06. KFP: Endocrinology Flashcards
(156 cards)
1
Q
What would you advise patients before commencing them on sodium-glucose co-transporters (SGLT-2) such as empagliflozin?
A
- Advise increased risk of genitourinary infections
- Advised to withhold medication if acute illness and not eating
- Advise if fasting for a procedure, need to withhold for three days prior
2
Q
Lifestyle recommendations for type 2 diabetes?
A
- Aim for at least 150 minutes of moderate intensity aerobic activity per week
- Aim for two to three sessions of resistance training per week
- Recommend a low glycemic index diet (e.g. Whole grain breads, pasta, fruits, dairy products)
- Limit foods high in saturated fats
- Recommend 5 to 10% weight loss
- Advise less than 2 standard drinks per day for men and women
3
Q
In the management of diabetes, who would you refer the patient to?
A
- Diabetes educator
- Podiatrist
- Optometrists to monitor for diabetic retinopathy
- Exercise physiologists for exercise plan
- Endocrinologist to optimise diabetes management (all patients <25yo need referral)
- Aboriginal health care worker to assist in engagement in diabetes management (if Aboriginal)
- Dietitian for education on diabetic diet
4
Q
What are some complications in early onset type 2 diabetes compared with older onset type 2 diabetes?
A
- Complications greater with onset at a younger age
- Life expectancy reduced
- Non alcoholic fatty liver disease is twice as common
- Earlier onset of microalbuminuria and end stage renal failure
- Earlier onset and greater prevalence of diabetic retinopathy
- Earlier onset of neuropathy
- Apolipoprotein B concentration is higher despite statin therapy
- Risk of myocardial infarction is 14 times higher compared with age cohort, while older onset type 2 diabetes risk is 2 to four times higher
- Earlier onset of diastolic myocardial dysfunction
- Reduced fertility, and great pregnancy complications
- Risk of premature decline in cognitive function
- Higher rate of diabetes related psychological distress and psychological issues, especially depressione
- Limited work capacity and consequent social economic impact
- Reduced quality of life
5
Q
What weight loss reduction pharmacotherapies are available in the context of poorly control diabetes and obesity?
A
- Liraglutide (Saxenda) [private script] OR Tirzepatide (Mounjaro) [Private script] OR Semaglutide (Ozempic) - PBS eligible as a third line agent for diabetic management for HbA1c >7% and history of contraindication to combination of metformin and sulphonylurea
- Naltrexone + Buproprion (Contrave)
- Orlistat
- NOTE: phentermine is contraindicated if history of drug misuse
6
Q
In a patient with severe mental illness and diabetes, what factors may be contributing to poor glucose control?
A
- Antipsychotic medication
- Poor insulin technique OR inadequate site rotation OR lipohypertrophy / improper storage of insulin
- Poor compliance with diabetic medication
- Inadequate insulin dose OR inadequate insulin regime
- Excessive consumption of takeaway food OR diet high in saturated fats
- Alternative diagnosis OR latent autoimmune diabetes of adults (LADA)
- Obesity
- Smoking
- Alcohol consumption
7
Q
What are some important information points for patients about insulin delivery?
A
- Insulin can be stored at room temperature for up to one month
- Insulin pen needles should be used only once
- The abdomen is a preferred site for injecting
- Insulin needs to be injected only into subcutaneous tissue
- Insulin injection sites need to be rotated and regularly inspected
8
Q
What questions would you ask when discussing smoking cessation?
A
- Time to first cigarette - smoking within 30 minutes indicates nicotine dependence
- Presence of cravings OR irritability OR anxiety with abrupt cessation of smoking - withdrawal symptoms
- Previous attempts to quit OR strategies used for previous attempts to quit
- Assess readiness to quit smoking - as in indicator of whether further motivational interviewing techniques are required
- Barriers to quitting OR perceived benefits of smoking
9
Q
Nicotine withdrawal symptoms?
A
Craving for nicotine AND
Four or more of the following symptoms within 24 hours of abrupt cessation or reduction of tobacco:
* Irritability, frustration, anger
* Anxiety
* Difficulty in concentration
* Increased appetite
* Restlessness
* Depressed mood
* Insomnia
10
Q
Non pharmacological management options for smoking cessation?
A
- Discuss strategy to remove barriers to quitting
- Discuss craving strategies (The 4 Ds: Delay, Deep breaths, Drink water, Do something else to occupy your mind while craving passes) OR formulate a quit plan
- Agree on a quit date
- Refer to Quitline / tell social circle of intention to quit so they can support him
- Arrange regular reviews to assist in sustaining smoking cessation
11
Q
Pharmacological management options for smoking cessation?
A
- Combination nicotine replacement: patch + (gum OR lozenge OR inhaler)
- Varenicline: can be used in those with mental health issues but they should be monitored closely
- Buproprion: essential interaction with antipsychotics (lower seizure threshold)
12
Q
What are some indicators of nicotine dependence?
A
- Smoking within 30 minutes of waking
- Smoking more than 10 cigarettes per day
- History of withdrawal symptoms in previous quit attempts
13
Q
What should patients be monitored for and warned of when using varenicline?
A
- Unusual mood changes
- Depression
- Behaviour disturbance
- Suicidal thoughts
14
Q
Which medications may bupropion interact with to lower seizure thresholds?
A
- Antidepressants
- Antipsychotics
- Oral hypoglycemic agents
- Antimalarials
15
Q
What is hyperosmolar hyperglycemia characterised by?
A
- Severe hyperglycaemia
- Hyperosmolality
- Dehydration
- Change in mental state
16
Q
What bedside investigations can be used to assess for hyperosmolar hyperglycaemic state vs diabetic ketoacidosis?
A
- Finger prick for random blood glucose
- Finger prick ketones OR urinalysis for ketones (urine ketone tests may be misleading when using SGLT2i agents)
17
Q
How would you manage hyperosmotic hyperglycemic state in a general practise setting?
