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Diabetes mellitus - P
Chronic elevation of blood glucose
Diabetes mellitus - Ix
Oral glucose tolerance test (OGTT): 75g glucose to a fasting patient, measure baseline fasting glucose and then 2h post glucose load (Normal >6 up to <7.8; DM >7 up to >11.1; IFG 6.1-6.9 up to <7.8; IGT <7 up to 7.8-11)
Diabetes mellitus - Cx
Macrovascular: CVA, MI, peripheral vascular disease. Microvascular: retinopathy, nephropathy, neuropathy.
Type 1 diabetes - P
Autoimmune destruction of beta cells leading to absolute insulin deficiency
Type 1 diabetes - A
Monozygotic concordance rate 45%. Strong association with either HLA-DR3 or DR4 or both. Peak age onset ~12 yrs.
Type 1 diabetes - Sy
Polyuria, polydipsia, weight loss, +/- ketoacidosis. Develops over days to months.
Type 1 diabetes - Si
Other features of autoimmune diseases
Type 1 diabetes - Ix
Blood: U&E, FBC, glucose, antibodies. Immunology: anti-islet cell Ab, anti GAD Ab. Urine: ketones, ABG.
Type 1 diabetes - Rx
Education, insulin, annual review of complications (fundoscopy, feet, vascular, neuro, nephro, thyroid)
Diabetic ketoacidosis - Precipitants [3]
Precipitants include infections, MI, omitting insulin
Diabetic ketoacidosis - Sy [4]
Syptoms of diabetes, n&v, abdominal pain, tachypnoea (Kussmaul respiration)
Diabetic ketoacidosis - Ix
Blood: glucose, ABG (met acid, large anion gap). Urine: ^^^ketones. Septic screen: CXR, urine, blood, stool cultures.
Diabetic ketoacidosis - Rx [4]
Insulin sliding scale, aggresive fluid replacement, monitor K+ and replace, treat underlying cause.
Type 2 diabetes - P
Combination of insulin resistance and inadequate production (beta cell destruction) / impaired insulin secretion (beta cell dysfunction)
Type 2 diabetes - A
Obesity, chronic pancreatitis, Cushing\\\'s syndrome. Monozygote concordance 90%. Peak onset ~50 years.
Type 2 diabetes - Sy
Often with complications of diabetes (e.g. peripheral vascular disease, CVA, MI), HONK, recurrent infection, pruritus
Type 2 diabetes - Si [3]
Increased BMI, retinopathy, peripheral neuropathy
Type 2 diabetes - Ix [4]
U&E, FBC, glucose, serum osmolalilty
Type 2 diabetes - Rx [5]
Education; metformin (overweight), sulfonylureas, insulin in some; annual review of complications (fundoscopy, feet, vascular, neuro, nephro, thyroid)
List the oral agents used in DM II, and their mechanisms
Biguanides and thiazolidinediones (improved sensitivity to insulin), sulphonylureas (stimulate insulin release), alpha-glucosidase inhibitors (prevent intestinal sugar absorption)
Hyperosmolar non-ketotic coma - A
Precipitant: infection, increased sugar intake, MI
Hyperosmolar non-ketotic coma - Sy
Polydipsia, polyuria, decreased consciousness, thrombosis
Hyperosmolar non-ketotic coma - Ix
^Na+, glucose (often >50 mmol/L), ^^osmolality
Hyperosmolar non-ketotic coma - Rx
CVP monitoring, fluid replacement, insulin, anticoagulation
Hyperosmolar non-ketotic coma - Px
Mortality 20-40%
Hypoglycaemia - A [7]
SAIL: sulphonylureas, alcohol/Addison\\\'s, insulinomas/insulin/infection, liver failure
Hypoglycaemia - Sy [5]
Cold sweat, tremor, irritability, loss of consciousness, collapse
Hypoglycaemia - Si [5]
Sweating, tachycardia, tremor, low GCS, fits
Hypoglycaemia - Ix
Plasma glucose <2.5mmol/L. If non-DM: insulin + C-peptide + pro-insulin (during hypo episode), LFT, ethanol levels, cortisol (short Synacthen test)
Hypoglycaemia - Rx
Oral glucose, im glucagon (avoid in alcoholics), iv glucose
Name the hormones of the anterior pituitary [6]
ACTH, TSH, LH, FSH, GH, prolactin
Name the hormones of the posterior pituitary [2]
ADH, oxytocin
Hyperprolactinaemia - Ae [5]
Prolactinoma; polycystic ovary syndrome; pregnancy, breast feeding; drugs (methyldopa, metaclopramide, haloperidol, oestrogen)
Hyperprolactinaemia - Sy [4]
Infertility, galactorrhoea, pressure effects (e.g. bitemporal hemianopia) loss of libido (men)
Hyperprolactinaemia - Ix [3]
Full pituitary hormone profile, MRI pituitary, perimetry (visual field measurement)
Hyperprolactinaemia - Rx
Microprolactinoma (<10mm) bromocriptine, cabergoline. Macroprolactinoma (>10mm) trial of same, trans-sphenoidal surgery if effecting vision
Hyperprolactinaemia - Cx
^risk of osteoporosis if untreated
Cushing\\\'s syndrome - desription
Chronic inappropriate secretion of free circulating cortisol
Cushing\\\'s syndrome - exogenous causes [5]
Iatrogenic, steroids, pseudo Cushing\\\'s, excess alcohol, depression
Cushing\\\'s syndrome - ACTH dependent causes [5]
Pituitary overproduction of ACTH stimulating adrenal glands, Cushing\\\'s disease, ectopic ACTH secretion, small-cell lung carcinoma, carcinoid
Cushing\\\'s syndrome - ACTH independent causes [2]
Autonomous cortisol secretion, adrenal adenoma/carcinoma/hyperplasia
What are the 3 categories of Cushing\\\'s syndrome [3]
Exogenous, ACTH dependent, ACTH independent
Cushing\\\'s syndrome - Symptoms [9]
Weight gain, poor wound healing, infection, depression, menstrual disturbance, low libido, hirsuitism, headache, osteoporosis
Cushing\\\'s syndrome - Signs [10]
Plethoric moon face, buffalo hump, purple abdominal striae, centripetal obesity, proximal myopathy, hirsuitism, thin skin, easy bruising, HTN, acne
Cushing\\\'s syndrome - Ix [4]
24h urine (free cortisol), random blood cortisol (loss of circadian rhythm), low dose/high dose dexamethasone suppression tests, locate source
Cushing\\\'s disease - Rx
Trans-spenoidal surgery
Cushing\\\'s syndrome - Rx [3]
Metyrapone, ketoconazole; adrenalectomy
Cushing\\\'s syndrome - Cx [3]
Post-adrenalectomy: Nelson\\\'s syndrome (^pigmentation, ^pituitary size), adrenal insufficiency. Post-transphenoidal surgery: hypopituitarism
Cushing\\\'s syndrome - Px
Poor if untreated
Cushing\\\'s syndrome - Ix [4]
24h urine (free cortisol), random blood cortisol (loss of circadian rhythm), low dose/high dose dexamethasone suppression tests, locate source
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