Endocrine

Question 1

Long term steroid spiel

Answer 1

Complications:
Cataracts/glaucoma
Proximal myopathy
Diabetes
Skin integrity
Infections
Adrenal insuffiency
Osteoporosis and AVN
Mood and sleep disturbance
Weight gain - cushingoid appearance
Increased cardiovascular risk and dyslipidemia
GI - gastritis, peptic ulcer disease (not commonly in isolation)

Management:
Lowest possible dose and shortest course
Consider steroid sparing agents

Baseline measurements: BMI, BP, calculate FRAX score, BMD, lipids, HBA1c, test for Tb
Vaccinations

Patient education

• medical alert bracelet
• steroid treatment card
• regular physical excercise, appropriate diet
• unwell plan
  
  • seek medical attention
  • minor illness -> double steroid dose for 2-3 days
• don’t stop suddenly

Osteoporosis

• vitamin D supplementation
• bisphosphonates for those on 7.5mg prednisone or greater for 3 months or more
• annual measurement of BMD

Hyperglycemia

• check blood sugars
• target 4-7 fasting, 7-10 post prandial
• if not achieving with lifestyle
  
  • oral hypoglycemic if BSLs less than 15
  • insulin if BSLs greater than 15 (combined with metformin)
• target HBA1c less than 7 (3 monthly)

Pre-operative

• hydrocortisone before anesthetic
• every 8 hours after surgery for 4 doses then taper back to physiological dose

Testing for adrenal insufficiency
- taper down steroid to physiological dose, withold steroid night before then test early morning cortisol (if less then 80 confirmed adrenal suppression)

Physiological daily dose of steroids:
5-7.5mg of prednisone
20-30mg hydrocortisone

Question 2

Diabetes spiel

Answer 2

Duration of disease
Mode of presentation

Treatment:
Insulin - type, dose, insulin sensitivity factor, carbohydrate counting, injection sites (lipodystrophy), who injects
Orals - side effects
Adherence to treatment

Control:
Monitoring BSL, HBA1c

Complications:

1. Microvascular
   - peripheral neuropathy
   - autonomic neuropathy
   - retinopathy
   - nephropathy
2. Macrovascular
   - peripheral vascular disease
   - cardiovascular disease
   - cerebrovascular
3. Hypoglycemia
   - frequency
   - symptoms
   - treatment plan
4. DKA/HHS
   - admissions
   - management plan
5. Hyperglycaemia
   - management plan
   - sick day rules
6. Infections
   - urine/skin
   - foot ulcers

Psychosocial: driving, work, mental health, acceptance, social support, insight, medical alert bracelet, social support, employer support

Associated illnesses:
Autoimmune, pancreatitis, steroid use, vision, cognitive impairment

Management:
diabetes nurse
ophthalmology - every 2 years
podiatry - annually
monitoring of renal function - microalbuminuria testing
assessment for neuropathy
postural BP
modification of other cardiovascular risk factors
- ACE-I to reduce progression to ESRF
obstetric health and risks
avoidance of hypoglycemia

Patient education

• exercise - decrease insulin or supplement with glucose
• sick day - continue insulin, supplement food for liquid glucose, test for ketones, test BSL more frequently, early presentation to hospital

Question 3

Management of hyperthyroidism

Answer 3

Pharmacological:

1. antithyroid drugs
   - Carbimazole
   - Propylthioruracil
2. Beta-blockers
   - for tremor and tachycardia
3. Iodine
   - causes transient hypothyroidism (Wolff-Chaikoff effect)
   - only if plan to remove thyroid within 2 weeks

Thyroid removal:
- require life-long thyroid hormone replacement
1. Radioactive iodine
Indications:
- Graves with moderate goitre and no eye signs
- Toxic adenoma with mild hyperthyroidism
- Toxic multinodular goitre with severe manifestations - CHF, AF, psychosis
CI:
- pregnancy and breastfeeding
- incontinence
- allergy to iodine
2. Surgery
- indications: large goitre, drug compliance concerns, disease relapse
- risks of surgery and damage to surrounding structures
- requires GA