A
- Urgently discuss acute management of HHS with an endocrinologist
- Arrange urgent transfer to nearest emergency department
- Note: IV fluid replacement needs to be done under strict monitoring
18
Q
What factors would you search for to determine if someone requires diabetes testing in children?
A
- Polyurea OR weight loss OR polydipsia
- Body mass index at or above 85th centile OR waist circumference to height ratio more than 0.5
- Maternal history of diabetes OR maternal history of gestational diabetes during child’s gestation
- First degree relative with type 2 diabetes
- Acanthosis nigricans - sign of insulin resistance
- Elevated blood pressure OR dyslipidemia OR small for gestational age OR non alcoholic fatty liver disease - conditions associated with obesity and metabolic syndrome
- Use of psychotropic medications
19
Q
Differentials for sudden painless loss of vision of the right eye?
A
- Right retinal detachment
- Right vitreous haemorrhage
- Right central retinal artery occlusion OR right central retinal artery branch occlusion / Right central retinal vein thrombus OR right central retinal vein branch thrombus
- Right temporal arteritis
- Right optic neuritis
20
Q
What medication can be added to slow diabetic retinopathy?
A
Fenofibrate 145mg daily PO
21
Q
What patient education points would you discuss before commencing insulin for a diabetic patient?
A
- Advice to commence paired pre and postprandial finger prick blood glucose testing OR fasting morning finger prick blood glucose testing
- Aim for fasting blood sugar level 4-7mmol/L OR target of postprandial blood sugar level is 5-10mmol/L
- Create a sick day management plan OR more frequent blood sugar monitoring when sick
- 15g of quick acting carbohydrate if blood sugar level less than 4mmol/L (half a can of regular non-diet soft drink, half a glass of fruit juice, 3 teaspoons of sugar or honey or 6-7 jelly beans) and then wait 15 minutes before repeating a BSL check
- Notify driver licencing authority of initiation of insulin / check blood sugar levels every two hours when driving
- Notify availability of the national diabetes services scheme - access to subsidised syringes/pen needles/ glucometer strips
- Insulin reduction when altered eating patterns - e.g. fasting, dieting
22
Q
How would you manage an episode of hypoglycemia?
A
- 15g of quick acting carbohydrate if blood sugar level less than 4mmol/L (half a can of regular non-diet soft drink, half a glass of fruit juice, 3 teaspoons of sugar or honey or 6-7 jelly beans)
- Wait 15 minutes before repeating a BSL check
- Provide some longer acting carbohydrate if the patients next meal is more than 15 minutes away
23
Q
How would you start an initial basal insulin regimen for a patient with type 2 diabetes?
A
Long acting insulin 0.2 units/kg (up to 30 units) initially subcut, daily at the same time each day
- Long-acting basal insulin is usually given at bedtime but giving in the morning may be associated with less overnight hypoglycaemia than evening dose.
Consider a morning dose in a patient who:
- Is older and at high risk of hypoglycemia
- Has had nocturnal hypoglycemia
24
Q
What specific advice do you give regarding insulin storage and injecting technique?
A
- Insulin should be given 30 minutes before a meal
- Injection of insulin into abdominal subcutaneous tissue
- Injection site rotation to avoid lipohypertrophy
- Insulin can be stored at room temperature for up to one month
- Safe disposal of sharps into sharps container
25
How would you assess for peripheral neuropathy?
* 10g monofilament pressure sensation at metatarsal joints OR distal plantar aspect of both great toes
* Ankle reflexes - absent in peripheral neuropathy
* Vibration sensation with 128Hz tuning fork
* Pinprick sensation of the lower limb
* Proprioception at both great toes
26
Differentials for neuropathy aside from diabetic peripheral neuropathy?
* Vitamin b12 deficiency
* Hypothyroidism
* Renal disease
* Neurotoxic drugs Including amiodarone, statins, antiretrovirals, tacrolimus, chemotherapies
* Excessive alcohol
27
Pharmacological options for the treatment of diabetic peripheral neuropathy?
* Amitriptyline - first line treatment
* Pregabalin OR gabapentin OR sodium valproate - anticonvulsant
* Topical nitrate spray
28
What specific risks are there when prescribing glucagon-like peptide-1 (GLP-1) analogues?
* Nausea/vomiting (due to delayed gastric emptying) OR diarrhoea OR constipation OR abdominal pain OR dyspepsia
* Pancreatitis
* Risk of worsening diabetic retinopathy
* Injection site erythema OR injection site swelling - injection site reaction
* Cholelithiasis OR cholecystitis
29
Why should GLP-1 receptor agonists (Ozempic) and DDP4 inhibitors (linagliptin) not be used together?
They are both incretin mimetics, and therefore do not provide additional glycaemic benefits together
30
What should be considered in preconception counselling in the context of polycystic ovarian syndrome?
* Glycaemic status assessment: oral glucose tolerance test
* Lipid profile check
* Rubella Serology
* Hepatitis b surface antibodies and antigen
31
What preconception advice would you give a patient who has polycystic ovarian syndrome and a bmi of 36 and smokes?
* Advise commencement of folic acid 5mg daily at least one month prior to planned conception (higher dose for BMI > 30)
* Discuss how to calculate ovulation/fertility window OR optimal timing for intercourse
* Discuss genetic carrier screening options (cystic fibosis, spinal muscular atrophy, fragile X syndrome)
* Recommend smoking cessation
* Aim 5 to 10% weight loss
* Advise 150 minutes of moderate exercise over at least five days per week
* Screen for domestic partner violence
* Advise avoiding raw fish OR soft cheese OR deli meats OR other appropriate food safety advice
* Dental check up before pregnancy
* Iodine supplement ation of 150 microg daily
32
What are the complications of gestational diabetes?
* Prematurity
* Perinatal asphyxia
* Macrosomia / birth injury - largely due to macrosomia
* Intrauterine growth restriction - due to impaired placenta perfusion
* Respiratory distress
* Hypoglycaemia OR hypocalcaeamia - metabolic disturbances
* Hyperbilirubinaemia
* Ventricular hypertrophy OR atrial septal defect OR ventricular septal defect OR patent ductus arteriosus - congenital cardiac conditions
33
What are some risk factors for gestational diabetes mellitus?
