Endocrine long case Flashcards
Endocrine questions - thyroid/pituitary
Heat intolerance/cold intolerance (hyperthyroidism, hypothyroidism)
Tremor
Constipation/diarrhoea
Drying of skin hair and/or nails
Previous head injury
Frequent, high volume urine
Previous history of Coeliac disease, T1DM, hypercalcaemia, rheumatoid arthritis
Endocrine questions - Diabetes symptoms and background
Symptoms of hyperglycaemia (Frequent, high volume urine, Increased appetite, increased thirst, Blurred vision)
Background (FHx, Previous diabetes diagnosis, age of diagnosis, type)
Macrovascular complications (Previous history of MI, peripheral vascular disease, stroke)
Microvascular complications (Previous kidney disease, peripheral neuropathy, retinal disease)
Autonomic microvascular complications (postural dizziness, gastroparesis, erectile dysfunction, urinary retention)
Cataracts and glucoma
Infections Recurrent skin infections and UTIs
Current management (Currently on insulin, recent HbA1c, blood sugar levels,)
Self care/control assessment (BSL monitoring, diet, care plan, hypoglycaemia, action plan, driving, insulin site rotation and dosing, DKA frequency and hospitalisations)
Multidisciplinary team (podiatry, dietician, educator, ophthalm, dentist, psychologist)
Autoimmune disease (Coeliac, Hashimoto’s or Grave’s, pernicious anaemia, Addison’s)
Obstetric history
Complications of obesity
Stroke
Hypertension
Dyslipidaemia
T2DM
Steatohepatitis
Gout/OA
Coronary artery disease
Atrial fibrillation
OSA/OHS
GORD
DVT
PCOS/hirsuitism
Depression
Obesity history
Family history
Age obese
Recent wt. changes
CVD factors - Hypertension, dyslipidaemia, T2DM, smoker
Endocrine factors - sweating, easy bruising, headaches, visual disturbances, cold intolerance
Sleeping/OSA history
At risk medications
Insight
Attempts at weight loss
Social and occupational problems
Medications that contribute to weight gain
Insulin
Glucocorticosteroids
Sulfonylureas
olanzepine/antipsychotics
thiazolidazonides
Endocrine differentials for obesity
Cushing’s syndrome
Pituitary tumour
Myxoedema
Congenital - Laurence-Moon-Beidl, Beckworth-Wedleman,
Initial management of obesity
Mental health assessment, BP, lipids/HDL, TFTs, midnight cortisol, HbA1c and FBSL
Intensive weight loss and diet program, with >16 sessions for 6 months
Low calorie diet with aim of >500-750kJ deficit
Physical exercise 30mins/day 5x week
Consider weaning or ceasing medications that promote weight gain if safe - glucocorticoids, SSRIs, antiepileptics incl. gabapentin, antipsychotics
Consider metformin if high risk of T2DM
Consider weight negative anti-diabetic agents
20 Side effects of glucocorticosteroids
Obesity
Cushingoid facies
HTN
T2DM
Hirsuitism
Skin fragility
Proximal myopathy
Pancreatitis
Acne
Immunosuppression
Candida
Cataracts
Glucoma
Osteoporosis
Avascular necrosis of hip
Peptic ulcer disease
Hypokalaemia
Peripheral oedema
Suppression of hypothalamic-pituitary axis
Mood disorders/psychosis
Glucocorticosteroid history
Dose, duration and reason for GCS use
History of weight gain, insomnia, polyphagia, ankle oedema, irritability, insomnia
History of recent diabetes dx, HTN, cataracts, glucoma
DEXA, vitamin D level, calcium supplimentation, use of bisphosphonates
Bony pain, hip pain on movement
Previous infections - PJP, CMV, TB, cryptococcus, candida
Thigh weakness and pain
History for osteoporosis
Lower back pain
Pain at night
Falls
PHx - vitamin D deficiency, chronic corticosteroid use, chronic renal failure, hyperthyroidism, hyperparathyroidism, multiple myeloma, Cushing’s syndrome, hypogonadism, premature menopause
Previous vertebral fractures
Use of bisphosphonates, calcium, vitamin D
Osteoporosis investigations
DEXA
Vitamin D (1,25 dihydroxy), calcium, magnesium phosphate
UEC creatinine
Serum testosterone
SPEP
24hr cortisol
TFT
serum N-telopeptide, urinary deoxypridinoline
Causes of secondary diabetes mellitus
Medications - glucocorticoids, diazoxide, thiazides, OCP
Cushing’s disease
Acromegaly
PCOS
Pancreatic insufficiency (chronic pancreatitis, Cystic fibrosis)
Gestation
Haemochromatosis
