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Long case clinical skills > Endocrine long case > Flashcards

Endocrine long case Flashcards

1
Q

Endocrine questions - thyroid/pituitary

A

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

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2
Q

Endocrine questions - Diabetes symptoms and background

A

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

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3
Q

Complications of obesity

A

Stroke

Hypertension

Dyslipidaemia

T2DM

Steatohepatitis

Gout/OA

Coronary artery disease

Atrial fibrillation

OSA/OHS

GORD

DVT

PCOS/hirsuitism

Depression

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4
Q

Obesity history

A

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

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5
Q

Medications that contribute to weight gain

A

Insulin

Glucocorticosteroids

Sulfonylureas

olanzepine/antipsychotics

thiazolidazonides

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6
Q

Endocrine differentials for obesity

A

Cushing’s syndrome

Pituitary tumour

Myxoedema

Congenital - Laurence-Moon-Beidl, Beckworth-Wedleman,

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7
Q

Initial management of obesity

A

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

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8
Q

20 Side effects of glucocorticosteroids

A

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

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9
Q

Glucocorticosteroid history

A

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

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10
Q

History for osteoporosis

A

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

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11
Q

Osteoporosis investigations

A

DEXA

Vitamin D (1,25 dihydroxy), calcium, magnesium phosphate

UEC creatinine

Serum testosterone

SPEP

24hr cortisol

TFT

serum N-telopeptide, urinary deoxypridinoline

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12
Q

Causes of secondary diabetes mellitus

A

Medications - glucocorticoids, diazoxide, thiazides, OCP

Cushing’s disease

Acromegaly

PCOS

Pancreatic insufficiency (chronic pancreatitis, Cystic fibrosis)

Gestation

Haemochromatosis

Ataxia telangiectasia

Glucagonoma/vipoma

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13
Q

Examination for diabetes

A

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)

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14
Q

Management goals in diabetes (new dx)

A

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

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15
Q

Management of Osteoporosis

A

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)

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16
Q

MEN syndromes

A

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
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17
Q

Risk factors for T2DM

A
  1. Prior cardiovascular, peripheral vascular or cerebrovascular event
  2. Impaired fasting glucose or impaired glucose tolerance
  3. Age > 35 and Chinese, Indian or Pacific Islands
  4. Age > 40 and HTN or BMI > 40
  5. Gestational diabetes mellitus
  6. Polycystic ovarian syndrome
  7. Antipsychotics
  8. Aboriginal or Torres Strait Islanders
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18
Q

Clinical indicators of undiagnosed or poorly controlled DM

A
  1. polyuria, polydipsia, lethargy, polyphagia
  2. Recurrent bacterial or fungal infections
  3. Blurred vision
  4. New or progressive sensory neuropathy
  5. Poor wound healing
  6. Weight loss
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19
Q

Initial management of confirmed IFG, IGT or diabetes mellitus

A
  1. Lifestyle modification
  2. Allied health referrals
  3. BP, BMI and lipid assessments
  4. Waist circumference
  5. Depression/anxiety screen (PAID tool)
  6. Yearly microvascular complications screen
  7. Influenza and pneumococcal vaccinations
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20
Q

Additional general management on diabetes diagnosis

A

Notify RTA

Register with national diabetes services scheme

Assess CAD risk

Assess modifiable risk factors

Depression/anxiety screen

Referral to diabetes teams

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21
Q

Clinical signs of glucose intolerance, T2DM and/or metabolic syndrome

A

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

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22
Q

Disadvantages of HbA1c

A

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

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23
Q

Tests for T1DM

A

Insulinoma antigen 2 (IA-2)

Glutamic acid decarboxylase (GAD)

