Diabetes Mellitus

Presentation

 Asymptomatic

 Polyuria, Thirst

 Weight loss, Lack of energy

 Superficial infections

 Complications: Ketoacidotic, Retinopathy, Polyneuropathy, Impotence, Arterial disease.

Diagnosis

 Fasting glucose > 7.0 mmol/L

 Random blood glucose > 11.1 mmol/L on two occassions

 2 hour Glucose tolerance test > 11.1 mmol/L

Treatment

 The care of diabetes is based on self management by the patient, who is helped and advised by those with specialised knowledge.

 A good relationship with the patient is essential as the understanding and cooperation of the patient is the key to good glycaemic control.

Complications

 IHD

 Renal failure

 Stroke

 Neuropathy

 Vascular disease (eg claudication)

 Retinopathy  Infections Risk Factors  High cholestrol  Hypertension  Smoking  Alcohol  Obesity Education/negotiation

 Explanation of Diabetes (for type 1):

 Due to lack of insulin from damage to pancreas

 What insulin does: shifts sugar from blood to cells – without it there is too much sugar in the blood

 Leads to symptoms: weight loss, polyuria, etc

 Also leads to nasty complications over time

 Requires lifelong replacement with insulin

 Monitoring blood glucose (with finger prick) and adapting treatment accordingly (IDDM)

 Exercise. “Give sensible suggestions eg walking the dog, taking the stairs instead of lift

etc instead of advising to join Gym”.

 Diet (low fat diet, low glycaemic index foods eg bread, pasta etc)

 Weight loss - If patient is over weight

 Reduce risks: Stop smoking (call the Quitline: 0800 778 778)

 Medication:

 Explain that when ill more, not less, insulin is required

 Consider exposing to a „hypo‟ to show how to abort it with sweets etc  Medical management:

 Introduce to specialist nurse, dietician, chiropodist, and diabetic association

 Regular follow up

 Referral is necessary to: ophthalmology, renal, cardiology, etc

 Must inform LTSA (if patient has a driving licence)?

Drugs

 Sulfonylureas (Thin NIDDM‟s)  Biguanides (Fat NIDDM‟s)

 Glucosidase inhibitors

 Insulin (IDDM‟s and NIDDM‟s not controlled by above measures)

 Treat hypertension vigorously. ACE inhibitors reduce progression of kidney disease. Treat hyperlipidaemia.

Complications

 Vascular disease

 Kidneys - Check urine regularly for protein ie dipstick

 Retinopathy - Arrange regular fundoscopy for all patients

 Cataracts

 Diabetic feet - Educate on foot care eg daily foot inspection, comfortable shoes etc

 Neuropathy

 Autonomic neuropathy - postural hypotension, impotence, diarrhoea at night

 Hypoglycaemia ( if on insulin or sulphonylureas)

134: Test and Interpret Capillary Glucose

Advantage Meter

 Calibration – Before using a strip from a new pack, insert the code key found in the pack into the meter. It ensures the meter is using the latest data.

 Insert test strip. – Meter turns on automatically.

 Obtain a small drop of blood.

 Washing the patients hand/finger is important

 Reduces the risk of infection in puncture site

 Makes sure that no food residue is on the hands that will give a falsely high result

 Washing in warm water improves the circulation

 Obtaining blood from the side of the finger is recommended as it is easier and less painful. If blood is not coming out get them to wiggle the finger (squeezing causes bruising)

 Touch and hold the drop of blood to the right-hand edge of the yellow window. – The blood will automatically be drawn into the yellow window of the test strip, and the test will begin.

 Make sure the yellow window is completely filled with blood. – Additional blood can be applied to the edge of the strip within 15 seconds of the first drop.

Miscellaneous

 Only use test strips that are designed specifically for advantage meter. Strips aren‟t interchangeable between different brands of machine.

 Store strips between 4 and 30 degrees, out of direct sunlight

Interpretation

Fasting Blood Glucose 2 hours post glucose tolerance test Diabetes > 7.0 (was 7.8) mmol/l > 11.1 mmol/l

Impaired Glucose Tolerance > 7.8 Impaired Fasting Glycaemia

(new category)

> 6.0

127: Abnormal Thyroid Function

Tests for thyroid disorders

 Thyroid function tests

Condition TSH T4 T3 Hypothyroidism  Primary  Secondary * N or  *  N or  N or  Hyperthyroidism *  * Sick euthyroid N or  N or  N or  *main test  False values

 T3 and T4  in pregnancy, thyroglobulin excess, and oestrogens

 T3 and T4  with salicylates, NSAIDs, phenytoin, corticosteroids, carbamazepine, etc.

