Week 23 - Cases 1-4 Flashcards
what is balantitis circinata
a skin condition associated with reactive arthritis which presents with ring shaped dematitis on the glans penis
what is balantitis xerotica albicans
lichen sclerosis affecting the male genitals
what can candidal balantitis be caused by
diabetes
what are the risk factors for candidal balantitis
- Diabetes mellitus
- Use of oral antibiotics
- Poor hygiene in uncircumcised males
- Immunosuppression (including HIV infection)
what is the criteria to diagnose diabetes in symptomatic patients
fasting glucose test greater than or equal to 7
random glucose test greater than or equal to 11.1
what is the criteria to diagnosis diabetes if the patient is asymptomatic
Fasting Glucose Test greater than or equal to 7
Random Glucose Test greater than or equal to 11.1.
- this criteria must be met on 2 separate occasions
if a patient is asymptomatic what should be requested in regards to the HbA1c request
a second Hba1c shoud be requested.
Two consecutive Hba1c results equal to or greater than 48 is diagnostic of type 2 diabetes. However, it is not as sensitive as fasting samples and therefore cannot exclude diabetes if the HBA1c is less than 48.
what are the occasions where you should not use hb1Ac to diagnose diabetes
● Pregnant women or women who are 2 months postpartum.
● People with symptoms of diabetes for less than 2 months.
● People at high diabetes risk who are acutely ill.
● People taking
medication that may cause hyperglycaemia (for example long-term corticosteroid treatment).
● People with acute pancreatic damage,
including pancreatic surgery
.
● People with end-stage renal disease (ESRD).
● People with HIV infection
what are the hallmark symptoms of type 2 diabetes
● Tiredness
● Polyuria/polydipsia
● Recurrent infections e.g., thrush
● Increased hunger
● Unintentional weight loss
● Blurred vision (retinopathy)
● Foot ulcers/sores (due to peripheral neuropathy)
● Areas of dark skin e.g., in armpits/neck (acanthosis nigricans):
what is acanthosis nigricans due to
insulin resistance
what is checked at an annual diabetic review
urine
HbA1c
Foot examination
height and weight
BP
eye tests
cholesterol
blood sugards
what is the most common cause of blindness in adults aged 35-65 years of age
retinopathy
what is important to monitor in regards to the kidneys in diabetics
the albumin:crreatinine ratio
how do we decide if medication is necessary for a patient with diabetes
HbA1c is checked every 3-6 months until it is at a stable level on unchanging therapy, if lifestyle measures have failed and HbA1c is 48 or higher, then medication is considered
what is the first line medical treatment of type 2 diabetes and what is its mechanism of action
Metformin is the first line medical therapy for type 2 Diabetes. It is a biguanide which leads to activation of AMP-activated protein kinase (AMPK). This has a dual effect of increasing insulin sensitivity and decreasing hepatic gluconeogenesis.
what is the most common side effect of metformin
GI disturbances
an initial starting regimine would be 500mg once daily, but this can be titrated up to 1g twice daily if necessary. taking metformin with meals or using modified release preparations can reduce GI side effects
what kind of medications might need to be considered, other than blood sugar medications
statins and anti-hypertensives
who are statins recommended in
Recommended in most Type 1 diabetics, and Type 2 diabetics with a QRISK over 10%
what is the BP target for patients with diabetes
below 140/80 for all patients with diabetes
If there is ‘end organ damage’ (kidneys, eyes or any conditions affecting blood vessels), then it is 130/80.
what is the diagnostic criteria for diabetic ketoacidosis
● Capillary Blood Glucose (BM) >11 (or known diabetes)
● Capillary Ketones >3mmol/L (or urinary >2+)
● Venous pH <7.3 or venous bicarb <15mmol/L
Must have all three for a diagnosis.
what are the principles of management of diabetic ketoacidosis
● Fluid resuscitation to restore circulatory volume
● Correct electrolyte imbalances (in particular; potassium)
● To treat hyperglycaemia, clear ketones and suppress further ketogenesis
Management of diabetic ketoacidosis (DKA) is mostly following a set algorithm which all trusts will have, however establishing why someone has developed DKA is just as important. For example: Treating an underlying infection.
