Endocrinology Flashcards

Question

diabetes targets

Answer 1

Individualise targets and avoid hypoglycaemia HbA1c: - general = <7% - short duration without medication = <6% - with complications = 8% Blood glucose: - fasting = 4-8mmol/L - post prandial = <10mmol/L

Answer 2

Glycaemic control usually assessed by HbA1c. Ketone monitoring is usually unnecessary, save SGLT-2 inhibitors when sick. Blood glucose self monitoring (with a glucose strip and blood glucose monitor) - used when treated with insulin or sulfonylureas. - can be used in absence of these medications to educate about effect of dietary intake and exercise, to assist with reinforcement and motivation, when sick or pre-surgery, when taking drugs (eg. corticosteroids) or with major lifestyle changes Continuous glucose monitoring can be used in patients using insulin.

Answer 3

Decrease in insulin, increase in counter-regulatory hormones (glucogon, cortisol, catecholamines, growth hormone). Particularly balance between insulin and glucagon. Low insulin and high glucagon decreases hepatic level of fructose-2, 6-bisphosphate, thus increasing the activity of fructose-1, 6-bisphosphatase and decreasing the activity of phosphofructokinase-1. In addition, the ratio glucagon to insulin increases the activity of phosphoenolpyruvate carboxykinase and decreases the activity of pyruvate kinase. This shifts the handling of pyruvate towards gluconeogenesis and away from glycolysis. There is also an increase in glycogenolysis and the low levels of insulin reduces expression of the Glut-4 glucose transporter, which decrease glucose uptake. At the same time, there is an increase in lipolysis and beta oxidation, forming Acetyl Coa, available as an energy substrate. Overtime there is a buildup in ATP, decreasing flux through the electron transport chain and increasing available NADH which inhibits the krebs cycle and increases levels of acetyl coa. Acetyl CoA does not inhibit beta oxidation, so it continues to build up and is diverted towards ketogenesis, with the formation of acetoacetate, which can be converted to D-beta-hydroxybutyrate or acetone. At physiological pH, these ketone bodies exist as keto acids and are neutralised by bicarbonate. As bicarb is depleted, ketoacidosis develops.

Answer 4

Provisional: - HHS or DKA due to polydypsia, polyuria - HHS favoured due to absence of nausea, vom, abo pain and most prominent feature is drowsiness Encephalopathies - hypernatraemic - hypogylcaemic (insulin) - septic - electrolyte deficiency Encephalitis Meningitis Drugs and alcohol - intoxication - withdrawal (wernicke's) - anticholinergic effects Unlikely: - sagittal sinus thrombosis - subacute subdural - brain tumour - non-dominant hemisphere stroke - depression - dementia

Answer 5

- FBC (anaemia in hypothyroid, hypocortisol, hypogonadism) - EUC (hyponatraemia in ACTH deficiency) - serum prolactin - insulin like growth factor 1 - 24 hour urinary free cortisol - late-night salivary cortisol Consider - LH, FSH (gonadotroph) - TSH and T4 - beta HcG for suspected germ cell tumour Imaging MRI (with gadolinium enhancement) - causes of pituitary mass usually take up gadolinium more than surrounding tissue but less than normal. - If mass is seen as seperate from rest of pituitary it is unlikely to be adenoma. - cysts may be enhanced in T2 and hypointense T1. - meningioma = homogeneous uptake - craniopharyngioma = solid and cystic with enhancement of solid

Answer 6

Symptomatic (polyuria, polydypsia, impaired vision, DKA HHS) with random >11.1 HbA1c 6.5% Fasting plasma glucose >7.0 2hr glucose tolerance >11.1 Impaired: - fasting plasma 5.6-6.9 - glucose tolerance 7.8-11 - HbA1c 5.7-6.4 Results need to be repeated

Answer 7

For both: -family hx Type 2: - older age - overweight - physical inactivity - HTN - dyslipidaemia - CVD - racial - gestational diabetes - pre diabetes - polycystic ovary syndrome

Answer 8

Typical symptoms -polyuria, polydypsia, fatigue, weakness, nocturia Acute complications - DKA (nausea, vom, abdo pain) - HHS (significant fatigue) ``` Chronic complications (Type 2) -blurry vision, paresthaesias, infections (skin, UTI), weight loss ``` Risk factors Past MHx - hospitalisation (DKA, HHS) - presence of complications - hypoglycaemic episodes - CVD Medications -use, compliance, efficacy, side effects Psychosocial - smoking - diet - functional impairment, distress