* Obstetric history of GDM
* Increased maternal age
* Increased BMI
* Excessive weight gain in early pregnancy
* Polycystic ovary syndrome
* Obstetric history of high birth-weight baby
* Obstetric history of pregnancy loss
* Family history of diabetes
* Ethnic group with high prevalence of type 2 diabetes (e.g. ATSI, Hispanic, African, South or East Asian and Pacific Islander peoples)
* Being a migrant to a country
34
How do you diagnose gestational diabetes?
* Fasting plasma glucose >/= 5.5mmol/L OR
* Two hour plasma glucose >/= 8.0mmol/L (post OGTT)
35
What postpartum advice would you provide to a patient who has gestational diabetes?
* Oral glucose tolerance test 6 to 12 weeks postpartum
* Hba1c every year OR fasting blood glucose every year OR oral glucose tolerance test every two to three years
* Recommend high fibre diets OR five serves of vegetables daily OR reduced fat dairy products
* 150 minutes of moderate exercise at least five days per week
* Weight loss of 5 to 10%
36
What is geographic tongue/benign migratory glossitis?
It is a benign oral inflammatory condition characterised by loss of epithelium.
It is characterised by irregularly shaped, red, map like, smooth and swollen patches surrounded by white lines. It can occur suddenly.
It occurs more often in patients who have psoriasis.
It resolves over time without treatment.
37
What are some differential diagnosis for geographic tongue?
* Oral candidiasis
* Oral psoriasis (rare)
* Oral lichen planus
* Trauma
* Herpes simplex
* Systemic lupus erythematosis
* Oral leukoplakia
38
What is chronic plaque psoriasis?
* Symmetrical, well demarcated, erythematous thickened plaques with overlying silver scales
* Presents with itch, especially during flares. Pain occurs when plaques are thickened and cracked
39
What are some differentials for itchy, painful, thickened rash?
* Chronic plaque psoriasis
* Seborrheic dermatitis
* Discoid eczema
* Lichen simplex
* Tinea capitis
* Tinea corporis
* Pityriasis rosea
* Pityriasis rubra pilaris
* Cutaneous lymphoma
* Secondary syphilis
40
What are available treatments for palmoplantar psoriasis?
Mild psoriasis:
- Emollients: thick, greasy barrier creams
- Keratolytics: urea or salicyclic acid to thin down the thick scaling skin (calcipotriol ointment topically)
- Coal tar: to improve the scale and inflammation
- Topical steroids: ultrapotent ointment applied initially daily for 2-4 weeks, if necessary under occlusion (Betamethasone diproprionate 0.05% ointment topically)
More severe palmoplantar psoriasis:
- Phototherapy
- Acitretin
- Methotrexate
41
Differentials for syncope?
* Vasovagal syncrope
* Bradyarrhythmia or tachyarrhythmia or long QT syndrome
* Seizure
* Psychogenic non epileptic seizure
42
Causes of syncope?
Neurally mediated reflex syncopal syndromes
* Vasovagal faint
* Carotid sinus syncope
* Situational faints
Cardiac arrhythmias
* Sinus node dysfunction including bradycardia or tachy cardia
* Atrioventricular conduction system disease
* Paroxysmal superventricular an ventricular tachycardias
* Inherited syndromes: Brugada syndrome, Wolff-Parkinson-White
* Implanted device malfunction
* Drug-induced proarrhythmias
Orthostatic
* Autonomic failure
* Volume depletion
Structural cardiac or cardiopulmonary disease
* Cardiac valvular disease
* Acute myocardial infarction
* Obstructive cardiomyopathy
* Acute aortic dissection
* Pericardial disease
* Pulmonary embolus
Disorders with impairment or loss of consciousness
* Metabolic disorders including hypoglycemia, hypoxia, hyperventilation with hypercapnia
* Epilepsy
* Intoxications
* Vertebro basilar transient ischemic attack
43
What are some initial investigations for syncope?
* FBC
* EUC
* Glucose
* Venous Blood Gas
* D-dimer: if suspecting PE
* Blood alcohol: if clinically indicated
* ECG
* Consider CT brain
44
Differentials for a wrist swelling/lump?
* Ganglion cyst
* Lipoma - soft, painless slow growing mobile nodule
* Epidermoid cyst - pearl like cysts or nodules, often with a central punctum, that is freely mobile on palpation
* Tenosynovial giant cell tumour - does not transilluminate, is fixed
* Tendinous xanthoma - yellow papules may be the first evidence of hyperlipidemia
* Tophus (if history of gout) - uric acid deposits can produce firm subcutaneous nodules
* Rheumatoid nodule - firm, nontender, flesh coloured, subcutaneous lesions
45
Firstline management options for ganglion cysts?
* Reassure no treatment needed as a benign in nature
* Aspiration of ganglion cyst
* Ibuprofen 400mg TDS PO PRN
46
Relevant history questions for months of increasing breathlessness an worsening exercise tolerance, dry cough that is most bothersome at work?
* Use of personal protective equipment at work
* Similar symptoms in work colleagues
* Fever
* Associated rash - systemic lupus erythematosis/systemic sclerosis
* Other sore joints OR morning stiffness - rheumatoid arthritis
* Weight loss OR night sweats OR hemoptysis - malignancy
* Lower limb oedema - cardiac disease
47
Differentials for months of increasing breathlessness an worsening exercise tolerance, dry cough that is most bothersome at work (stone mason)?
* Silicosis / interstitial lung disease due to occupational exposure
* Work associated / occupational asthma
* Hypersensitivity pneumonitis
* Idiopathic pulmonary fibrosis
* Sarcoidosis
* Systemic lupus erythematosus / rheumatoid arthritis / systemic sclerosis
* Lung malignancy
* Emphysema
48
What diseases can silica dust cause?