is sliding scale insulin used for diabetic ketoacidosis treatment
no, the treatment is a fixed rate infusion of insulin
what is the aggressive fluid resuscitation given for diabetic ketoacidosis
Initially, aggressive fluid therapy is needed. One litre of IV fluid over one hour (if the systolic BP is over 90), or if it is lower, boluses of fluid are required (This would be 500ml of 0.9% sodium chloride over less than 15 minutes).
what electrolyte is essential to monitor during DKA therapy
potassium
when is diabetic ketoacidosis treatment stopped and what is given next
When a patient is eating and drinking normally, and their pH is over 7.3, or their blood ketones are less than 0.6 mmol/L, stop the fixed rate insulin infusion, and go onto subcutaneous insulin.
what is the diagnosis for type 1 diabetes in adults - as stated by NICE
Diagnose Type 1 diabetes on clinical grounds in adults presenting with hyperglycaemia, bearing in mind that people with Type 1 diabetes typically (but not always) have one or more of:
ketosis
rapid weight loss
age of onset below 50 years
BMI below 25 kg/m²
personal and/or family history of autoimmune disease
what are the three different types of insulin available in the UK
Human Insulin produced by recombinant DNA technology.
Human insulin analogues: modified insulin to produce specific kinetic characteristics e.g., modified duration of action.
Animal insulins (rarely used) from pigs or cows.
what is a basal bolus mode of administration
This is where a long-acting insulin is given by subcutaneous injection to act as the endogenous insulin (basal or base insulin); and then rapid acting insulin is given with meals to replicate the normal response to food (bolus). Typically, three boluses are given a day with meals, but the amount of insulin will vary, as will the number of boluses, if a different number of meals are consumed. Patients become experts at managing their own diabetes.
what are mixed, bi-phasic regime of administration
These are quite varied, but usually have one, two or three insulin injections per day. Premixed insulin preparations, which contain insulins of different durations of action.
what is a continuous regime administration
Continuous regime: Insulin pumps can be used to deliver rapid acting insulin at a very slow rate as background insulin and extra mealtime insulin can be delivered by the patient according to what they eat. The insulin is delivered subcutaneously via a cannula and there are two main types – ‘tethered pumps’ and ‘patch pumps’. They can give patients more control over what they eat, and more stable blood glucose levels.
how many times a day should a type 1 diabetic check their insulin
at least four times a day
when is it particularly important to check glucose levels
check before each meal, and before bed
what are the blood glucose targets for diabetes, in waking and then before meals
5-7 mmol/L – on waking
4-7 mmol/L – before meals, and at other times of the day
what are the sick day rules for a patient with diabetes
Checking blood sugar more frequently
Staying hydrated
Eat little, and often
Keep taking medications
what is hyperosmolar hyperglycaemic state
There is also a condition known as hyperosmolar hyperglycaemic state (HHS) which presents in patients with type 2 diabetes. Patients often have glucose levels over 40 mmol/L. Profound dehydration accompanies this, and the mortality from this is much higher than diabetic ketoacidosis (DKA) (10-20%)
what are the results seen with primary hyperthyroidism
Elevated Free T4 (thyroxine) and free T3 (triiodothyronine) with suppressed TSH (thyroid stimulating hormone).
what is TSH low in primary hyperthyroidism
Production of TSH (thyroid stimulating hormone) is regulated by feedback from circulating free thyroid hormone concentrations. Elevated levels of Free T4 (thyroxine) and Free T3 (triiodothyronine) therefore suppress TSH (thyroid stimulating hormone) production from the anterior pituitary.
what does a normal thyroid consist of microscopically
consists of follicles lined by a cuboidal epithelium and filled with pink, homogenous colloid. The follicles vary somewhat in size. The interstitium, which may contain “C” cells is not prominent.
