Endocrine long case Flashcards

Question

Monogenetic diabetes characteristics

Answer 1

Onset before 25yrs of age Lower level hyperglycaemia Non-ketotic diabetes mellitus Autosomal dominant inheritance Primary defect in function of beta pancreatic cells

Answer 2

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

Answer 3

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

Answer 4

Oral hypoglycaemic agents or insulin Hyperglycaemia from intercurrent illness Pregnancy and pre-pregnancy planning Any new treatment changes to monitor effect Unreliable HbA1c monitoring

Answer 5

Diabetic educator Podiatrist GP and endocrinologist Dentist Community care nurse Aboriginal care worker and social worker Pharmacist Ophthalmologist and optometrist Dietician Psychologist Exercise physiologist

Answer 6

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

Answer 7

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

Reduce by 2 units 4

Reduce by 4 units if BSL<4 on any day

Answer 8

**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)

Answer 9

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

Answer 10

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

Answer 11

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)

Answer 12

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

Answer 13

Risk increases with one or more factors - PVD - Neuropathy - Previous ulceration Aboriginal and Torres Strait Islander are high risk regardless

Answer 14

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

Answer 15

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)

Answer 16

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

Answer 17

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

Answer 18

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

Answer 19

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

Answer 20

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

Answer 21

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

Answer 22

Poor glycaemic control Hypertension Duration diabetes \>10 years Pre-existing diabetic retinopathy Pregnancy Microalbuminuria Dyslipidaemia Anaemia

Answer 23

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

Answer 24

1. Ataxia/unsteadiness walking 2. Burning, aching pain or foot tenderness 3. Prickling sensations in feet 4. Numbness legs or feet \>1 - neuropathy present

Answer 25

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

Answer 26

Diabetes Hypertension Established CVD Family history of CKD Obesity Smoking Aboriginal or Torres Strait Islander aged \>30

Answer 27

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

Answer 28

**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) - gl**ycaemic 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*

Answer 29

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

Answer 30

Stress response to sustained illness Organ failure Malignancy Chemotherapy Steroids Frequent injections Poor appetite Poor nutrition Cachexia Dehydration Difficulty taking meds Weight loss

Answer 31

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

Answer 32

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

Answer 33

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

Answer 34

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

Answer 35

Short term \< 12 weeks - phentermine (sympathetic amine) Longer term \> 12 weeks - Orlistat - Phentermine/topiramate combination - Lorcaserin (seratonin agonist) - Naltrexone/bupropion - GLP1RA - liraglutide

Answer 36

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