Ataxia telangiectasia
Glucagonoma/vipoma
Examination for diabetes
BMI and central abdominal features
BP including postural exam
Cutaneous stigmata of diabetes and dyslipidaemia
Foot exam
Cardiovascular exam for CCF
Carotid bruits
Neurological exam for sensory neuropathy and residual stroke deficits
Visual fields, pupils, eye movements and fundoscopy
Abdominal exam for AAA, renal bruits and hepatomegaly
Body habitus (BMI, Cushingoid features, striae for weight gain, acanthosis nigricans and skin tags, abdominal assessment)
Postural blood pressure and postural pulse (Autonomic neuropathy)
Hydration, injection marks, amputations, acanthosis nigricans
Oral cavity - hygiene, periodontal disease and candidiasis
Hepatomegaly (steatohepatitis)
Management goals in diabetes (new dx)
Patient education and self advocacy
Weight loss of 5-7% body weight
Vigorous exercise 30mins 5x/wk
Low calorie, low sodium, low saturated fat mediterranean diet
Reduction atherosclerotic disease risk
Screen for complications (ECG, fundoscopy, PVD, foot exam, CT B if evidence TIA on Hx)
Prevention of microvascular disease
Smoking cessation
Alcohol reduction
Prevention of depression and anxiety
Reduction in fetal abnormalities in pregnancy
Prevent road fatalities
Support from multidisciplinary team
Management of Osteoporosis
1) Review and correct underlying cause - serum testosterone, TFT, Vit D, renal function, SPEP, 24hr cortisol
2) Low impact weight bearing exercise, cessation of smoking, reduction of alcohol, 1.5g calcium daily
3) Bisphosphonates for T<2.5 or pathological fracture or older
- Oral - alendronate, risendronate, etidronate; risk of ONJ
- IV Denosumab
- HRT if indicated for woman in age group
- Raloxifene (SERM) (SE: thromboembolism) and calcitriol
- Pulsed teriparatide for refractory cases
- Strontium for post menopausal (second line)
MEN syndromes
MEN 1 - Pituitary tumour, parathyroid tumour, phaechromocytoma
MEN 2a- Medullary thyroid cancer, phaechromocytoma, parathyroid tumours
MEN 2b - Medullary thyroid cancer, phaeochromocytoma, neuromas
- Distinguish MEN1 from MEN2 by excluding pituitary tumour in the presence of phaechromocytoma
- Distinguish MEN 2a from b by excluding parathyroid tumour by checking calcium
- Autosomal dominant
Risk factors for T2DM
- Prior cardiovascular, peripheral vascular or cerebrovascular event
- Impaired fasting glucose or impaired glucose tolerance
- Age > 35 and Chinese, Indian or Pacific Islands
- Age > 40 and HTN or BMI > 40
- Gestational diabetes mellitus
- Polycystic ovarian syndrome
- Antipsychotics
- Aboriginal or Torres Strait Islanders
Clinical indicators of undiagnosed or poorly controlled DM
- polyuria, polydipsia, lethargy, polyphagia
- Recurrent bacterial or fungal infections
- Blurred vision
- New or progressive sensory neuropathy
- Poor wound healing
- Weight loss
Initial management of confirmed IFG, IGT or diabetes mellitus
- Lifestyle modification
- Allied health referrals
- BP, BMI and lipid assessments
- Waist circumference
- Depression/anxiety screen (PAID tool)
- Yearly microvascular complications screen
- Influenza and pneumococcal vaccinations
Additional general management on diabetes diagnosis
Notify RTA
Register with national diabetes services scheme
Assess CAD risk
Assess modifiable risk factors
Depression/anxiety screen
Referral to diabetes teams
Clinical signs of glucose intolerance, T2DM and/or metabolic syndrome
Hypertension
Acanthosis nigricans
Skin tags on body or face
Central adiposity (not required if BMI >35)
Hirsuitism in women
Tendon xanthomas
Xanthalesmas
Eruptive xanthomata
Straie, buffalo hump
Neck circumference and Mallampatti
Disadvantages of HbA1c
Cannot assess impaired glucose tolerance
Underestimated in chronic anaemic states and advanced CKD
Overestimated in iron deficiency, splenectomy and alcoholism
May be over intercurrent illness and hyperglycaemic meds
Some haemoglobinopathies may artificially raise or lower the HbA1c
Tests for T1DM
Insulinoma antigen 2 (IA-2)
Glutamic acid decarboxylase (GAD)
C peptide level
Indicators of adequate DM self management