What are the three most common causes of hyperthyroidism in the UK?
toxic multinodular goitre
Grave’s disease
Solitary toxic adenoma
what examination signs are specific for Grave’s idsease
pretibial myxoedema
opthalmoplegia
thyroid acropathy
exopthalmos
Which thyroid auto-immune antibodies are most likely to be raised in Graves’?
thyroglobulin antibodies
present in 80% Hashimoto’s thyroiditis
what are the clinical signs of thyroid eye disease
Retraction of upper and lower lids ( sympathetic overdrive)
Lid lag
Swelling of the eyelids / conjunctiva ( “chemosis”)
Exposure /dehydration of the cornea ( dry eye &inadequate blink coverage)
Protrusion of the eyeballs “ Exophthalmos”/”Proptosis” ( swollen orbit)
Double vision/squint ( inflammation and fibrosis of muscles)
Optic neuropathy ( visual failure from optic nerve compression)
what is given to treat thyroid eye disease
Treat thyroid dysfunction
Stop smoking
Artificial tears
Selenium
Surgical intervention to improve lid closure
Prisms in glasses for squint/ diplopia ( may need surgery eventually)
If severe /threat to optic nerve high dose steroid/immunosuppression
Surgical orbital decompression
what are the three main treatment options for hyperthyroidism
- Antithyroid medication: methimazole, carbimazole, propylthiouracil
- Total thyroidectomy
- Radioactive iodine therapy
what are prescribed for hyperthyroid patients to help control physical symptoms such as anxiety, tremor and palpitations
beta-blockers
they are not a definitive treatment but can be useful to control symptoms in the short term, whilst awaiting definitive therapy
what are the potentially serious side effects of carbimazole
● Neutropenia (low neutrophil counts, a type of granulocyte white blood cell)
● Agranulocytosis (an acute febrile condition marked by severe decrease in blood granulocytes)
if someone on carbimazole was pregnant, what would you do to their medication
switch them to polyuracil
how frequently do you monitor blood tests after giving carbimazole
Initially, you should order TFTs (thyroid function tests) every 4-6 weeks (whilst the dose is being titrated). This should be reduced to approximately every 3-6 months once the patient is euthyroid, and a maintenance dose is achieved.
How does radioactive iodine work? What are its complications, and which other medical specialty should review patients, prior to treatment?
Radioactive Iodine-131 is taken orally and is then rapidly taken up by the thyroid gland. The release of radiation destroys the tissue over a period of 6-18 weeks.
Early complications include neck discomfort, and possible precipitation of Graves’ ophthalmopathy.
Ophthalmology should review to check that they don’t have Graves’ opthalmopathy.
Longer term there is a progressive incidence of hypothyroidism with most patients requiring treatment with thyroxine after several years.
what are the blood test results for primary hypothyroidism
Low T3 (Triiodothyronine), with low T4 (thyroxine) production from the thyroid means there is reduced negative feedback to the pituitary. As such, the TSH (thyroid stimulating hormone) is raised.
This has likely been caused by radio-active iodine.
what is the most common cause of primary hypothyroidism in the UK
autoimmune thyroiditis (Hashimoto’s)
antibody-mediated destruction of thyroid tissue.
What do these thyroid function tests show?
- TSH 9.41 (0.40-5.00 mU/L)
- T3 4.2 (3.00-6.00 pmol/l
- T4 12.5 (10-21 mol/l)
Subclinical hypothyroidism. T3 and T4 are at the lower end of normal range, however TSH is raised due to reduced negative feedback to the pituitary from T3/T4.
Billy is a 72 year old gentleman who has recently been discharged from hospital following admission for a fractured neck of femur.
On his discharge summary the hospital doctor has asked you to review Billy because his thyroid blood test is abnormal. What does it show? How will you manage him?
* TSH 0.3 (0.40-5.00 mU/L)
* T3 2.8 (3.00-6.00 pmol/l
* T4 11.1 (10-21 mol/l)
Most likely Euthyroid Sick Syndrome – systemic illness causing transiently low T3/4 and TSH.
Rarely, these TFT results could be due to secondary hypothyroidism
Check if they are symptomatic.
If they are euthyroid clinically, repeat TFTs in 1 month
what happens to levothyroxine treatment when someone is pregnant
Increase levothyroxine by 20-50micrograms (or 25%).
Repeat TFTs (thyroid function tests) every 4-6 weeks. Titrate to TSH (thyroid stimulating hormone) <2.5pmol/l.
