Endocrine

Question 1

Obesity management

Answer 1

Multidisciplinary team approach: nurse specialist, dietitian, psych, paeds, family
If detected early, easier to maintain weight than lose it
Dietary approach
- parental support, reinforce role as educator
- avoid comfort/reward foods
- appropriate edu style
- promote intake of healthy food
- promote physical activity and reduce inactivity
Pharmaco
- orlistat: ljpase inhibator for those above 12
- metformin
Bariatric surgery
- if mature
- severe obesity with complications
- all other interventions failed

Question 2

Diagnosis of T1DM

Answer 2

• meets criteria of DM (like T2DM)
• autoantibody testing - glutamic acid decarboxylase, anti-islet, insulin autoantibodies, protein tyrosine phosphatase antibody

Question 3

Insulin therapy for T1DM

Answer 3

Total daily insulin is 1U/kg/day

Basal-bolus regimen

• preferably 4 injections a day
• premeal lispro and aspart insulin analogs, bolus will be 50-60% of total daily insulin
• glargine/determir at bedtime, 12hrly in young kids, basal is 25-30% of total daily dose, 40-50% in older kids
• relate insulin to food intake and exercise

Question 4

Long term management of T1DM (+ insulin)

Answer 4

Diet: carb counting
Exercise
- avoid strenuous physical activity if BG high with ketonuria/ketonemia
- avoid physical activity at peak action of insulin
- monitor BG in evening and night afterwards to avoid nocturnal hypo
Monitoring
- SMBG 4-6 times per day, more frequently when sick, preferably 4-6mmol/l
- Self-monitoring of urinary/blood ketonesc especially when uncontrolled hyper, intercurrent illness and impending ketoacidosis
- HbA1C annually, target <7.5%
Diabetic education
Medic alert wear DM tag
Regular review for long-term complications
- ophthal yearly
- urine MCS
- CVS risk
Psychosocial
- depression, rebellious, at-risk

Question 5

Biochemical criteria for DKA diagnosis

Answer 5

• hyperglycemia is blood glucose > 11mmol/l
• venous pH <7.3 or bicarbonate <15 mmol/l
• ketonemia and ketonuria

Question 6

Tests for DKA

Answer 6

• FBC, ketones, RBG, BUSE, VBG, Blood culture, serum osmolarity and anion gap
• urinalysis, FEME, culture
• ECG (hypo/hyperkalemia)

have to monitor BGL and bedside ketone hourly, 2hrs and 4hrly later is VBG, UEC, Ca, Mg, PO4

Question 7

Managing DKA

Answer 7

Airway
Breathing
Circulation
- keep NBM
- 2 large IV bore catheter
- O2 if shock/severe circ impairment
- cardiac monitoring
- antibiotics if febrile
- urinary catheter if unconscious for strict fluid monitoring
- fluid replacement 1-2 hrs before starting insulin therapy. 10ml/kg bolus immediately if shock, over 1-2 hrs of severe volume depletion.
- then give deficit over 48 hours (for dehydration more than 5%), maintenance and ongoing losses. initially 0.9% NS, then 0.45% NS + 5% dextrose if RBS drops below 17 or blood glucose falls >5 mmol/hr, KCL after 1 hour as acidosis improves.
- insulin therapy 0.05-0.1unit/kg/hr but dont given in bolus
- once clinically well and tolerating fluids transition to SC insulin and eventually stop IV insulin
- monitor fluid input, output, BUSE, acid-base, neuro state hourly, monitor ECG

Question 8

Signs of cerebral oedema in DKA

Answer 8

• occurs suddenly usually between 6-12 hrs after starting therapy
• early signs is headache, irritability, lethargy, vomiting
• later is depressed consciousness, incontinence, thermal instability
• very late is bradycardia, increased BP, respiratory impairment
• mx by propping patient up to 30 degrees, reduce fluid admin to 1/3rd, mannitol 0.5-1g/kg/IV over 10-15 mins and repeat if no response in 30min-2hrs

Question 9

Management of hypothyroidism

Answer 9

Begin levothyroxine IMMEDIATELY at diagnosis, within 2 weeks of life
Mix with water or breast milk, NOT formula milk
Follow-up (serum TSH and T4)
- <1 month weekly
- 1-6 months monthly
- 6 months -3 years: 3 monthly
- >3 years: every 6-12 months
At 3 year old, can stop thyroxine for 4 weeks and repeat TFT