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Dexamethasone Suppression Test and the Synacthen Test
Cushing’s Syndrome 2. Addison’s Disease Feature Dexamethasone Suppression Test Synacthen Test Purpose To assess adrenal suppression and identify causes of Cushing’s syndrome (e.g., pituitary vs. adrenal cause). To evaluate adrenal gland function, specifically assessing adrenal response to ACTH to diagnose adrenal insufficiency. Mechanism Administers dexamethasone (a glucocorticoid) to suppress ACTH…
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Type 2 diabetes: Goals for optimum management
Parameter Goals/Recommendations Diet – Follow Australian dietary guidelines with attention to quantity and type of food.– If CVD risk is a concern, recommend an individual dietary review. Body Mass Index (BMI) – Therapeutic goal: 5-10% weight loss for people who are overweight or obese with type 2 diabetes.– For BMI…
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Diabetes – Insulin
Action: Facilitates glucose uptake, lowers blood glucose levels. Efficacy: Most potent glucose-lowering agent.HbA1c: reduce 1.5 – 3.5% w monotherapy Side Effects: Hypoglycemia, weight gain. Studies: UKPDS and ORIGIN trials confirm cardiovascular safety and reduced microvascular complications. Types of Short-Acting Insulin Type Insulin Name Brand Name Onset Duration Rapid-Acting Insulin Insulin…
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Galactorrhea
Hyperprolactinemia
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starting Insulin and Insulin education
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Pituitary disease
Pituitary adenoma – are the most common pituitary tumours– may be functional or non-functioning– defined as : microadenomas if <10 mm in maximum diameter macroadenomas if ≥10 mm in maximum diameter ‘giant’ pituitary adenomas if >4 cm in maximum diameter Clinically non-functioning pituitary tumours (absence of any clinically significant hormonal hypersecretion, clinical problems…
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Hyperprolactinaemia
Physiology Causes of hyperprolactinaemia Examples Physiological (transient hyperprolactinaemia) – These increases are transient, and usually do not exceed twice the upper limit of normal reference ranges. PregnancyLactationExerciseCoitusChest wall/nipple stimulationStressSeizure Macroprolactinaemia– arises when immunoglobulins in serum bind prolactin to create high-molecular-weight forms of prolactin. – As clearance of these macroprolactin molecules…
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Testosterone deficiency (hypoandrogenism)
Androgen physiology Aetiology of androgen deficiency Primary: Secondary: Primary Hypogonadism Secondary Hypogonadism Two-sided relationship between OSA, obesity, and testosterone level. OSAS and obesity contribute to reduce testosterone level in bloodstream; at the same time, lower testosterone level worsens obesity and sleep disorders. OSA, obstructive sleep apnea; OSAS, OSA syndrome Partial/Transient…
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Psychogenic polydipsia
excessive thirst and compulsive water drinking. Signs and symptoms of psychogenic polydipsia include
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Adrenal fatigue
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Adrenal insufficiency (Addison’s disease)
Adrenal Insufficiency can be defined Real, Iatrogenic, and Imagined 1. Real (Primary and Secondary) Adrenal Insufficiency 2. Iatrogenic Adrenal Insufficiency 3. Imagined (Functional) Adrenal Insufficiency Symptoms: Nb: if the cause of adrenal cortex deficiency is due to ACTH deficiency, then will have no pigmentation & will have less postural hypotension/…
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Cushing’s syndrome & disease
Circadian rhythms & stress 🡪 CNS higher centres (NA, ACH, 5HT) 🡪 Hypothalamus (CRH) 🡪 Anterior pituitary (ACTH) 🡪 Adrenal cortex fasciculata (cortisol) Symptoms Clinical Features of Cushing’s Syndrome: DIAGNOSIS: Management
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Hyperaldosteronism
(Conn’s syndrome – both hyper-secretions are “C” diseases – cf. Cushing’s) Causes: clinical features: Differentials for Hypertension with Hypokalemia Labs Factors affecting the aldosterone-to-renin ratio (ARR) Causes of false-positive ARR Beta-blockerCentral agonists (clonidine, α-methyldopa)Nonsteroidal anti-inflammatory drugsLicoriceRenal impairmentOral oestrogens Causes of false-negative ARR DiureticsDihydropyridine calcium channel blockersAngiotensin-converting enzyme inhibitors and angiotensin…
