5/12/21 Flashcards
Discuss commencement of insulin. Dosing and titration numbers.
Counselling when starting insulin?
NDSS medication change registration → to allow patients access to strips and pen needles
timing and frequency of SMBG, timing of meals, dose adjustment
impact of diet → carb counting, impact of irregular eating patterns - religious fasting, intermittent fasting etc.
impact of physical activity
hypoglycaemia management
insulin delivery techniques → rotation of sites, injection technique, storage of insulin
weight management and mitigation of weight gain
Sick day management
Notification re: driving
Prevent progression or worsening of diabetic retinopathy?
To reduce risk and slow progression of Diabetic Retinopathy → optimise glycaemic control, blood lipid levels and bloods pressure + smoking cessation
monitor progression of diabetic retinopathy with ophthalmologist
Risk factors of progression of Diabetic Retinopathy?
Poor Glycaemic Control
Poor Lipds
Poorly controlled HTN
Anaemia
Pregnancy
Microalbuminuria
Examination for Peripheral Neuropathy
- 10g monofilament - pressure sesnation
- Ankle Reflexes
- Vibration Sensation on dorsum of great toe
- Protective sensation - 10g monofilament
- Pinprick sensation
Investigations in Peripheral Neuropathy?
Diabetes
B12 Deficiency
Hypothyroidism
Renal Disease
Excessive Alcohol Consumption
Bloods: B12, TFT, UEC, HbA1c
Medical Management of Peripheral Neuropathy?
Review Glycemic Control
Symptomatic Management
Anticonvulsants → pregabalin (75mg po daily, review in 7 days), gabapentin, valproate
Antidepressants → amitryptiline (10mg nocte review in 7/7), duloxetine, venlafaxine
Topical Nitrate Spray
Opioid Analgesics
Examples of SGLT2 inhibitors and dosing please.
Dapagliflozin 10mg PO Daily
Empagliflozin 10mg PO Daily
Ertugliflozin 5mg PO Daily
OPtions and dosing of Dpp4 inhibitors?
Aloglitptin 25mg once daily
Linagliptin 5mg once daily (safe in all stages of renal impairment)
Saxagliptin 5mg once daily
Sitagliptin 100mg once daily
Vildagliptin 50mg BD
Which med in patients with t2dm, poor glycaemic control on metformin + CVD?
SGLT2 inhibitors - flozins
Counselling for SGLT2 Inhibitors
increased risk of UTI, urinary frequency or incontinence
increased risk of euglycaemic ketoacidosis
cease medication at least 3 days prior to surgery or procedures that require hospital stay. if day procedures, cease day of the procedure.
CV screening in PCOS? What about in the context of pregnancy?
Smoking
BP - annual check
Lipid profile - annually if BMI >25
Screen with OGTT, fasting glucose or HbA1c
if high-risk use OGTT (e.g history of GDM, Impaired Fasting Glucose, Impaired Glucose Tolerance, FHx of diabetes, hypertension or high risk ethnicity) → every 1-3 years (annually if IFG/IGT)
If PCOS and planning pregnancy → complete OGTT (esp if over 30yo)
Pre-Conception Consult
CST
No safe alcohol
Smoking Cessation
Safe Exercise - moderate intensity 150mins/week
Folic Acid supplementation - 5mg 1 months prior to planned conception
Social Supports + Domestic Partner Violence
Mental Health
Preconception Genetic Screening
Diet - healthy well balanced diet
if overweight/obese - drop 5-10% weight prior to conception
Folic Acid Supplementation in pregs? Same for all?
400-500 microgs for at least 4 weeks prior to pregnancy and for the first 12 weeks of gestation
if high risk → 5mg daily same time frame
- high risk -> malabsorption, BMI >30, GDM, anticonvulsant medication, previous neural tube defect
Examinations in First Antenatal Consult
BP
BMI
HR
Thyroid
Teeth and Gums
Breast + Nipples
Heart
CST if needed
Abdomen - uterine size and fetal heart if indicated
Urinalysis - protein and glucose
Diagnosis of GDM?
Fasting glucose >= 5.5
OGTT 2 hours > 8
DO NOT USE HBA1C
How to do the OGTT in pregs?
75g OGTT
fast 8-12 hours overnight
start before 9:30am
drink glucose drink wihtin 5min, remain seated througout 2 hour period
use metoclopramide if vomit
Follow-up following diagnosis of GDM?
conduct OGTT 2 hour test - 6-12 weeks post-partum
if normal - HbA1c every 3 years
if HbA1c >6 → further investigation and advice before next pregnancy
Risks to infant with GDM?
congential abnormalities
preterm birth
perinatal asphyxia
macrosomia****
resp distress
hypoglycaemia
hypocalcaemia
polycythaemia**
Low iron stores
hyperbilirubinaemia
transient hypertrophic cardiomyopathy
6 week - Postnatal Consultation
Enquire about vaginal discharge (lochia) and whether ceased
Ask about healing of the perineum if vaginal delivery
Review abdomen (uterus should be impalpable) and Caesarean Wound if present
Check for any urinary or bowel problems (incontinence)
Check if breast-feeding and whether there are concerns - Breastfeeding
Check if intercourse has resumed and whether there are problems or concerns
Discuss contraception options - Contraception
Advise on post-natal exercises
Adequate diet, rest and personal care, sleep, exercise
Psychological Health - Edinburgh Post-Natal Depression Scale (Post-Natal Depression (PND)), social supports
Consider Pelvic Examination - checking perineum and pelvic floor strengths
Cervical Screening Test (if due) - Cervical Cancer + Screening
Review antenatal screening tests for follow-up action - rubella booster
Other → smoking and alcohol