* Acute silicosis
* Chronic bronchitis
* Emphysema
* Lung cancer
* Scleroderma
49
How will you manage occupational related silicosis?
* Encourage to notify Safework of the practises which exposed patient to silica dust
* Cease exposure to silica dust OR consider changing his type of work
* Encourage OR support smoking cessation
* Recommend pneumococcal vaccine / recommend influenza vaccine
* Refer to a respiratory physician for further management
50
Listen mandatory pieces of information on a WorkSafe certificate
* Workers demographic details - name, address, DOB
* Date of injury
* Date of doctor's examination
* Diagnosis
* Capacity assessment - including physical, mental and functional capacity
* Suitability for employment - including dates of incapacity
* Doctors proposed treatment plan
* If the worker has participated in voluntary work OR employment other than with the pre-injury employer as part of return to work
51
What is pelvic inflammatory disease?
A syndrome comprising a spectrum of inflammatory disorders of the upper genital tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess and pelvic peritonitis
52
What are some possible causes of pelvic inflammatory disease?
* Polymicrobial
* STIs: Neisseria gonorrhoea, Chlamydia trachomatis, mycoplasma genitalium
* Intrauterine device insertion
53
What are some pharmacological options for smoking cessation?
* Nicotine 2mg lozenge prn OR nicotine 2mg gum prn OR nicotine 1mg spray prn OR nicotine 15mg inhalator PRN
* Varenicline daily PO - 12 week course
* Bupropion daily PO - 9 week course
54
Differentials for mild deranged liver function tests/chronic liver disease?
* Hepatic steatosis
* Chronic hepatitis b infection OR chronic hepatitis c infection
* Autoimmune hepatitis
* Hemochromatosis - LFTs less likely to be deranged when pre-menopausal
* Celiac disease
* Hyperthyroidism or hypothyroidism
* Wilson's disease - rare cause of LFT derangement
* Alpha1 anti trypsin deficiency - rare cause of LFT derangement
* Liver cancer OR hepatoma - very unlikely in an otherwise well young patient
* Epstein-Barr virus OR cytomegalovirus infection - can cause mild transaminitis, but unlikely in this case given no other infectious symptoms
55
What is the diagnostic criteria for metabolic syndrome?
Based on meeting 3 of 5 criteria:
* Elevated Triglycerides: >/= 1.7mmol/L
* Reduced HDL: < 1.3mmol/L
* Elevated waist circumference (population specific): Waist circumference >/= 88cm
* Elevated blood pressure
* Elevated fasting glucose
56
What are some potential consequences of metabolic associated fatty liver disease?
* Liver fibrosis
* Liver cirrhosis
* Liver failure
* Liver cancer
* Cardiovascular disease
* Type 2 diabetes
* Cancers
57
What are the options to check for liver fibrosis?
* Liver elastography (fibroscan) - gold standard
* Calculate fibrosis stage with Fibrosis-4 score OR NAFLD Fibrosis Score
58
List non-pharmacological management strategies for metabolic associated fatty liver disease.
* Advise that not drinking any alcohol is the safest option
* Aimed to achieve at least 7 to 10% weight loss - improves histological features of steatosis
* Recommend hypocaloric diet / refer to dietitian for dietary plan for weight loss
* Aim 30 to 60 minutes of moderate intensity exercise five days a week / refer to exercise physiologist for a personalised exercise plan - physical activity independent of weight loss has a modest impact on hepatic steatosis
* Discuss hepatitis a or hepatitis b immunisation - Avoid additional preventable liver disease
59
How often is screening for hepatocellular carcinoma required for Metabolic associated fatty liver disease and cirrhosis? What tests are used?
Time interval: Q6 monthly
Tests: liver ultrasound and serum alpha-fetoprotein
60
What are some differentials for thrombocytopenia?
* Immune thrombocytopenia purpura
* Doxycicline induced thrombocytopenia OR drug induced thrombocytopenia
* Vitamin b12 deficiency
* Chronic liver disease
* HIV OR viral induced thrombocytopenia
* Myelodysplastic syndrome OR haematological malignancy
* Artefactual thrombocytopenia
* Autoimmune disease e.g. SLE
* Gestational thrombocytopenia (if pregnant)
* Congenital thrombocytopenia (if no previous normal result)
61
What examination findings would you search for in severe thrombocytopenia?
* Petechiae OR purpura OR ecchymoses - signs of bleeding
* Mucosal bleeding or haematuria
* Splenomegaly OR hepatomegaly - infective, malignant or hepatic disease
* Local or general lymphadenopathy - infective or malignant process
* Spider naevi OR palmer erythema OR gynaecomastia OR asterixis OR jaundice - signs of chronic liver disease
62
List specific advice / precautions you'd give to a patient with severe Immune thrombocytopenia purpura?
* Avoid activities that can potentially result in significant head injury
* Do not take aspirin or other non steroidal anti inflammatories for pain
* Restrict alcohol intake to no more than 10 standard drinks a week or two standard drinks a day
* Present for urgent medical attention if experiencing significant bleeding from the bowels or mucous membranes or accidental injuries / present to emergency if experiencing severe headache or focal weakness or sensory changes or visual changes
63
Differentials for a left groin lump in a 6 week old female infant?
* Left indirect inguinal hernia (99% vs 1% being direct)
* Herniation of left ovary
* Inguinal lymphadenopathy
* Left femoral hernia (rare)
64
What should you look for in a full term female infant with bilateral inguinal hernias that may contain ovaries?
Androgen insensitivity syndrome
65
What is the management for an indirect inguinal hernia in an infant?
* Early referral to a paediatric surgeon for hernia repair within two weeks
* Educate parents in one hotel for the signs of a strangulated hernia / advise to go to the emergency department if infant develops a fixed lump when crying or the lump changes colour or if there is persistent vomiting
66
What are some features to suggest a groin lump is a hernia?