Answer 9

Exam - full cardiovascular including peripheral vascular - examination of the feet, including assessment of ankle reflexes, pulses, vibratory sensation, and monofilament touch sensation - dilated retinal examination - skin for infections and acanthosis nigricans

Answer 10

Goals - restore circulating blood volume - inhibit lipolysis, gluconeogenesis and ketogenesis - address precipitating factors - re-establish normal physiology and electrolyte balance Issues - acidosis - dehydration - hypokalaemia (hyper) Fluids IV - start early - resuscitate, restore, maintain Insulin IV - infusion @ o.1unit/kg/hr - don't drop BG >5mmol/L (cerebral oedema) - aim for 10-15mmol/L - begin 5% glucose infusion, maintain insulin infusion - goal is to address acidosis, not hyperglycaemia - hyperglycaemia corrected in 4-8hrs but acidosis may take 24 Potassium - total body depletion - insulin and correction of acidosis drives K into cells - need to provide K once urinary flow is established ``` Monitoring -hourly BG, ketones, VBG (pH), electrolytes (Na, K) until -patient alert -ketoacidosis reversed -tolerating oral fluids ``` ``` Education -review precipitating events -symptoms and triggers of DKA -self management during illness or reduce fluid intake check BG and ketones often maintain hydration present to medical attention early ```

Answer 11

approx 1% mortality -usually due to precipitant DKA related - gastrointestinal bleeding - oedema (pulmonary) Treatment related - oedema (cerebral) - Thrombosis (venous) - Hypoglycaemia, hypokalaemia

Answer 12

Decrease in insulin, increase in glucagon and other counter-regulatory hormones (cortisol, catecholamines, growth hormone). Decrease in insulin is less than DKA. Insulins inhibition of lipolysis is far greater than inhibition of gluconeogenesis, which is thought to explain absence of ketogenesis in HHS. Decrease in hepatic fructose 2, 6-bisphosphate, which increases the activity of fructose-1, 6-bisphosphatase and decreases the activity of phosphofructokinase-1. Likewise, there is an increase in activity of phosphoenolpyruvate carboxykinase, and decrease for pyruvate kinase. Overall there is a shift in the handling of pyruvate towards gluconeogenesis and away from glycolysis. At the same time, there is decrease expression GLUT-4, decrease glucose uptake, and an increase in glycogenolysis. Overall, marked increase in blood glucose, increasing plasma osmolality. This draws water out of cells and increases ECF volume. Initially, this dilutes the electrolyte concentration in the blood. There is an osmotic diuresis of relatively electrolyte deficient water, thus increasing plasma osmolality.

Answer 13

``` Bedside: glucose -elevated (>45 mmol/L) ABG/VBG -mild acidosis (normal anion gap) -bicarb may be marginally low Dipstick -glucosuria -ketones may be present Capillary ketones -prefered -may be present (but low) ``` ``` Bloods FBC -leukocytosis EUC and CMP -elevated urea and creatinine (dehydration) -Na low (1.5 for every 5.6) -K normal or increased -Ca, Ph, Mg low -Lactate (normal) -Lipids may be elevated -LFTs (baseline, encephalopathy) ``` Consider: - blood, sputum, stool culture - urinalysis - chest xray - ECG and trops - tox screen - thiamine - EEG

Answer 14

Note that they are thought to exist along a continuum Demographic: - DKA = Type 1, younger, first presentation - HHS = elderly, Type 2 Triggers: - same - Dehydration and unable to tolerate oral fluids in elderly HHS Symptoms: - onset more acute for DKA - both polyuria, polydypsia, weakness - DKA has nausea, vom, abdo pain - HHS notable lethargy, confusion, stupor Signs: - dehydration for both - DKA = fruity breath, Kussmaul breathing - HHS = focal neuro signs and seizures Investigations: - glucose >45 HHS, <35 DKA - pOsm variable in DKA, >320 mmol/kg in HHS - high anion gap acidosis more typical of DKA - ketones may be present in both, but higher level in DKA Treatment: -almost identical Prognosis: - 1% mortality DKA - significantly higher for HHS (5-15%) - for both, usually due to underlying condition - higher rate in HHS may be related to older demographic

Answer 15

Every 3-4 months - HbA1c - SMBG results - hyperglycaemia symptoms - hypoglycaemic episodes - dietary intake - exercise - weight - blood pressure - foot exam - injection sites - diabetes distress Every 12 months - vitamin B12 (if on metformin) - peripheral neuropathy - retinopathy (may be 2 years) - UACR - lipid levels - smoking

Endocrinology Flashcards

(39 cards)