Endocrine Flashcards
Physical examination sign of diabetes***
○ General examination
- Hand: fungal infection, acanthosis nigricans
- Face and neck: cataract
- Abdomen: insulin injection marks, lipodystrophy
○ Systemic examination - Fundoscopic: diabetic retinopathy - Lower limb: diabetic foot and peripheral vascular disease □ Amputation □ Dry, shiny skin □ Charcot's joint deformity □ Claw toes □ Hammer toes □ Hallux valgus □ Peripheral pulses - Ankle brachial pressure index
Diagnosis of diabetes mellitus**
- Capillary plasma glucose: if abnormal (in asymptomatic only; symptomatic directly VBG) -> Step 2
- Venous blood glucose:
- asymptomatic individual will required 2 abnormal reading while symptomatic only require 1
- Asymptomatic: when reading between normal and DM -> OGTT
- Symptomatic: when reading normal -> OGTT
Cut off point for DM investigation***
- HbA1c: >= 6.3%
- VBG
Fasting: >=7.0 mmol/L
Random: >=11.1 mmol/L - OGTT
0hr: <6.1/ >=7.0
2hr: <7.8/>=11.1
Group of oral hypoglycemia agents***
- Biguanide (eg: metformin):
increase insulin sensitivity and help weight, won’t cause hypoglycemia;
avoid if eGFR <36mL/min due to risk of lactic acidosis - DDP4 inhibitors (eg: sitagliptin):
block DDP-4 enzyme which destroys hormone incretin - Glitazone:
increase insulin sensitivity;
SE: hypoglycemia, fractures, fluid retention, increase LFT (monitor every 8 weeks for 1 year, stop if >3 fold);
CI: past or present CCF, osteoporosis, monitor weight and stop if increase/ edema - Sulfonylurea (eg: gliclazide):
increase insulin secretion
SE: hypoglycemia, weight gain - SGLT-I (eg: empagliflozin):
reduce renal reabsorption of glucose
Type of insulin**
- Ultra-fast: Novorapid, at start of meal/ just after
- Pre-mixed: Novomix, 30% short + 70% long
- Long acting: insulin glargine, used at bedtime, no awkward peak, so good if nocturnal hypoglycemia is an issue
Target for control DM***
- Glycemic:
4.4-7 for fasting glucose,
<7% for HbA1c - Lipid:
TG: <=1.7 mmol/L
HDL: Male >1.0/ Female >1.2
LDL: <=2.6
BP: 130-139/70-79mmHg
Exercise: 150min/week
Body weight: 10% weight loss in 6 months if obese/ overweight
Follow up for DM**
- 3-6 months after initiation of therapy
0. 5-1% above target: + 1 additional OHA OR intensification of insulin
1-2% above target: +2 OHA OR intensification of insulin
> 2% above target: initiation of insulin OR intensification of insulin
- Reassess HbA1c after 3-6 months
Complication of DM***
> Macrovascular
□ Heart: ischemic heart disease
□ Vascular: peripheral arterial disease, hypertension
□ Cerebral: cerebrovascular accident
> Microvascular
□ Retinopathy: diabetic retinopathy
□ Nephropathy: nephrotic syndrome, end-stage renal failure
□ Neuropathy: peripheral neuropathy
Features of Cushing’s syndrome
- New onset or difficult to control DM/ HPT
- Proximal muscle weakness
- Purple abdominal striae
- Round facies
- Buffalo neck hump
- Central obesity
Definition of metabolic syndrome*
> Central obesity (BMI >30), plus 2 of:
- BP >= 130/85
- Triglyceride >=1.7 mmol/L
- HDL <= 1.03 (male)/ 1.29 (female) mmol/L
- Fasting glucose >= 5.6 mmol/L
- Type 2 DM
Causes of DKA
> T1DM
- Poor compliance to insulin
- Bacterial infection
- Intercurrent illness (eg: MI)
- Failure of insulin infusion pump
> T2DM
- Acute coronary syndrome
- Infection (eg: UTI)
- Cerebrovascular accident
Investigation of DKA**
○ Diagnosis criteria (all 3 must present)
- Capillary blood glucose >11 mmol/L
- Capillary ketones >3 mmol/L or urine ketones >= 2+
- Venous pH <7.3 and/or bicarbonate <15 mmol/L
○ Assess complication - BUSE □ Serum potassium level initially high due to extracellular shift in exchange of hydrogen □ Blood urea increased □ AKI secondary to hypovolemia - FBC (WCC count)
○ Look for cause
- ECG (Rule out MI, Assess cardiac effect of hyperkalemia)
- Midstream specimen of urine
- CXR
- Blood culture
Management of DKA**
> Immediate management
- Fluid therapy
- Insulin therapy
- Electrolyte management - Potassium
- Treat underlying causes
- Constantly reassess and monitor patient, assess the response and complication of treatment (eg: fluid overload, cerebral edema)
Patient education before discharge for DKA
- Importance of compliance to medication
- Monitoring of blood sugar levels (esp during infection, trauma)
- If feel sick, check for urinary ketone levels with home test strip
- Go to hospital immediately if appear significantly ill, dehydrated, confused or very weak, severe abdominal pain with vomiting
Indication for urgent hemodialysis
“AEIOU”
- Acidosis refractory to treatment
- Electrolyte imbalance: hyperkalemia refractory to treatment
- Intoxication
- Overload (fluid) refractory to treatment
- Uremic encephalopathy