She needs to be referred to be under the care of an endocrinologist ante natally. She will need close monitoring of her Thyroid Antibodies. If antibodies are raised at 28/40, she will need additional growth scans.
Sahar Mahmood, a 50-year-old female, attends for an appointment with the practice nurse. She is well and reports no current symptoms but has a family history of cardiovascular disease, so was keen to have her blood pressure checked, and routine blood tests.
Her Hba1c is 52. Should you:
Repeat Hba1c in 3 weeks
Sahar’s Hba1c is in the diabetic range however she is asymptomatic, therefore needs a second Hba1c test to confirm the diagnosis.
Rebecca Fortune is a 72-year-old female who has just been diagnosed with Type 2 diabetes. Her Hab1c is 85 and she reports mild polydypsia. She has a past medical history of hypertension, peripheral vascular disease, and she smokes 15 cigarettes per day. Her QRISK is calculated at 41.9%.
Alongside lifestyle interventions, what medical therapy will you initiate?
Metformin + Canagliflozin
Rebecca has established cardiovascular disease. NICE guidance would therefore recommend initiating Metformin, and Canagliflozin as first-line therapy.
Rachael Whittaker presents to her GP with weight loss, anxiety, and tremor. Alongside raised T4, what other blood test would suggest Grave’s disease, as the underlying cause of her hyperthyroidism?
Raised TSH receptor antibodies
You would expect TSH levels to be low / undetectable in all hyperthyroid patients. Raised TSH receptor antibodies are present in 90% of patients with Graves’ disease. Anti-TPO and Thyroglobulin antibodies are associated with Hashimoto’s thyroiditis.
Justin Clarke presents to the emergency department with decreased GCS. He is a known type 1 diabetic, and friends report he can be a little inconsistent with taking his insulin.
His blood glucose level is 27.5, his blood ketone levels are 5.3 and pH on venous blood gas is 7.10.
What is your immediate management of Justin?
Commence a fixed-rate insulin infusion + IV fluids
This patient fulfils the diagnostic criteria for DKA. He therefore needs fluid resuscitation with careful monitoring of serum potassium and a fixed rate insulin infusion.
Commence a fixed-rate insulin infusion + IV fluids
Correct answer.
This patient fulfils the diagnostic criteria for DKA. He therefore needs fluid resuscitation with careful monitoring of serum potassium and a fixed rate insulin infusion.
- needs to be on effective contraception to avoid pregnancy
- should report any symptoms of infection, especially a sore throat urgently to a medical professional
- there may be a small risk of pancreatitis with carbimazole
what does carbimazole cause
agranulocytosis and neutropenia therefore is important to check the patients FBC
in what form does carbimazole come and how often is it taken
it is in tablet form and is taken daily
what is diabetes insipidus characterised by
polydipsia, polyuria and formation of inappropriately hypotonic (dilute) urine
what are the two types of diabetes insipidus that exist
Two types exist: central DI, due to reduced synthesis or release of arginine vasopressin (AVP) from the hypothalamo-pituitary axis; and nephrogenic DI, due to renal insensitivity to AVP.
what are the recognised risk factors for central DI
pituitary surgery, craniopharyngioma, infiltrative pituitary stalk lesions, traumatic brain injury, subarachnoid haemorrhage, congenital hypothalamo-pituitary defects, autoimmune disorders, and Wolfram syndrome
what are the risk factors for nephrogenic DI
include lithium therapy, chronic kidney disease, and chronic hypercalcaemia or hypokalaemia.
what are both types of DI associated with
hypernatraemia, and this may present as a medical emergency
what is the treatment of choice in central DI
the synthetic AVP analogue desmopressin (DDAVP) is the treatment of choice
what is the treatment of choice for nephrogenic DI
is treated with an adequate fluid intake; salt restriction and diuretics may help reduce polyuria.
what does diabetes insipidus result from
It may result from an absolute or relative deficiency of arginine vasopressin (AVP), also known as antidiuretic hormone (ADH), which is produced by the hypothalamus and secreted via the posterior pituitary, or by resistance to its action within the renal collecting ducts.
what are the first line investigations used for diabetes insipidus
urine osmolality
serum osmolality
serum glucose
serum sodium