Understand their condition and treatment options
Contribute to, review and monitor a plan of care
Engage in activities that protect and and promote health
Monitor and manage the symptoms and signs of the condition
Manage the impact of the condition on physical function, emotions and interpersonal relationships
Monogenetic diabetes characteristics
Onset before 25yrs of age
Lower level hyperglycaemia
Non-ketotic diabetes mellitus
Autosomal dominant inheritance
Primary defect in function of beta pancreatic cells
New diagnosis of T1DM
Ketosis or ketonuria (may not be initially present)
Polyuria or polydipsia
Weight loss or BMI <25
Age < 50
Personal and/or family history of autoimmune disease
Rapid onset symptoms
Prevention of diabetes mellitus
Patient education
5-7% reduction of weight loss
Low kJ and low fat diet
Moderate intensity exercise 150mins/wk
Metformin for BMI > 35
Involvement of family and GP
Indications for self monitoring of blood glucose
Oral hypoglycaemic agents or insulin
Hyperglycaemia from intercurrent illness
Pregnancy and pre-pregnancy planning
Any new treatment changes to monitor effect
Unreliable HbA1c monitoring
Members of the DM multidisciplinary care team
Diabetic educator
Podiatrist
GP and endocrinologist
Dentist
Community care nurse
Aboriginal care worker and social worker
Pharmacist
Ophthalmologist and optometrist
Dietician
Psychologist
Exercise physiologist
Poor glycaemic control factors
Poor patient health literacy and numeracy
Snacking, irregular eating patterns
Inadequate insulin site rotation
Insulin under dosing or skipping
etOH
Poor exercise
Poor vision or dexterity
Poor cognition
Insulin dosing in the community
Decision made if physician or patient led
Set target at FBSL 6-8, PPBSL 6-10
Start basal dose 10 units mane or 0.1units/kg
Up titrate 2-4 units every two days IF FBSL is > 7, or 4 units >10
Reduce by 2-4 or stop units if FBSL <4
IF patient led - uptitrate by two units every three days until BGL achieved
No change if 6<bsl></bsl>
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Diabetic foot exam
General foot care (fungal nail, tinea, corns and calluses)
Venous insufficiency (Inverted champagne bottle appearance of calves, Bilateral erythema, haemosiderin staining, varicose veins, dermatitis)
Cutaneous diabetic stigmata - diabetic dermopathy, necrobiosis lipoidica diabeticorum, lipodystrophy
Foot morphology - (Amputations, charcot’s foot, flattening of dorsal arches, claw and hammer toes)
Peripheral arterial vascular disease (dusky appearance, peripheral pulses and capillary refill, popliteal and femoral pulses/femoral bruit)
Ulcers (neuropathic, venous and arterial)
Neurological exam (sensation to 10g monofilament, proprioception and vibration sense, power, reflexes)
Diabetic visual exam
Evidence of ptosis (CNIII), proptosis, chemosis or myxoedema
Visual acuity with glasses (retinopathy, cataracts, glucoma)
Visual field examination (MCA or PCA infarcts, glucoma)
Eye movements (CV III and VI palsies)
Pupils (CN III - spared)
Fundoscopy (microaneurysm, dot haemorrhages, flame haemorrhages, new vessels, prior laser surgery; angioid streaks)
Asymmetry of lower hemiface (old MCA infarct)
Mouth for dentition, candida, and Mallampati
Management of T2DM algorithm
Assessment of patient health literacy and numeracy skills
Lifestyle modification including exercise and dietary change
3 monthly reviews and consider other reasons for poor glycemic control and patient understanding
Commence or increase routine BSL monitoring
Metformin as first line
Sulphonylurea, dipeptidyl-peptidase inhibitor (DPP-4i) or sodium glucose cotransporter inhibitor second line (SGLT2i)
Add a third agent above or glucagon-like-peptide receptor antagonist (GLP-1A) or basal insulin
Factors on deciding on stringent versus liberal control
Hypoglycaemic risk
Disease duration
Life expectancy
Significant comorbidities
Established vascular complications
Patient attitude and expected treatment efforts (may be influenced)
Resources and support (may be influenced)
Clinical considerations in deciding oral T2DM therapy
