Diabetes and endo

Question 1

Dx T1DM

Answer 1

raised random BM >11.1
urine dip - glycosuira and ketones
fasting BM >7

Question 2

Mx T1DM

Answer 2

Insulin therapy:
multiple daily injection basal bolus ( go to)- long acting insulin and short acting insulin before meals
continuous subcutaneous insulin infusion - programmable pump that delivers continuous supply
1, 2 or 3 insulin injections per day - short + long acting mixed together

HbA1C - at least 4 times per year, <48 (6.5%)
5 capillary BM per day (increased in times of stress - ie illness)
real time continuous glucose monitoring if:
frequent severe hypos
impairment of awareness of hypos (cause they faint)
can’t recognise or communicate symptoms of hypo

EXPLAIN HOW TO IDENTIFY DKA
monitor for complications from 12 years

Question 3

causes of hypos

Answer 3

in neonates common as they have high energy requirements

insulin excess - overtreated, medication (SULPHONYLUREA), insulinoma, AI
w/o insulin excess: liver disease (glycogen stores), not eaten
reactive/non-fasting - galactosemia, maternal diabetes

Question 4

mx of hypo

Answer 4

mild-moderate - oral glucose (lucozade), check BMs in 15 mins, as symptoms improve give long acting complex carbs
severe -
if in hospital give IV 10% glucose (5ml/kg bolus then steady)
if not in hospital - IM glucagon or conc glucose gel (seek help if no improvement in 10 mins)

Question 5

causes of hypothyroidism

Answer 5

maldescent of thyroid
iodine deficiency
TSH deficiency
inborn hormone problems

Question 6

How does congential hypothyroidism present

Answer 6

faltering growth
feeding problems
jaundice
constipation
pale skin 
hoarse cry

Question 7

Mx hyperthyroidism

Answer 7

PTU or CBZ (causes neutropenia - safety net about going to doctors if sore throat or fever)
beta-blockers
2nd line - radio iodine or surgery

Question 8

actions of PTH

Answer 8

Increase bone resorption
increase vit d metabolism to increase gut absorption
increase renal reabsorption of calcium

Question 9

biochemistry of hypoparathyroidism

Answer 9

low calcium
low vit d
high posphate
normal ALP

Question 10

cause of hypoparathyroidism

Answer 10

diGeorge - no thymus no parathyroid

Question 11

biochemistry of pseudohypoparathyroidism

Answer 11

low calcium
high posphate
normal or elevated PTH

Question 12

features of children with pseudohypoparathyroidism

Answer 12

short
fat
short metacarpals
teeth enamel hypoplasia

Question 13

Mx of hypocalcaemia

Answer 13

acute - IV calcium glauconate

chronic - oral calcium, vit d analogues (avoid hypercalciuria as it can causes stones - monitor urine when on these)

Question 14

Mx hypercalcaemia

Answer 14

rehydrate
diuretics (to remove excess Ca)
bisphosphonates

Question 15

Presentation of CAH

Answer 15

virilisation of female
boys have large penis
develop secondary sexual characteristics early
salt losing (addisonian) crises

70-80% have failure of aldosterone production too (high potassium low sodium)

Question 16

Dx CAH-

Answer 16

17ahydroxyprogesterone massively raised 
if salt losing:
low sodium
high potassium
metabolic acidosis
hypoglycaemia

Question 17

Mx CAH

Answer 17

affected females can get surgery

acute salt losing crisis:
IV saline, IV hydrocortison, IV dextrose

Long term:
life long glucocorticoids to suppress ACTH (increase at times of stres)
MR if salt loss
monitor growth

Question 18

Mx precocious puberty

Answer 18

gonadotrophin dependent:
GnRH agonist suppress puberty via negative feedbacl
GH therapy can stunt growth

gonadotrophin independent:
CAH - adjust aromatase inhibitors
McCune albright - ketoconzole, GnRH agonist, aromatase inhibitors

Question 19

mx of delayed puberty

Answer 19

boys:
1 observation
2 3-6 months testosterone

girls:
1 observation
2 3-6 months oestrogen

Question 20

causes of disorders of sexual development

Answer 20

excessive androgens in females (CAH)
inappropriate response to androgens in males:
can’t make DHT (aromatase deficiency), can’t respond to androgen (androgen insensitivity)
hermaphroditism - presence of XX and XY cells

If ambiguous genitalia measure sex hormons, adrenal hormones and karyotype
US internal structures

Question 21

Mx DKA

Answer 21

When DKA diagnosed record -
vital signs, level of consciousness, dehydration status, body weight, hx of nausea or vom
measure -
pH + pCO2 (VBG), U+E, plasma bicarbonate

Fluid and insulin therapy
can give oral fluids and SC insulin if child is ALERT, not nauseous, vomiting or dehydrated
otherwise give IV

start IV insulin (0.05-0.1 units/kg/hr) infusion 1-2 hours after beginning IV fluid therapy in children

if no response after 6-8 hours increase insulin

IV fluid bolus:
shock - 20ml/kg saline
not shock - 10ml/kg
add this to maintenance fluids

consider catheter to monitor urine

Question 22

How do you work out fluid deficit

Answer 22

5% fluid deficit in mild to mod DKA pH >7.1
10% fluid deficit in severe DKA pH <7.1

fluid deficit volume = % deficit x weight x 10

Question 23

what are the maintenance fluid requirements in DKA

Answer 23

<10kg - 2ml/kg/hr
10-40 - 1ml/kg/hr
40+ - 40ml/hr

lower than usual because of risk of cerebral oedema

Question 24

which fluids should you use in DKA

Answer 24

0.9% saline until glucose <14
0.9% saline + 5% glucose when glucose drops below 14
GIVE FLUIDS WITH 40MMOL/L KCL

Question 25

When do you change from IV to SC insulin

Answer 25

Change when child is alert, not nauseous or vomiting, and can take oral fluids
Start SC insulin 30 minutes before IV finishes
Start pump 60 mins before IV finishes

Question 26

monitoring in DKA

Answer 26

monitor BM, vital signs, fluid output, level of consciousness (mod. GCS) ever hour
NB - in children <2, severe DKA, or at high risk of cerebral oedema monitor GCS and HR every 30 mins

continuous ECG if on IV to check hypokalaemia (ST depression, flat p waves)

Question 27

How to manage cerebral oedema in DKA

Answer 27

mannitol or hypertonic NaCl

Question 28

How to manage hypokalaemia in DKA

Answer 28

<3mmol/L
stop infusion
discuss w/ paediatrc crit care consultant

Question 29

what to discuss with DKA parents

Answer 29

factors that led to episode
how to manage intercurrent illness (viral illness)
arrange to see diabetes specialist