* Lump is more noticeable with crying
* Cannot get above the swelling
* No transillumination
67
What are some signs of an incarcerated hernia?
* Abdomen is more distended than usual
* Presence of nausea/vomiting, irritability and pain
* Presence of oedema, erythema and tenderness
* Fever
* Swelling that is red or pale blue grey in colour and is noticeably tender
* A swelling that does not change in size when your child is crying
68
What is are the recommended timeframes for hernia repair in infants?
- Birth to 6 weeks?
- 6 weeks to 6 months?
- Over 6 months?
- Birth to 6 weeks: surgery within 2 days
- 6 weeks to 6 months: surgery within 2 weeks
- Over 6 months: surgery within 2 months
69
Differentials for a lump just anterior to the anus in an infant?
* Perineal pyramidal protrusion
* Skin tag
* Injury from sexual assault
70
What's the biochemical criteria for diabetic ketoacidosis?
* Hyperglycaemia, defined by a BGL > 11mmol/L
* Venous pH < 7.3 or bicarbonate < 15mmol/L
* Presence of blood ketones or urinary ketones (abnormal ketone level is > 0.6mmol/L)
71
Clinical scenarios in which euglycaemic ketoacidosis can occur?
* Patients taking SGLT2 inhibitors
* Pregnancy
* After excessive alcohol intake
* People on extremely low carbohydrate diets
72
When should there be caution with the use of SGLT2i?
* Urinary frequency
* Urinary incontinence
* Genitourinary infections
* Dehydration
73
Symptoms of ketosis?
* Nausea
* Vomiting
* Dyspnoea
* Fruity odour
* Abdominal pains
* Altered level of consciousness
74
What are some risk factors for euglycaemic ketoacidosis in patients using SGLT2is?
* Intercurrent illness
* Surgery
* Reduced food and fluid intake
* Reduced insulin doses
* Previous ketoacidosis
* Missed diagnosis of Type 1 diabetes or latent autoimmune diabetes of adulthood
* History of alcohol abuse
75
What perioperative scenarios should SGLT2is be stopped to reduce the risk of euglycaemic ketoacidosis?
* Surgery and procedures requiring bowel preparation (e.g. colonoscopy) - stop 3 days before the procedure and on the day
* Surgery and procedures requiring 1 day or longer in hospital - stop atleast 2 days before the procedure and on the day of the procedure)
* Day procedures, including gastroscopy - stop on the day of procedure and minimise the duration of fasting before and after the procedure
76
What is the starting dose for initial full thyroxine replacement?
Levothyroxine 1.6microg/kg (to the nearest 25microg) daily PO - adjust dose every 4-8 weeks as required
77
What is the starting dose for initial partial thyroxine replacement?
Levothyroxine 25-50microg/kg (to the nearest 25microg) daily PO - adjust dose every 4-8 weeks as required
* Note: start at the lower end for a patient with cardiovascular disease - high starting doses can precipitate or exacerbate cardiac ischaemia
78
What is Klinefelter's syndrome?
* Syndrome caused by presence of two or mote X chromosomes
* Characterised by impaired testosterone production and spermatogenesis
* Most common cause of androgen deficiency in men
79
What is the most consistent feature of Klinefelter's syndrome?
Small testes volume < 4mL
80
Clinical features of Klinefelter's syndrome?
* Taller than average height
* Reduced facial hair
* Reduced body hair
* Breast development (gynaecomastia)
* Feminine fat distribution
* Osteoporosis
* Small testes (testicular atrophy)
* Varicose veins)
81
When should the AUSDRISK tool be used to check if a person is at high risk of developing Type 2 Diabetes Mellitus?
Use every 3 years in non-Indigenous adults over the age of 40
82
Which antihyperglycaemic agents have the highest risk of hypoglycaemia?
Sulfonylureas and insulin
83
Which antihyperglycaemics provide the greatest reduction in HbA1c?
Insulin and GLP1 receptor agonists
84
Which antihyperglycaemic provides the most weight loss?
GLP1 receptor agonists
85
Which two antihyperglycaemic classes should not be used together and why?
GLP1-receptor agonist (e.g. semaglutide) and DPP-4 inhibitors (e.g. linaglipin) - there is no additional glycaemic or other benefits (both work to increase GLP1 activity)
86
What are the options for the pharmacological management of hyperthyroidism with significant symptoms (e.g. atrial fibrillation, heart failure, marked weight loss, proximal myopathy) or biochemically severe hyperthyroidism (serum FT3 or FT4 more than 2.5 times the upper limit of normal)?
* First line: carbimazole 30-45mg PO, daily in 2-3 divided doses; adjust at 4-6 week intervals
* Second line: prophythiouracil 300-450mg, daily in 2-3 divided doses; adjust at 4-6 week intervals
87
What are the options for the pharmacological management of hyperthyroidism with mild symptoms or biochemically mild to moderate hyperthyroidism without symptoms?
* First line: carbimazole 10-20mg PO, daily in 2-3 divided doses; adjust at 4-6 week intervals
* Second line: prophythiouracil 100-200mg, daily in 2-3 divided doses; adjust at 4-6 week intervals
88
What can propylthiouracil be associated with, and therefore making it the second line choice for hyperthyroidism?
Severe liver injury
89
Indications for propylthiouracil to treat hyperthyroidsm?
* If carbimazole is not tolerated
* For maintenance therapy before conception and in the first trimester of pregnancy
* Thyroid storm
90
How long can TSH remain suppressed for after correction of hyperthyroidism?
Months. Therefore, base initial dose adjustment on serum T3 and T4 concentrations
91
What is an important side effect of antithyroid medications?
Agranulocytosis
* Most likely to occur in the first few months of therapy
* Advise to immediately stop the drug and seek medical assessment if they experience: acute malaise, fever or injection (typically severe pharyngitis)
92
What management of primary hyperthyroidism is available after pharmacotherapy?
* Radioiodine
* Thyroidectomy
93
Indications for radioactive iodine therapy in the management of primary hyperthyroidism?
