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
ABCDE Rule for Melanoma Diagnosis
A → Asymmetry → one half different from the other
B → Border → usually irregular
C → Colour → varies within the lesion. pigment is largely or completely absent in hypomelanotic melanoma
D → Diameter → greater than 6mm, sometimes melanomas are diagnosed when smaller than this - an increasing diameter is more important than size
E → Evolution → changing or evolving
Mx of melanoma
Excisional Biopsy with 2 mm lateral margin and as deep as the subcutaenous fat
Main Parameter for Melanoma Prognosis?
BRESLOW THICKNESS
If complete excision following initial excisional biopsy of melanoma - what are the next steps? what is incomplete excision?
If histology confirms melanoma → will need definitive wide local excision.
if initial excision removed all the lesion - WLE should take place within 4 weeks.
if some lesion was left behind after first excision → WLE should take place ASAP.
Margins of the WLE depend on the tumour thickness
Management of Subungal Haematoma
Trephination → only perform in <48hours
after 48hours - most haematomas have clotted and trephination is typically not effective
Characteristics of Superficial Spreading Melanoma
Larger size than most moles: > 6 mm and often 1–2 centimetres in diameter at diagnosis
Irregular shape
Variable pigmentation: colours may include light brown, dark brown, black, blue, grey, pink and red
There may be skip areas, which are skin coloured, or white scars due to regression
Smooth surface at first, later becoming thicker with an irregular surface that may be dry or warty.
EFG Rule in context of Melanoma
Elevated
Firm
Growing
for NODULAR MELANOMA
Clinical Features of SCC
Can appear suddenly, grow rapidly OR grow slowly over weeks to months
tender and painful
on sun exposed sites
raised scaly lump
common in those who are immunosuppressed
Mnaagement of SCC
Need biopsy to establish diagnosis - margin 3-5mm
review every 6 months for skin check for at least 2 years after excision
Worrying features of a cutaenous horn?
Pain
Large Size
Induration at the Base
Anatomic Site → Nose, Ears, Backs of Hands, Scalp, Forearms, Face and Penis
Wide base or low height to base ratio
Redness at the base of the horn base
Lack of terrace formation - rapid unorganised growth
Treatment of Bowen’s DIsease. COnsiderations.
Biopsy - but can use topical therapy or photodynamic therapy in regions where the skin heals poorly. Cannot use topical therapies if the disease has extended into the hair follicles
Imiquimod 5% topically, at night 5 times weekly for up to 6 weeks.
Fluorouracil 5% cream topically, once daily for 3-4 weeks
Photodynamic Therapy
History of Fitness to Drive in diabetic.
Driving History → accidents and pattern of driving
How often pt gets lost
Diabetes
Recent Hypoglycaemic Episodes
Compliance with Medications
Hypoglycaemic Aareness
History of Syncopal Episodes
Signs of CVA
Sleep Disorders
Insight into dementia if present
Examination findings in Fitness to Drive
Visual Examination - visual acuity, visual fields
Co-ordination, Balance, Mobility
Peripheral Neuropathy
Hearing Assessment of Impairment
Other means to assess fitness to drive other than history and examination of the patient.
Collateral History regarding driving history
Geriatric Assessment for Capacity
Occupational Therapist for Driving Assessment
Anonymous enquiry from Driving Licensing Authority about the requirements
Next steps of management if patient is deemed not safe to drive?
advice patient that he is not able to drive
advise him to inform the drivers license authority
notify the NOK that pt is not fit to drive
Offer assistance and support to look for alternate transport options
document the discussions in detail in medical records
Presentation of Optic Neuritis. Assocaited condition?
Associated with Multiple Sclerosis
Monoocular, visual loss + Eye pain
can be with central scotoma commonly
also can have photpsias → flickering or falshes of light
sudden - hours to days - peaking within 1-2 weeks
Fundoscopy - 2/3 is normal. inflammation has retrobulbar neuritis
Associated conditions of uveitis?
Ankylosing Spondylitis
Inflammatory Bowel Disease (IBD)
Behcet Syndrome
Mnaagement points for allergic conjunctivitis - nonpharm and pharm
NonPharm - do not rub eyes, no contact lenses, cool compresses,
Management → anti-histamine + mast-cell stabiliser
Azelastine Eye Drops or Ketotifen or Olopatadine - Patanol
2nd line ->. Antihistamine only or Mast-Cell only
Clinical Features and Management of Episcleritis?
NO BLOOD OUTSIDE THE VESSEL
Localised area of congestion
minimal discomfort, minimal pain, nil impact on vision, unilateral
Associated with autoimmunse
RA - Rheumatoid Arthritis (RA)
IBD
SLE
Management
self-resolving
can trial topical NSAIDS
Difference between scleritis and episcleritis?
severe pain differentiates between episcleritis and scleritis
also presents with photophobia, deep-red or purplish scleral hue
Management of Herpes Keratitis?
Immediate referral to ophthalmology***
Topical Antiviral Therapy → aciclovir 3% eye ointment 5 times daily for 10-14 days or at least 3 days after healing whichever is shorter
Oral antiviral therapy → valaciclovir 500mg po BD for 7-10 days
Management of Flash Burn?
Pain Relief
Topical ABx
NO need for topical anaesthetic
NO need for eye patching
Management of Hyphaema?
Eye Patch
Bed Rest with 30 degree head elevation
Dilate pupil for examination and pain Relief
Control Nausea and Vomiting
Topical Pain Relief
Referral to Ophthalmologist
Clinical Features + Fundoscopy of Retinal Artery Occlusion vs Retinal Vein Occlusion?
Artery - Cherry Red Spot + Pale Retina
Vein - Sunset Storm
Fundoscopy Findings of Diabetic Retinopathy?
Non-Proliferative -> microaneurysms, cotton wool spots, tortuous vessels, exudates
Proliferative -> neovascularisation around the optic disc or retina
Clinical Feature of Retinal Detachement?
Pain Loss of Vision
Recent history of flashes and floaters
presence of dark shadow or curtain moving over the visual field
Clinical Features of Macular Degeneration?
Sudden fading central vision
Distortion of Vision
Straight lines may seem wavy and objects distorted - Amsler Chart
Central Vision eventually completely lost
Peripheral Fields normal
Risk Factors for Cataracts?
Older Age
Smoking
Alcohol Consumption
Sunlight Exposure
Lower Educational Status
Occur prematurely in people with diabetes
Systemic Corticosteroids
Clinical Features of Bacterial Keratitis?
95% of contact lens infections
Red Eye
Reduced visual acuity
Pain
Eyelid Swelling
Photophobia
Corneal Epithlial Defect