Established or high risk cardiovascular disease
hypoglycaemic risk
Gastrointestinal illness, including gastroparesis and IBD
Weight loss requirement
Renal dysfunction
Specific pharmcological effects of agents on patient
Amputation risk assessment
Risk increases with one or more factors
- PVD
- Neuropathy
- Previous ulceration
Aboriginal and Torres Strait Islander are high risk regardless
Management of resistant T2DM on third line agent
If on triple therapy : switch one or more agents to insulin or GLP-1A or another agent
If on GLP-1A : Add basal or premixed insulin
If on basal insulin : add SGLT2 GLP-1A or basal bolus insulin
Diabetic foot amputation risk management
Ankle brachial index
Neuropathy assessment with 10g monofilament
Foot care information
Footwear assessment to assist with pressure off-loading and redistribution
Regular podiatry review (6 months or more frequent)
High cardiovascular risk groups
(>15% 5 year risk)
Pre-existed CVD
Diabetes mellitus and age > 60
Diabetes with microalbuminuria ACR > 2.5mg/mmol men, 3.5 women or >20mcg/min
Stage III CKD or higher (eGFR <45)
Diagnosis of familial hypercholesterolaemia
Systolic BP > 180 or diastolic BP >110
Serum cholesterol > 7.5
Texas wound grading system
Grades 0-III
- Grade dependent on skin break (I), tendon or capsule (II) or bone/joint (III)
Grade A-D - A absence of ischaemia or infection B infection, C ischaemia D both
Factors requiring urgent foot multidisciplinary team
Deep ulcers
High risk foot with active ulcer
Ulcer not reducing in size after 4 weeks
low ABI or absent pulse
Ascending cellulitis
Charcot neuroarthropathy
Management of high risk CVD
Lifestyle advice with aggressive smoking cessation therapies, diet, exercise as per moderate risk
Concurrent BP management
- <140/90 with CKD or in general
- <130/80 with T2DM particularly with microalbuminuria
Lipid lowering therapy LDL <2.0, HDL >1.0, Trigs <2.0
Monitor for response 6-12 weekly to adjust antihypertensive and statin dose
Aspirin only for known CVD, prior ischaemic stroke/TIA, valve replacement
Management of intermediate risk CVD (10-15%)
Lifestyle advice:
- Diet rich in vegetables and fruit, low in sugar, saturated fat and salt
- Smoking cessation
- Alcohol limit to 1 glass red wine, increase tea intake
Medicate for BP if >160/100, FHx of premature CVD, SE Asian, Aboriginal, Middle Eastern
- Re-assess 6-12 weeks
- lipid BP and medication tolerance, adjust as required
- Review absolute CVD risk
- Withdrawal with profound medication changes
Management of low risk CVD <10%
Lifestyle advice on mediterranean diet exercise
Smoking cessation and alcohol reduction
Antihypertensive therapy only if BP >160/100
Consider withdrawal for people who make profound lifestyle changes
Risk factors for progression of diabetic retinopathy
Poor glycaemic control
Hypertension
Duration diabetes >10 years
Pre-existing diabetic retinopathy
Pregnancy
Microalbuminuria
Dyslipidaemia
Anaemia
Types of autonomic neuropathy
Orthostatic hypotension
Gastroparesis
Diarrhoea
Incomplete/delayed bladder emptying
Erectile dysfunction and retrograde ejaculation in males
Reduced vaginal lubrication and erousal in females
Silent cardiac ischaemia, impaired SNS cardiac response, dysrhythmias, arrest
Hypoglycaemic unawareness
Unexplained ankle oedema
Diabetic neuropathy score
- Ataxia/unsteadiness walking
- Burning, aching pain or foot tenderness
- Prickling sensations in feet
- Numbness legs or feet
>1 - neuropathy present
Management of diabetic nephropathy
Stringent glycaemic control HbA1c <7.0
Blood pressure control <130/80
ACEI or ARB for renoprotection (but no benefit with both)
Smoking cessation to reduce progression
Cardiovascular risk modification is microalbuminuria is an independent risk factor for CVD
General risk of CKD in the following populations
Diabetes
Hypertension
Established CVD
Family history of CKD
Obesity
Smoking
Aboriginal or Torres Strait Islander aged >30
Indications for renal specialist referral
eGFR < 30
Macroalbuminuria ACR >30mg/mmol
Decrease in eGFR by 25% or a sustained decrease in eGFR by 15ml/min/1.73m2 within 12 months