* Severe Grave's disease with large goitre (e.g. causing tracheal obstruction or narrowing)
* Recurrent severe Graves disease
* Severe hyperthyroidism in an older patient
* Subclinical or mild hyperthyroidism in an older patient (usually associated with nodular thyroid disease)
* Hyperthyroidism due to a toxic adenoma or multinodular goitre
* Young patient with mild Graves disease whose TSH-receptor antibody remains elevated despite antithyroid drug therapy
94
Indications for thyroidectomy in the management of primary hyperthyroidism?
* Severe Grave's disease with large goitre (e.g. causing tracheal obstruction or narrowing)
* Recurrent severe Graves disease
* Hyperthyroidism due to a toxic adenoma or multinodular goitre
* Young patient with mild Graves disease whose TSH-receptor antibody remains elevated despite antithyroid drug therapy
* Thyroid cancer
95
What is the short synacthen test used for?
The assessment of primary adrenal insufficiency (Addison's disease)
96
What is the dexamethasone suppression test used for?
To diagnose Cushing's syndrome
97
Clinical manigestations of adrenal insufficiency?
* Chronic malaise
* Lassitude / lack of energy
* Fatigue (worsened by exertion and improved with bed rest)
* Weakness
* Anorexia
* Weight loss
* Gastrointestinal symptoms
* Hypotension
* Electrolyte abnormalities
* Hyperpigmentation - most characteristic physical finding that results in brown hyperpigmentation that is generalised but is most conspicuous in areas exposed to light (e.g. face, neck and back of hands) and areas exposed to chronic friction or pressure (e.g. elbows, knees, spine, knuckles, waist, midriff); pigmentation is also prominent in the palmar creases, where it escapes being worn away by friction
98
How is adrenal insufficiency diagnosed?
* Early morning low serum cortisol
* Short ACTH stimulation test/ short synacthen test - synacthen is a manufactured drug that acts like adrenocorticotrophic hormone by stimulating the adrenal gland to produce more cortisol ---- if the pituitary is not working for more than a few weeks, the adrenal glands will shrink and not be able to respond to the Synacthen
99
Characteristics of hyperosmolar hyperglycaemia?
* Severe hyperglycaemia
* Hyperosmolality
* Dehydration - usually severe
* Change in mental state
* Littele or no ketoacidosis
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What is a safe rate of fall of blood glucose concentration in the management of hyperosmolar hyperglycaemia?
A fall between 4-6 mmol/L per hour
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Describe the management of hyperosmolar hyperglycaemia state?
Investigation for and management of concurrent infection or conditions e.g. pancreattis, stroke, myocardial infarction
Identification and management of precipitating factors such as:
* Inadequate or omitted doses of antihyperglycaemic drug e.g. insulin
* Discontinuing antihyperglycaemic drugs
* Starting drugs that induce hyperglycaemia
Intravenous fluid replacement using sodium chloride 0.9%:
* Replace 50% of estimated fluid loss within the first 12 hours and the remainder in the following 12 to 36 hours
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Differentials for neuropathy?
* Diabetes
* Vitamin B12 deficiency
* Hypothyroidism
* Renal disease
* Alcohol
* Neurotoxic drugs
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How should screening for peripheral neuropathy be performed?
Assessing loss of sensitivity sensitivity to the 10g monofilament or loss of sensitivity to vibration at the dorsum of the great toe
104
Symptomatic management for painful peripheral neuropathy?
The following agents may be used alone or in combination:
* Anticonvulsants: pregabalin, gabapentin, valproate
* Antidepressants: amitriptyline, duloxetine, venlafaxine
* Topical nitrate spray
* Opioid analgesics
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What time period is folic acid supplementation required in conception and pregnancy?
1 month before conception to 3 months after conception
106
Why is oral glucose tolerance testing contraindicated in women who have undergone bariatric surgery?
Risk of dumping syndrome - diarrhoea, nausea, lightheadedness caused by rapid gastric emptying after consuming high amounts of refined sugar.
* As a result of the hyperosmolar environment, fluid shifts rapidly from the intravascular compartment to the small bowel lumen, causing distension, cramping, nausea, vomiting, diarrhoea, tachycardia, palpitations, diaphoresis
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What nutritional supplementation is required after bariatric surgery?
Multivitamin and multimineral - containing iron, folic acid, thiamine, vitamin B12
* Sleeve gastrectomy: two daily
* Roux-en-Y gastric bypass: two daily
* Adjustable gastric band: one daily
Citrated calcium - elemental calcium 1200-1500mg/day
Vitamin D - aim levels >30ng/mL - typically requiring 3000 units/day
Additional iron and vitamin B12 as required
108
When is high dose folic acid supplementation (5mg daily) indicated?
* Anti-convulsant medication use
* Diabetes mellitus
* Previous child or family history of neural tube defect
* BMI > 30
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Clinical features of Cushing syndrome?
Clinical features:
* Central weight gain (truncal obesity)
* Hair growth and acne in females
* Muscle weakness (especially proximal myopathy)
* Amenorrhoea/oligomenorrhoea (females)
* Thin skin/sponteanous bruising
* Polymyalgia/polydipsia (diabetes mellitus)
* Insomnia
* Depression
Signs:
* Moon face
* Buffalo hump (intrascapular fat pad)
* Supraslavicular fat pads
* Purple striae
* Large trunk and thin limbs: the "lemon with matchsticks" sign
* Facial plethora
* Hypertension
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Causes of Cushing syndrome?
* Iatrogenic-chronic corticosteroid use
* Pituitary ACTH excess (Cushing disease)
* Bilateral adrenal hyperplasia
* Adrenal tumour (adenoma, adenocarcinoma)
* Ectopic ACTH or (rarely) corticotrophin-releasing hormone (CRH) from non-endocrine tumours (e.g. oat cell carcinoma of lung)
111
Initial screening options for Cushing's syndrome?
