Endo5 Flashcards
(43 cards)
What are the trimester by trimester TSH target ranges in pregnancy?
first trimester 0.1–2.5 mIU/L
second trimester 0.2–3.0 mIU/L
third trimester 0.3–3.0 mIU/L
How would you manage overt hypothyroid or a very elevated TSH in pregnancy?
Overt hypothyroidism (OH) TSH \>2.5 with low T4
or TSH >10 irrespective of T4 level
Treatment of OH with levothyroxine is recommended. The goal is to normalise maternal serum TSH values within the trimester specific pregnancy reference range. Commencement of thyroxine while awaiting specialist review is generally appropriate (eg. 50–100 µg/day)
What is subclinical hypothyroidism in pregnancy? How would you manage it?
TSH between 2.5–10 with normal T4 levels
Evidence is variable as to the effect of SCH on pregnancy and the fetus<br></br>At this stage, the associated risk of obstetric complications has been more clearly demonstrated than the risk of neurocognitive deficits in the fetus. In addition, TPO Ab positivity may in itself be associated with fetal miscarriage and levothyroxone intervention in TPO antibody positive women with SCH may be beneficial
Options include treatment with levothyroxine to normalise maternal serum TSH or 4 weekly monitoring of TSH
Obtain TPO Ab levels while awaiting specialist review
How would you manage a patient with KNOWN (pre-existing) hypothyroidism in pregnancy?
Levothyroxine adjustment should be made as soon as pregnancy is confirmed
Aim to normalise TSH levels (ie. TSH <2.5) by increasing levothyroxine by two additional tablets weekly or by 25–30% and monitor thyroid function test
4 weekly
This adjustment can also be made preconception in women planning pregnancy
How do you rate severity of Vitamin D deficiency?
mild
30 to 49 nanomol/L
moderate
12.5 to 29 nanomol/L
severe
lower than 12.5 nanomol/L
Who should have their Vitamin D measured?
people at increased risk of vitamin D deficiency, such as those who:
are institutionalised or housebound (eg chronic illness, disability)
wear _clothing that covers most of the skin (_eg for cultural or occupational reasons)
have dark skin (Fitzpatrick skin types V and VI [Note 2])
have a medical condition (eg end-stage liver disease, kidney disease, hyperparathyroidism) or take a drug (eg r_ifampicin, antiepileptics_) that affects vitamin D metabolism and storage in the liver
have fat malabsorption (eg due to cystic fibrosis, coeliac disease or inflammatory bowel disease) or gastrectomy.
Who should be treated with Vitamin D?
Vitamin D supplementation is recommended for people who:
- have uncomplicated moderate or severe vitamin D deficiency (serum 25-hydroxyvitamin D concentration lower than 30 nanomol/L), particularly if symptomatic
- are starting drug therapy for osteoporosis and have a serum 25-hydroxyvitamin D concentration lower than 50 nanomol/L (see also Vitamin D and osteoporosis)
- have osteomalacia or rickets.
Treatment of adult with mild vitamin D deficiency?
- consider lifestyle measures to increase exposure to sunlight first line.
If supplementation is preferred, use:
colecalciferol 25 to 50 micrograms (1000 to 2000 international units) orally, daily
Ensure anyone taking vitamin D also has 1300mg of Calcium in their diet.
Treatment of moderate to severe vitamin D deficiency?
colecalciferol 75 to 125 micrograms (3000 to 5000 international units) orally, daily for 6 to 12 weeks,
followed by 25 to 50 micrograms (1000 to 2000 international units) orally, daily.
What are three distinct forms of Diabetic retinopathy?
- Macular oedema - which includes diffuse or focal vascular leakage within the macula
- DR - caused by microvascular changes
- Retinal capillary non perfusion
DR - non proliferative - micro anuerysms, retinal haemorrhages, malformation and tortuous vessels - may be asymptomatic
proliferative - abnormal vessel growth on the optci disc or retina
What methods can be used to screen for diabetic retinopathy?