CKD with refractory HTN despite 3 agents
Diabete medication adjustment in CKD, AKI, other precautions
Reduce metformin dose with eGFR 30-60, cease if eGFR<30, or in severe hepatic inpairment
Reduce DPP4i (sitagliptin, alogliptin, saxagliptin) with eGFR <60, with the exception of linagliptin; consider pancreatitis risk, acute nasopharygitis on commencement
Reduce sulphonylurea (gliclazide, glipizide, glimepiride, glibenclamide) dose reduce in CKD to reduce hypoglycaemic risk
SGLT2i (dapagliflozin, empagliflozin, canagliflozin) - glycaemic effect diminishes with eGFR<45, although plausible renoprotective effect; avoid concurrent use of frusemide; monitor for UTI/fungal infection and euglycaemic DKA
Acarbose - cease if eGFR <25,
GLP-1RA (exanetide, liraglutide) - avoid if eGFR <30, increased pancreatitis risk
Thiazolidiendiones (pioglitazone, rosiglitazone) - avoid in CCF, osteoporosis, ESRF, genitourinary cancer
Driving advice
Ongoing general medical (2yrs private) or specialist review (1yr commercial)
Drive only if BSL > 5mmol/L
Not driving more that 2 hours without a snack
Not delaying or missing meals
BSL checks prior to and every 2 hrs whilst driving
Adequate glucose for self treatment
Safely stopping vehicle to treat mild hypoglycaemia with glucose, waiting 30mins before checking BSL and making sure BSL >5
Factors influencing glycaemic control end of life
Stress response to sustained illness
Organ failure
Malignancy
Chemotherapy
Steroids
Frequent injections
Poor appetite
Poor nutrition
Cachexia
Dehydration
Difficulty taking meds
Weight loss
Glycaemic goals in palliative care
Liberal BSL range 6-15
Avoid DKA, HHS and hypoglycaemia
Avoid excessive skin pricks and injections
Avoid unnecessary tests
Minimise glycaemic tablets
Consider changes to oral intake, cachexia and intercurrent illness in adjusting insulin doses
Conditional driving requirement
Conditional licence if on insulin or hypoglycaemic agents
Conditional licence subject to periodic review and requires
- End organ issues satisfactorially treated not interfering with driving (e.g. peripheral neuropathy, visual impairment, amputation etc.)
- Treatment regimen that minimises hypoglycaemic risk
- Hypoglycaemic awareness and adequate action plan
- Recent hypoglycaemic episode treated after 6 week period of non driving
Sick day management for DM
Commence action plan if BSL > 15 or feeling unwell
- Increased in self monitoring blood glucose Q2H or Q4H
- Monitor serum or urinary ketones if T1DM or on SGLT2i
- Maintain normal meals if possible, Consider soups and easy to digest foods
- If BSL > 15 consume non glucose fluids, consider increasing basal insulin by
- IF BSL < 15 consume oral rehydration fluids and reduce insulin
- If nausea vomiting, withhold meformin and GLP-1RA
- If unable to tolerate foods and BSL continues to rise or drop seek urgent medical care
- Consider cause and treat intercurrent illness with GP/ED review
Diabetes and pregnancy
Balanced diet, physical activity and healthy weight management
Pre-pregnancy and trimesterly opthalmological review for retinopathy
Stringent BSL control to reduce risk of fetal macrosomia, IUGR, and pre-eclampsia
Increase folate supplementation 5mg 1 month before pregnancy continuing for 12 weeks to reduce neural tube defects
TFTs for hypothyroidism patients for increased thyroxine
Renal review if eGFR <45 or ACR >30mg/mmol or elevated creatinine
Withhold ACEI, ARB, CCBs, beta blockers for hypertensive patients; consider renal advice
Pharmacotherapy for Obesity
Short term < 12 weeks - phentermine (sympathetic amine)
Longer term > 12 weeks
- Orlistat
- Phentermine/topiramate combination
- Lorcaserin (seratonin agonist)
- Naltrexone/bupropion
- GLP1RA - liraglutide
Indications and considerations for obesity pharmacotherapy
BMI >27 as an adjunct to diet, exercise and behaviour modification
Consider serotonin syndrome, refractory HTN and NMS on lorcaserin
Increased suicidality on toperimate and naltrexone
Fat soluble vitamins on orlistat with ciclosporin, thyroxine anticonvulsants