* 1mg overnight dexamethasone suppression test
* Midnight salivary cortisol (measured twice)
* 24 hour urinary free cortisol (measured twice)
112
What is the recommended level of physical activity to reduce cardiovascular disease?
Atleast 30 minutes of moderate intensity physical activity (e.g. brisk walking) on 5 or more days of the week (atleast 150 minutes/week), including muscle strengthening exercise atleast twice per week
113
What needs to be considered before prescribing exercise/physical activity program?
* Special attention to exertion-induced symptoms: chest or abdominal discomfort, claudication or syncope
* T2DM: frequently have silent macrovascular disease
* HOCM: heavy weightlifting and high intensity aerobic exercise are not recommended
* Long QT syndrome: exercise may trigger a cardiac arrhythmia
* Proliferative retinopathy, and for 3 months after laser retinal treatment: vigorous exercise is contraindicated
* Exercise may be relatively contraindicated in patients with peripheral neuropathy, a history of recurrent falls or uncontrolled hypertension
* Foot assesment with emphasis on appropriate footwear
* Referral to an accredited exercise physiologist is recommended
114
What should be advised to patients on sulfonylureas or insulin about exercise?
* Check BGLs before and during exercise
* Check every 30-45 minutes during exercise
* Ideal pre-exercise BSL range is 5.0-13.9mmol/L
115
What is firstline treatment for gestational diabetes?
Insulin
116
Are ACEi contraindicated in pregnancy?
Yes
117
What common medication changes are required for diabetic pregnant patients?
* Metformin: discuss with specialist - may or may not continue - ideally should stop before labour
* Other antihyperglycaemic agents: stop
* Insulin: Discuss with specialist which type and regimen to start
* Lipid-modifying drugs: cease statins
* Anti-hypertensives: stop ACEi and ARB
118
Symptoms of hypoglycaemia?
* Adrenergic (autonomic): pale skin, sweating, shaking, palpitations, feeling anxious
* Neuroglycopenic (due to altered brain function): hunger, difficulty concentrating, confusion, inappropriate behaviour, loss of consciousness, seizures
119
How long can the risk of hypoglycaemia in a diabetic patient last for after exercise?
Can last for at least 12 hours or longer after exercise
120
Management of an episode of hypoglycaemia?
Unconscious and BGL < 4mmol/L:
* Administer 1mg glucagon IM/subcut (usually respond in 6 minutes if enough liver glycogen stores; can give a second glucagon dose 20 minutes after the first)
* If IV access: glucose 50% 20mL
Conscious and BGL < 4mmol/L (rule of 15):
* Provide 15g of quick-acting carbohydrate that is easy to consume e.g. half a can of regular non-diet soft drink
* Wait 15 minutes and repeat BSL
* Provide some longer acting carbohydrate if the patient's next meal is more than 15 minutes away (e.g. a sandwich; one glass of milk)
* Test glucose every 1-2 hours for the next four hours
121
What implication does a hypoglycaemic episode have on driving?
Advise not to drive for atleast 6 weeks while diabetes re-stabilisation is undertaken
122
Recommended dosing for oral iron supplementation?
Elemental iron 100-210mg daily PO
* Many iron-containing supplements from health food stores and pharmacies do not have enough elemental iron
123
Side effects of oral iron supplements?
* Nausea
* Bloating
* Constipation
* Diarrhoea
124
What substances/medications reduce the absorption of oral iron?
* Calcium supplements
* Proton pump inhibitors
* H2 receptor antagonosts
* Antacids
* Tea
125
HbA1c disconcordance: Causes of abnormally low HbA1c?
* Anaemia - haemolytic anaemia, haemoglobinopathies
* Recovery from acute blood loss
* Blood transfusions, iron transfusions
* Chronic blood loss
* Chronic renal failure
126
HbA1c disconcordance: Causes of abnormally high HbA1c?
* Iron deficiency anaemia
* Splenectomy
* Alcoholism
127
Advice for a diabetic patient about driving?
* Check BSL before driving (aim > 5mmol/L)
* Carry a blood glucose meter when going for a drive
* Carry fast acting and longer acting carbohydrate foods or drinks as extra supplies in the car
* Wear identification of having diabetes
128
Renal dose adjustment for metformin XR?
* eGFR > 60mL/min: maximum 2g daily
* eGFR 30-60mL/min: maximum 1g daily
129
Renal dose adjustment for sitagliptin?
* eGFR > 50mL/min: maximum 100mg daily
* eGFR 30-50mL/min: maximum 50mg daily
* eGFR <30mL/min: maximum 25mg daily
130
Renal dose adjustment for empagliflozin?
* eGFR > 30mL/min: maximum 25mg daily
131
Indications for dose reduced apixaban?
* Age: 80 or older
* Weight: 60kg or less
* Serum creatinine: 133 or more
132
Which diabetic patients need annual screening for retinopathy instead of the usual two years?
* People with duration of diabetes > 15 years
* Suboptimal glycaemic control (HbA1c > 8%)
* Systemic disease - poorly controlled hypertension, lipids; other diabetes complications; foot ulcers
* ATSI
* People from a non-English speaking background
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Which patient populations are at high risk of cardiovascular disease (and therefore, likely need a statin and anti-hypertensive)?
* Diabetes and age > 60yo
* Diabetes with microalbuminuria (urine ACR >2.5mg/mmol for men, >3.5mg/mmol for women)
* Moderate or severe CKD (persistent proteinuria or eGFR < 45mL/min)
* A previous diagnosis of familial hypercholesterolaemia
* Systolic BP >180 or diastolic BP >110
* Serum total cholesterol > 7.5mmol/L
134
What do you measure when suspecting type 1 diabetes?
* Glutamic acid decarboxylase (GAD) antibody
* Insulinoma antigen-2 (IA2) antibody
135
What level of hyperglycaemia may require temporary insulin and hospital admission?
Hyperglycaemia >/= 15mmol/L
136
What are some risk factors/triggers for developing euglycaemic diabetic ketoacidosis in patients receiving SGLT2 inhibitors?