C peptide level

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24
Q

Indicators of adequate DM self management

A

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

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25
Q

Monogenetic diabetes characteristics

A

Onset before 25yrs of age

Lower level hyperglycaemia

Non-ketotic diabetes mellitus

Autosomal dominant inheritance

Primary defect in function of beta pancreatic cells

26
Q

New diagnosis of T1DM

A

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

27
Q

Prevention of diabetes mellitus

A

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

28
Q

Indications for self monitoring of blood glucose

A

Oral hypoglycaemic agents or insulin

Hyperglycaemia from intercurrent illness

Pregnancy and pre-pregnancy planning

Any new treatment changes to monitor effect

Unreliable HbA1c monitoring

29
Q

Members of the DM multidisciplinary care team

A

Diabetic educator

Podiatrist

GP and endocrinologist

Dentist

Community care nurse

Aboriginal care worker and social worker

Pharmacist

Ophthalmologist and optometrist

Dietician

Psychologist

Exercise physiologist

30
Q

Poor glycaemic control factors

A

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

31
Q

Insulin dosing in the community

A

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>

<p>Reduce by 2 units 4<bsl>

<p>Reduce by 4 units if BSL&lt;4 on any day</p></bsl></p>

</bsl>

32
Q

Diabetic foot exam

A

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)

Ulce​rs (neuropathic, venous and arterial)

Neurological exam (sensation to 10g monofilament, proprioception and vibration sense, power, reflexes)

33
Q

Diabetic visual exam

A

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

34
Q

Management of T2DM algorithm

A

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

35
Q

Factors on deciding on stringent versus liberal control

A

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)

36
Q

Clinical considerations in deciding oral T2DM therapy

A

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

37
Q

Amputation risk assessment

A

Risk increases with one or more factors

  • PVD
  • Neuropathy
  • Previous ulceration

Aboriginal and Torres Strait Islander are high risk regardless

38
Q

Management of resistant T2DM on third line agent

A

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

39
Q

Diabetic foot amputation risk management

A

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)

40
Q

High cardiovascular risk groups

(>15% 5 year risk)

A

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

41
Q

Texas wound grading system

A

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

42
Q

Factors requiring urgent foot multidisciplinary team

A

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

43
Q

Management of high risk CVD

A

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

44
Q

Management of intermediate risk CVD (10-15%)

A

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
45
Q

Management of low risk CVD <10%

A

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

46
Q

Risk factors for progression of diabetic retinopathy

A

Poor glycaemic control

Hypertension

Duration diabetes >10 years

Pre-existing diabetic retinopathy

Pregnancy

Microalbuminuria

Dyslipidaemia

Anaemia

47
Q

Types of autonomic neuropathy

A

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

48
Q

Diabetic neuropathy score

A
  1. Ataxia/unsteadiness walking
  2. Burning, aching pain or foot tenderness
  3. Prickling sensations in feet
  4. Numbness legs or feet

>1 - neuropathy present

49
Q

Management of diabetic nephropathy

A

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

50
Q

General risk of CKD in the following populations

A

Diabetes

Hypertension

Established CVD

Family history of CKD

Obesity

Smoking

Aboriginal or Torres Strait Islander aged >30

51
Q

Indications for renal specialist referral

A

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

52
Q

Diabete medication adjustment in CKD, AKI, other precautions

A

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

53
Q

Driving advice

A

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

54
Q

Factors influencing glycaemic control end of life

A

Stress response to sustained illness

Organ failure

Malignancy

Chemotherapy

Steroids

Frequent injections

Poor appetite

Poor nutrition

Cachexia

Dehydration

Difficulty taking meds

Weight loss

55
Q

Glycaemic goals in palliative care

A

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

56
Q

Conditional driving requirement

A

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
57
Q

Sick day management for DM

A

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
58
Q

Diabetes and pregnancy

A

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

59
Q

Pharmacotherapy for Obesity

A

Short term < 12 weeks - phentermine (sympathetic amine)

Longer term > 12 weeks

  • Orlistat
  • Phentermine/topiramate combination
  • Lorcaserin (seratonin agonist)
  • Naltrexone/bupropion
  • GLP1RA - liraglutide
60
Q

Indications and considerations for obesity pharmacotherapy

A

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

Long case clinical skills (12 decks)

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