Colour fundus photography with interpretation by trained reader
Digital fundus photograpy
Direct opthalmoscopy or indirect slit lamp funduscopy through a dilated pupil.
What should you assess when looking at a diabetics vision?
- Visual acuity changes - due to refractory errors, (can use pinhole test to determine if there is a refractory error (blurring purely due to Ref Error is corrected by the pinhole).
- Cataracts (mainly with poor diabetic control and ketones) acute cataracts can have a snowflake appearance
- Fundoscopy through a dilated pupil (+/- retinal photography) - signs of DR, optic disc - eg glaucoma and ischaemic optic neuropathy
- Maculopathy - fundoscopy, retinal photography and surrogate markers eg fluroscein angiography
How would you describe the evolution of Diabetic retinopathy?
- Thickening of retinal basement membrane leads to a)microaneurysm formation and b) microvascular haemorrhages (dot and blot haemorrhages)
- Macrophages mop up the blood and the residual lipids showing up as hard exudates (defined border)
- Microinfarcts occur in occluded vessels - cotton wool spots (contain axoplasmic debris)
- Worsening retinal perfusion leads to neovascularisation
- These new vessels can burst causing vitreous haemorrhage or they can cause traction on the retinal pigment epithelium and lead to retinal detachment.
How is diabetic retinopathy managed?
- Photocoagulation
- For Macular oedema Anti VEGF and/or intravitreal steroids ar
What impact would newly diagnosed diabetic retinopathy have on your choice of lipid lowering therapies?
Fibrates should be considered in established diabetic retinopathy as they can slow deterioration (vs statins).
Which patients need urgent referral to an opthalmologist?
Patients with Sight threatening DR
- Macular oedema, proliferative DR, or severe non proliferative DR
How often should patients with Diabetic retinopathy be screened?
Most adults - EVERY 2 YEARS
Children from age of 9 - every 5 years
Certain high risk groups - yearly
- ATSI*
- Non english Speaking*
- Poor control (HBA1c over 8%)*
- Systemic disease - COMPLICATIONS micro/macro*
- Established disease - over 15 years!*
What are the minimum Medicare cycle of care requirements for a diabetic patient
Minimum
HbA1c Every year
Comprehensive eye examination Every 2 years
Weight, height, body mass index Every 6 months
Blood pressure Every 6 months
Foot examination Every 6 months
Total cholesterol, TG, HDL, cholesterol Every year Microalbuminuria Every year
Self care education Diet review Physical activity review Smoking status review Medication review
Specific examination of the diabetic foot should include?
• palpate pulses • assess level of sensation (eg neuropathy/signs of ischaemia)• assess for presence of foot deformity • assess for presence of nail deformity • assess for presence of active lesion.
How would you manage a patient with a diabetic foot ulcer?
M Metabolic/Medication
Optimise associated medical conditions, such as hyperglycaemia, hyperlipidaemia and hypertension.
A Assessment Examine diabetic foot ulcer and grade according to PEDIS classification (perfusion, extent [size], depth, infection and sensation).
D Debridement Surgically debride diabetic foot ulcer with necrotic or unhealthy tissue.
A Antibiotics Treat patient with diabetic foot ulcer with appropriate antibiotics on the basis of the severity of the infection.
D Dressing Perform frequent wound care with adequate dressings.
O Offloading Advise patient with diabetic foot ulcer to wear appropriate offloading shoes to reduce plantar pressure.
R Referral Facilitate early referral to a multidisciplinary diabetic foot team for optimal management of diabetic foot ulcer.
E Education Education on foot self-care should be provided to patients with diabetic foot ulcer or associated risk factors.
How often should diabetic neuropathy be assessed?
Yearly in all adults.
Kids - 5 years after diagnosis and then yearly
Common Complications of diabetic neuropathy?
Management of hypopituitarism?
Involves replace of Glucorticoids, Thyroid hormone, Gonadal hormones, GH and arginine vasopressin
NB: Do not start thyroxine before replacing glucocorticoids – or you could induce an adrenal crisis