 Thyroid isotone scanning: is indicated if

 Area of thyroid enlargement

 Hyperthyroid without thyroid enlargement

 Hyperthyroid with one nodule

 If subacute thyroiditis is a possibility

 Ultrasound: distinguishes cystic from solid (cancer) nodules

 Thyroid autoantibodies

 Fine needle aspirate

 CT: determine extent of neck compression from thyroid enlargement

Hyperthyroidism

 Symptoms

 Weight loss despite increase appetite

 Frequent stools

 Tremor

 Irritability; frenetic activity; emotional lability

 Dislike hot weather; sweating

 Oligomenorrhea

 Signs

 Tachycardia (even when sleeping); AF

 Warm peripheries

 Fine tremor

 Thyroid: enlargement, nodule, bruit

 Myopathy

 Graves: bulging eyes, lid lag, virtilgo, pretibial myxoedema

 Causes

 Graves: women 30-50yrs; autoantibodies against TSH receptors; associated with IDDM and pernicious anaemia

 Toxic adenoma

 Subacute thyroiditis: goitre (often painful); ESR; probable viral cause

 Self-medication: raised T4 low T3

 Toxic multinodular goitre

 Treatment

 Partial thyroidectomy

 Radioactive I131

Hypothyroidism

 Symptoms

 Increase weight, decrease appetite

 Constipation

 Dry skin, hair falling out, swollen ankles

 Dislike cold

 Lethargy, depression and mental slowing

 Hoarseness

 Menorrhagia

 Signs

 Goitre

 Bradycardia

 Dry skin and hair

 Slowly relaxing reflexes

 CCF

 Non-pitting oedema

 Causes

 Autoimmune (Hashimoto‟s)

 After thyroidectomy or radioactive treatment

 Drug induced: anti-thyroid drugs, amiodarone

 Iodine deficiency

 Treatment: Thyroxine

Thyroid examination

 Observe while swallowing water

 Palpate from behind. Find isthmus then move laterally

 Palpate lymph nodes

 Listen for bruits

 Test vocal cords (recurrent laryngeal nerve)

Ref: OHCM 4th Edition, pp 526 – 569. Murtagh, General Practice 2nd Edition, Chapter 20, pp 163 - 171

43: Galactorrhoea

 Usually due to hyperprolactinaemia (but normoprolactineamic galactorrhoea does occur, the

causes of which are poorly understood)

Hyperprolactinaemia

 Symptoms

 Women: oligo- or amenorrhoea, infertility, vaginal dryness, weight gain, apathy

 Men: impotence,  facial hair

 Both: libido, delayed or arrested puberty, symptoms relating to the primary cause

 Causes

 Physiological - pregnancy, breastfeeding, stress, REM sleep, nipple stimulation, coitus

 Drug induced - DA antagonists (Maxolon, phenothiazines), oestrogen, opiates, cimetidine

 Pathological - prolactinoma, acromegaly, stalk compression, idiopathic, PCO, primary hypothyroidism, chest wall injury, renal failure, liver failure

 Investigations

 At least three prolactin levels should be checked. Non-stressful between 10am-12.

 Visual fields

 Anterior pituitary function - IGF-1, T4 and TSH, LH and FSH

 MRI/CT of pituitary fossa

 Micro-prolactinoma (<10mm) - bromocriptine (SE =N+V, anorexia, hypotension. Increase dose slowly). Stop on becoming pregnant (pregnancy does not increase tumour size)

 Macro-prolactinoma (most common cause in men) - try bromocriptine unless there are visual symptoms, pressure effects or pregnancy is contemplated then surgery is indicated

76: Short Stature

Short stature = height below the 5th centile

 If both parents are short, their child will likely be short too (constitutional short stature accounts for 80% of short children). Likely height of a boy = (mother's height + 13cm + father's height)/2. For a girl do the same but subtract 13cm from father's height.

Variations from normal:

 Familial (genetic) short stature.Below 3rd centile but growing parallel ie normal growth rate. Parents are usually short and pubertal development usually occurs at the appropriate time

 Constitutional delay in growth and pubertal developmentCommon, short stature during childhood, delayed puberty and eventually catch up to peers. Often a family history

Pathological causes of short stature

 Intrauterine growth retardation

 Chronic disease - any system, growth failure usually with ass fall in weight velocity. A hormone or endocrine problem is unlikely to be the cause of poor growth if both weight and height are affected

 Skeletal disorders - Usually familial eg achondroplasia. Major features, upper body to lower body segment ratio. Limbs usually short and weight gain is usually normal

 Iatrogenic - Corticosteroid excess in children. Growth failure ass with weight gain. Irradiation to head/neck may result in pituitary hypofunction may lead to poor growth of spine and trunk

 Chromosomal abnormalities and syndromes - eg Turners syndrome

 Psychosocial - Poor/ineffective diet, physical or psych abuse, fall off of weight gain and linear growth

 Endocrine - least common pathological cause. Hypothyroidism, GH def, Cushing‟s syndrome, adrenal insufficiency. Fall off of linear growth exceeds fall in weight gain

History

 Height/weight compared to peers, duration of short stature

 Birth details

 Family history - mid parental height

Examination

 Height/weight

 Assess pubertal status

 General physical exam including BP - chronic disease, nutritional state, dysmorphic features

 Goitre or other signs of hypothyroidism - dry hair/skin, bradycardia, reflexes

 Evidence of midline brain development syndromes which may result in hypopituitism eg cleft palette

 Visual fields to exclude possibility of a pituitary lesion

Management

 Plot height/weight, compare with parents

Investigations

 Bone age xray

 FBC and ESR

 Urea, creatinine, and electrolytes

 Calcium and phosphate

 Thyroid function tests

Treatment

 Girls < 152cm

 Boys < 162cm

 Can use biosynthetic GH in GH def, Turner syndrome, growth retardation secondary to renal insufficiency, intrauterine growth retardation, and severe idiopathic short statue.

Skin

In document osce (Page 121-127)