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Adrenal Gland
the adrenal gland is made up of the outer cortex & inner medulla arterial supply comes from the inferior mesenteric artery & renal arteries as well as the aorta venous drainage of the L is via the L renal vein but the R drains directly into the IVC CORTEX 3…
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Central diabetes insipidus
Diabetes insipidus (DI) Diabetes insipidus CAUSES OF CENTRAL DIABETES INSIPIDUS ASSESSMENT DIAGNOSIS
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Hypocalcaemia
CAUSES HISTORY EXAMINATION INVESTIGATIONS MANAGEMENT
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Hypercalcaemia
is needed in many other enzymes as co-factor : ECF calcium concentration are maintained within a narrow range by feedback mechanisms that involve PTH and Vit D, which integrate signals btw the parathyroid glands, kidneys, intestines and bone. ↓ECF Ca2+ → ↑PTH secretion (1) PTH → ↑increased tubular reabsorption of…
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Parathyroid disease
Hyperparathyroidism three types of Hyperparathyroidism [CKD → impaired renal phosphate excretion → ↑ phosphate blood levels→ ↑ PTH secretion] [CKD → ↓ biosynthesis of active vitamin D → ↓ intestinal calcium resorption and ↓ renal calcium reabsorption → hypocalcemia → ↑ PTH secretion] Other: Presentation Hypoparathyroidism (failing parathyroid function or…
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Hypothyroidism
AETIOLOGY Clinical Features Appearance Puffy and pale faciesDry, brittle hairSparse eyebrowsDry, cool skinThickened and brittle nailsMyxoedema – fluid infiltration of tissues Energy and nutrient metabolism Cold intoleranceWeight gainFatigue Nervous system HeadacheParaesthesias (including carpal tunnel syndrome)Cerebellar ataxiaDelayed relaxation of deep tendon reflexes Cognitive/ psychiatric Reduced attention spanMemory deficitsDepression Cardiovascular BradycardiaDiastolic hypertensionPericardial…
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Thyroid Nodules and Cancers
Thyroid nodules are often picked up as incidental findings on clinical examination, or on imaging (usually carotid ultrasound) for another purpose. They can cause problems if they become large and compress the oesophagus / trachea. Causes of clinically detectable thyroid nodule: History Workup Treatment and Followup FNA Results FNA results…
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Thyroid storm
Precipitants of Thyroid Storm Pathophysiology Clinical Manifestations Organ System Symptoms Signs CNS Anxietyconfusiondelirium Hyperreflexiaseizurescoma psychosis, lethargy Cardiovascular Palpitationschest paindyspnoea Sinus tachycardiaatrial fibrillation on exertion widened pulse pressureheart failure Gastrointestinal Abdominal painnauseavomiting Diarrheajaundice diarrhea Thyroid Gland Neck fullness Tendernessdiffuse enlargementbruit Diagnosis Management Basics Disposition Take Home Points
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Hyperthyroidism
Thyroid Hormone Regulation Functions of Thyroid Hormone Hyperthyroidism Hyperthyroidism is characterized by an excessive concentration of thyroid hormones in tissues, caused by increased synthesis, excessive release of preformed thyroid hormones, or an endogenous or exogenous extrathyroidal source. Aetiology of Hyperthyroidism Common Causes (1) Graves’ Disease Pathophysiology Treatment Signs of Graves’…
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Thyroid – anatomy & function
Thyroid Hormone Regulation and Metabolism Active and Inactive Forms of Thyroid Hormones Function: Effects on Foetal Development Effects on Oxygen Consumption, Heat Production and Free Radical Formation Cardiovascular Effects Sympathetic Effects Pulmonary Effects Haematopoeitic Effects Gastrointestinal Effects Skeletal Effects Neuromuscular Effects Effects on Lipid and Carbohydrate Metabolism Endocrine Effects Other…
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Diabetic polyneuropathy
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Hypoglycaemia
https://www.racgp.org.au/getattachment/e5311638-b32d-4a11-88b3-9a35ee268d83/Hypoglycaemia-in-nondiabetic-patients-an-evidence.aspx Traditional Classification: Criticisms of Traditional Classification: Alternative Classification Based on Clinical Characteristics: from AustRAliAn FAmily PhysiciAn Vol. 39, no. 6, june 2010 = Hypoglycaemia in nondiabetic patients – an evidence based approach: Common Causes of Hypoglycaemia: Specific Hypoglycaemia Types: Idiopathic Postprandial Hypoglycaemia: Idiopathic Postprandial Syndrome (Pseudohypoglycaemia): Biochemical Differentiation of…
