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
Investigation for hyperthyroidism***
> Blood
- TFT
- Autoantibodies (TSH receptor stimulating immunoglobulin - Graves)
> Imaging
- Ultrasound
- Radionuclide scan with technetium
> Other
- FNAC
Management for hyperthyroidism***
> Grave disease
- Symptomatic: b blocker
- Definitive: antithyroid medication/ radioactive iodine ablation/ total thyroidectomy
> Toxic MNG
- Symptomatic: propranolol
- Definitive: thyroidectomy + lifelong thyroxine
Thyroid storm vs MNG
- TS similar to hyperthyroidism, but more sudden, severe and extreme
- Diagnosis: Burch-Wartofsky score
MOA of statin
- Competitive inhibitor of HMG-CoA reductase (early rate limiting step in cholesterol biosynthesis)
Why statin should take at bedtime
- Endogenous cholesterol synthesis is cyclic in nature, greatest production during fasting states
- Short half-life (eg: simvastatin) at bedtime for greatest drug concentration during peak endogenous cholesterol synthesis
- Longer half-life (eg: atorvastatin) allow flexibility in administration
Side effect of steroid treatment
- Cataract, glaucoma
- Thinning of skin
- Osteoporosis
- Obesity
- Hyperglycemia
- Immunosuppressive
DM retinopathy what to look for in fundoscopy?
- Micro aneurysm
- Dot/ blot hemorrhages
- Hard exudates
- Cotton-wool spot
- Flame hemorrhage
- Venous bleeding
- Neovascularization
Target BMI in diabetes
- 18.5 to 24.9 kg/m2
- If overweight/ obese, aim up to 10% weight loss in 6 months
Why hyperfiltration in early stage of diabetic nephropathy
- Activation of RAAS increase the level of angiotensin II
- Cause increase in efferent arteriole resistance
- The imbalance in tone between afferent and efferent arterioles increase intraglomerular pressure
- Overtime, triggers a sclerotic response
If proteinuria detected by dipstick, which stages of diabetic nephropathy?
- Stage 4: Overt proteinuria/ Macroalbuminuria
Causes of hypothyroidism
> Primary □ Without goiter - Complication from thyrotoxicosis tx: surgery, radioiodine □ With goiter - Hashimoto's thyroiditis - Iodine deficiency
> Secondary
□ Pituitary lesion
> Tertiary
□ Hypothalamic lesions
Investigation for hypothyroidism*
> Lipid profile: hyperlipidemia, hypercholesterolemia
Thyroid function test
□ Primary: increase TSH
□ Secondary, Tertiary: decrease TSH
Autoantibodies: anti-TSH receptor, antithyroglobulin, antithyroid peroxidase
Clinical feature of hypothyroidism
> Generalized slowing of metabolic processes □ Fatigue □ Slow movement and slow speech □ Cold intolerance □ Constipation □ Weight gain □ Delayed relaxation of deep tendon reflex □ Bradycardia
> Accumulation of matric glycosaminoglycans in tissue □ Coarse hair and skin □ Puffy facies □ Enlargement of the tongue □ Hoarseness
Clinical features of Grave’s disease
> Appearance
- Underweight
- Staring look
> Hands
- Sweaty, palmar erythema
- Thyroid acropachy
- Tachycardia
- Fine tremor
- Proximal myopathy
> Face
- Exophthalmos (inferior sclera visible)
- Lid retraction, lid lag
- Proptosis (seen from behind)
- Ophthalmoplegia
> Neck
- Thyroid bruit
- Thyroidectomy scar
> Leg
- Proximal myopathy
- Brisk reflexes
- Pretibial myxedema
Management for hypothyroidism
- Levothyroxine replacement
Follow up for DM
> 3 monthly
- Weight
- Waist circumference
- BP
- Feet: pulses, ABI, neuropathy
- Plasma glucose
- HbA1c
> Annually - above +
- BMI
- Eye: visual acuity, fundoscopy
- Lipid profile
- BUSE/ Cr
- LFT
- Urine microscopy
- Spot morning urinary albumin creatinine ratio
Classification of diabetic retinopathy
> Non-proliferative
- further classify into mild, moderate, and severe
- cotton-wool spot, intraretinal hemorrhage, hard exudate and microaneurysm
> Proliferative
- presence of neovascularization (disc or retinal vessels)
- vitreous or preretinal hemorrhage