* Intercurrent illness
* Surgery
* Reduced food and fluid intake
* Reduced insulin doses
* Previous ketoacidosis
* Missed diagnosis of Type 1 diabetes mellitus or Latent Autoimmune Diabetes of Adulthood
* History of alcohol abuse
137
Symptoms of euglycaemic diabetic ketoacidosis?
* Abdominal pain
* Nausea
* Vomiting
* Fatigue
* Metabolic acidosis
138
Management principles of diabetic ketoacidosis?
Progressively restoring acid-base balance and clear the body of excessive ketones. This involves:
* Correction of fluid loss with aggressive fluid replacement
* Correction of hyperglycaemia and supression of ketone production with insulin (with the addition of a glucose infusion when the blood glucose concentration has fallen)
* Correction of electrolyte disturbances, particularly potassium
* Investigation and management of concurrent conditions
139
What initial investigations are required for the work up of an incidental adrenal mass?
* 1mg overnight dexamethasone suppression test / midnight salivary cortisol / 24 hour urinary free cortisol - Cushing's syndrome
* 24-hour urinary metanephrines and catecholamines / plasma metanephrines- phaeochromocytoma
* If hypertensive: plasma aldosterone-renin ratio - primary aldosteronism
* Dedicated adrenal CT - benign vs malignant lesion
* Early morning cortisol and ACTH - adrenal insufficiency
140
Differentials for functional pituitary adenomas?
* Prolactinomas - causing hyperprolactinaemia
* Growth hormone-secreting adenomas - causing acromegaly
* Adrenocorticotrophic hormone (ACTH)-secreting adenomas - causing Cushing's disease
141
Clinical features of hyperprolactinaemia?
Females:
* Menstrual disturbance
* Infertility
* Galactorrhoea
Males:
* Erectile dysfunction
* Diminished libido
Children:
* Pubertal delay
142
Differentials for hyperprolactinaemia?
* Prolactinoma
* Disruption of the pituitary stalk (e.g. trauma, surgery, tumour)
* Pregnancy
* Hypothalamic disorder: tumour (craniopharyngioma, glioma), infiltration (sarcoidosis), radiotherapy
* Drugs: antipsychotics, oral contraceptive pills, cannabis, methyldopa, metoclopramide, domperidone, opioids, SSRIs, TCA
* Systemic disorders: hypothyroidism, renal disease, liver failure, epileptic seizures
* Neurogenic cause: breast stimulation and lactation, chest wall trauma or lesion, stress
* Pseudohyperprolactinaemia
143
Management of prolactinoma?
Dopamine agonist therapy
* First line: Cabergoline 0.5mg weekly PO, in one or two doses; increasing according to response by 0.5mg in monthly intervals, up to a maximum total weekly dose of 3mg
* Second line: bromocriptine
* Third line: Quinagolide
Microprolactinoma in a woman of childbearing age who does not desire fertility and who does not have distressing symptoms (e.g. galactorrhoea):
* COCP
Pituitary surgery - for patients who cannot tolerate or are resistant to dopamine agonists
Radiotherapy - for prolactinomas that continue to expand despite surgical and drug therapy
144
What has withdrawal of denosumab been associated with?
Multiple spontaneous vertebral fractures
145
What's the longest denosumab can be delayed?
4 weeks or 7 months from the last dose
146
What is your approach to ceasing denosumab?
Start bisphosphonate (preferably oral alendronate) no more than 6 months after the last dose of denosumab, and continue for 12 to 24 months
147
Which patients are at high risk of minimal trauma fracture?
* Age 75 years and older
* Previous hip or vertebral fracture
* Minimal trauma fracture after starting treatment (after excluding other causes of fracture)
* Hip T score of -2.5 or lower
148
When is raloxifene 60mg daily PO (selective oestrogen receptor modulator) indicated for osteoporosis management?
Women under 60 with spinal osteoporosis
* Reduces postmenopausal bone loss
* Doesn't reduce non-vertebral (including hip) fracture risk
* Reduces risk of breast cancer
* Increases risk of VTE, hot flushes
149
In what clinical scenarios should Aboriginal, Torres Strait Islander, Maori and Pacific Islander children and adolescents be screened from the age of 10 or at the onset of puberty (whichever is earlier)?
* BMI at or above 85th centile or waist circumference to height ratio more than 0.5
* Maternal history of diabetes or gestational diabetes during the child's gestation
* First degree relative with Type 2 diabetes
* Signs of insulin resistance (i.e. acanthosis nigricans)
* Other conditions associated with obesity and metabolic syndrome (ie. elevated blood pressure, dyslipidaemia, nonalcoholic fatty liver disease, polycystic ovary syndrome, small for gestational age)
* Use of psychotropic drugs
150
Methods of screening for diabetes in children and adolescents?
* HbA1c
* OGTT - if cannot be done, repeat HbA1c in 6 months
151
What needs to be checked while on metformin?
Vitamin B12 - as metformin can reduce vitamin B12 absorption and result in deficiency
152
Common adverse effects from anabolic-androgenic steroids?
* Anabolic-androgenic steroid induced hypothalamic pituitary gland suppression leading to testosterone deficiency (can take several months to resolve)
* Gynaecomastia (increased estradiol)
* Injection-related harms e.g. scarring and abscesses
* Steroid dependence
* Masculinisation for female users (potentially irreversible) - masculine physique, voice deepening, hirsutism, amenorrhoea, infertility
153
Which population groups using anabolic-androgenic steroids need particularly close monitoring?
Due to high risk of irreversible complications even with short term use:
* Young person < 21
* Women
154
Symptoms of anabolic-androgenic steroid induced hypothalamic pituitary gland suppression leading to testosterone deficiency?
* Depressed mood
* Fatigue
* Sleep disturbance
* Loss of libido
* Anxiety
* Reduced semen production in men
* Amenorrhoea in women
155
What are the non-reversible effects of anabolic testosterone on women?
* Deepened voice
* Enlarged clitoris
* Male pattern balding
156
