days (lifespan of blood cell)

• occurs when body can't utilize glucose
• incomplete transfer of glucose into cells (for use as energy) by insulin due to:
• --body cells don't recognize insulin (decreased insulin sensitivity)
• --cells top responding to action on insulin (increased insulin sensitivity)
• increases blood glucose (but not as high as DM)
• inslin resistant cells stop responding to action of insulin

• a group of risk factors that occur together and increase the risk for coronary artery disease, stroke, and T2DM
• diagnosis is established when >3 risk factors are present

• abdominal obesity
• --men - >102cm (>40 in)
• --women - >88cm (>35in)
• TG >150 mg/dl
• HDL-c
• --men - < 40mg/dl
• --women - < 50 mg/dl
• BP - > 130/85
• fasting glucose > 110 mg/dl

• polyuria (T1DM>T2DM)
• polydipsia (T1DM>T2DM)
• polyphagia (T1DM>T2DM)
• weight loss (T1DM>T2DM)
• hyperglycemia
• recurring badder infection in skin and gums
• numbness and tingling in hands and feet
• slow healing of cuts and bruises
• assymptomatic becaue of physical adaption
• blurred vision
• irritability
• glycosuria
• ketonuria
• fatigue and weakness

• hyperpigmented velvety patches of skin in axillary regions and in neck
• prediabetic and diabetics

• glucose intolerance
• dyslipidemia
• --high TG and low HDL
• cardiovascular diseasse
• obesity
• PCOs
• hypertension

• atherosclerosis
• macrovacular diseases:
• --cerebrovascular disease
• --cornoary artery disease
• --venal artery disease
• --peripheral vascular disease
• microvascular diseases
• neuropathy
• retinopathy
• decreased microcirculation to skin and organs
• decreases in wound healing and blood flow
• hyperglycemia
• neurological complications
• musculoskeletal

• eye:
• retinopathy, cataracts and glaucoma
• --lead to blindness
• --cause death or disability
• kidney
• neuropathy, microalbuminuria, and gross albuminuria
• --lead to kidney failure
• --can cause death or disability
• nerves
• neuropathy (peripheral and autonomic)
• --lead to amputation
• --can cause death and disability

• bood vessels in back of eye affected
• hemmorages and exudates
• ischemia
• edema
• neovascularization
• --growth of new vessels
• --leads to vision loss
• prevention
• --yearly dilated rentinal exam
• --blood glucose control (intensive combined therapy)
• --BP control (ace inhibitors)
• --lipid control
• --no contraindication to asprin
• treatment
• laser therapy for proliferative retinopathy or macular edema
• more prevelant in T1DM
• 25x increase in diabetics

• autonomic:
• gastroparesis, diarrhea, incontinence
• postural hypotension
• decreased HR
• peripheral:
• diabetic foot
• charcot's join - arthropathy
• polyneuropathy
• carpal tunnel

• finger-stick glucose test
• immediate physician referral
• alteration in mental status caused by
• --hypoglycemia
• --hyperglycemia

• exogenous insulin
• shots
• pumps
• inhaled
• oral
• diet whole grains
• balances
• serving size
• exercise

• DM
• acute stress
• steroids
• diuretics
• chronic liver disease
• renal disease

• increased urine
• thirst
• hunger
• gatigue
• weakness
• lethargy
• nausea
• blurred vision
• sever dehydration
• confusion
• seizures
• coma
• abdominal pain
• distention

• ketones in blood and urine
• fruity acetone breath
• weak
• rapid pulse
• immediate care is essential
• kussmaul resperation
• coma
• defer Rx if BS > 300-350 or 240 with ketosis until levels are corrected
• critical level BS >450 - NO EXERCISE

• sympathetic:
• pallor
• perspiration
• increased heart rate
• palpitation
• irritability/nervous
• weaknesshunger
• shakyness
• CNS:
• headache
• double/blurred vision
• slurred speech
• fatigue
• numbness in lips/tounge
• confusion
• convulsions/coma
• blood glucose <70
• can appear <60-70
• rapid large drop (ie. 400 to 200) can also hae glycemic effects
• hold Rx until BS is corrected
• critical level <50

• musculosckeletal activities increase glucose homeostasis
• new activity at a well-tolerated intensity and duration
• patients with active retinopathy and neuropathy should aboid anything that auses increased BP
• increases in BP may cause further damage
• ok to do low impact activities, strength training preferred (initially)
• pre-existing conditions may limit working to goal HR
• may have difficult with thermoregulation
• no resistance training, valsalva
• do not exercise alone
• when initiating exercise program, T1DM may:
• monitor BG beofre exercising, every 30 min and then 15 min after
• exercise >20min continuous aerobic activity
• reduce insulin dose
• increase food intake
• eat 10-15g carbo snack for each 30 min of exercise
• place fluid loss adequetly
• avoid:
• high intensity exercise
• exercise placing head below waist (bad for retinopathy), increases BP
• avoid insulin injection to active extremities

• gentle, progressive program
• patient education - self management
• monitor vitals