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Hyperosmolar Hyperglycaemic State / HONK
OVERVIEW PATHOPHYSIOLOGY Here is a more detailed comparison of Hyperosmolar Hyperglycemic Nonketotic State (HONK) and Diabetic Ketoacidosis (DKA), focusing on etiology, pathology, signs, symptoms, management, and follow-up based on Australian guidelines: Aspect HONK (Hyperosmolar Hyperglycemic Nonketotic State) DKA (Diabetic Ketoacidosis) Etiology – Common in type 2 diabetes, elderly patients.– Precipitating…
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Diabetic Ketoacidosis
Diabetic Ketoacidosis (DKA) potentially life-threatening complication of diabetes mellitus resulting from the consequences of insulin deficiency Precipitants for DKA Common triggers of DKA include: Ketosis-Prone Type 2 Diabetes (KPD) AFP: Ketoacidosis in a patient with type 2 diabetes – Flatbush diabetes Volume 44, Issue 1, January-February 2015 Evaluation for the…
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Diabetes – management of complications
Macrovascular Complications of Diabetes 1. Coronary Artery Disease (CAD) 2. Peripheral Artery Disease (PAD) 3. Cerebrovascular Disease HYPERTENSION DYSLIPIDAEMIA Microvascular Complications of Diabetes 1. Nephropathy Definitions in diabetic renal disease Normal Microalbuminuria (incipient nephropathy) Clinical ‘overt’ nephropathy Units 24 hour urinary albumin <30 30-300 >300 mg/day Urine albumin excretion rate <20…
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Diabetes – sick day plan
Preparation for Sick Days: When to Initiate the Sick Day Plan: Blood Glucose Monitoring: If You’re Unable to Access Support: Managing Low Blood Glucose (Hypoglycaemia): Important: Do not drive if blood glucose levels are below 5 mmol/L. Managing High Blood Glucose (Hyperglycaemia): Blood Ketone Monitoring: If Taking Diabetes Tablets or…
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Diabetes – Medications
The criteria for the diagnosis of diabetes are now: https://www.diabetessociety.com.au/guideline/hba1c-for-diagnosis-of-diabetes-mellitus-may-2023 In an asymptomatic patient the test should be repeated for confirmation of the result and diagnosis. An abnormal result on 2 different diagnostic tests is also acceptable Treatment Algorithm Overview https://www.diabetessociety.com.au/wp-content/uploads/2023/03/ADS_POSITION-STATEMENT_v2.4.pdf All patients should receive education on lifestyle measures, including:…
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Diabetes – Management
Initial Management Plan 1. Patient Education and Individualized Targets 2. Multidisciplinary Team (MDT) Approach 3. Non-Pharmacological Management 4. Lifestyle and Cardiovascular Risk Reduction 5. Ongoing Reviews and Monitoring Quarterly Review: Yearly Review: The Blood Glucose Profile in Type 2 Diabetes In type 2 diabetes, the blood glucose profile consists of…
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Diabetes – diagnosis and investigations
Diagnosis Assessing diabetes risk Patients should be assessed for diabetes risk Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK) AUSDRISK score developing type 2 diabetes within five years 5 or less: Low risk 6–11: Intermediate risk 12 or more: High risk The following people are also considered at high risk,…
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Diabetes types history and examination
Type 1 diabetes Type 2 DM: can occur in children + adolescents if overweight but usually older adults, often family hx. Most people are asymptomatic. Latent Autoimmune Diabetes of Adults (LADA): Monogenic diabetes Gestational diabetes mellitus: Medication induced diabetes: commonly prednisolone + olanzapine that may require hypoglycaemics, once med withdrawn…
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Thyroid disease in pregnancy
AFP – Thyroid disease in the perinatal period http://www.racgp.org.au/afp/2012/august/thyroid-disease-in-the-perinatal-period/ Etg therapeutic guidelines – thyroid disorders and pregnancy Hypothyroidism Management Hyperthyroidism Management TSH Measurement Recommendations Iodine Supplementation Isolated Hypothyroxinaemia
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Gestational Diabetes
Classification Diagnosis Screening: 2nd Trimester – 24-28 weeks gestation Screening : 1st Trimester if multiple RFs for early diagnosis: if Bariatric Surgery HbA1c vs GTT Risks from GDM Maternal risks of GDM Fetal/ neonatal risks of GDM Mx Medications Follow-up