Endocrine Med 2010 Step2

Endocrine DiseaseEndocrine Disease

ApiradeeApiradee SriwijitkamolSriwijitkamol, MD, MDDivision of Endocrinology and MetabolismDivision of Endocrinology and Metabolism

Department of MedicineDepartment of MedicineFaculty of Medicine Faculty of Medicine SirirajSiriraj HospitalHospital

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TopicTopic

Thyroid diseaseThyroid diseaseDMDM

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Hypothalamus

TRH

Pituitary

TSH

Thyroid

T4 T3T4-TBG T3-TBG

+

-

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Case 1Case 1

•• 66 year old lady66 year old lady•• Presents with:Presents with:

•• DepressionDepression•• MyalgiaMyalgia•• Weight gainWeight gain

•• On Examination:On Examination:•• Slow relaxing reflexesSlow relaxing reflexes•• Sinus Sinus bradycardiabradycardia•• BMI 32BMI 32•• Swelling on the anterior aspect of the neckSwelling on the anterior aspect of the neck

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Case 1Case 1

•• What is the diagnosis?What is the diagnosis?

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Case 2Case 2


•• Weight lossWeight loss•• DyspneaDyspnea on exertionon exertion•• PalpitationPalpitation

•• On Examination:On Examination:•• Diffuse thyroid enlargementDiffuse thyroid enlargement•• Sinus tachycardia, warm moist skinSinus tachycardia, warm moist skin•• ExophthalmosExophthalmos

For 6 months

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Case 2Case 2


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Case 3Case 3



•• On Examination:On Examination:•• Thyroid nodule 2 cm at right lobeThyroid nodule 2 cm at right lobe•• Sinus tachycardia, warm moist skinSinus tachycardia, warm moist skin•• No No exophthalmosexophthalmos, no , no pretibialpretibial myxedmeamyxedmea

For 2 months

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Case 3Case 3


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Tiredness / malaiseMental slownessReduced appetiteConstipationSensitivity to drugs Cold intolerance

/ Hypothermia

Change in appearanceAnaemiaHeart failureHypertensionBradycardiaDyspnoea

HYPOTHYROIDISM

Signs & Symptoms :-

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Aetiology

Thyroid TissueLoss or Atrophy

AutoimmunePost SurgeryPost IrradiationInfiltration

Decreased HormoneSynthesisDecreased Thyroxin Production

Primary (90%)

Dysfunction ofPituitary Gland

Tumour orsurgery

Decreased TSHProduction

Secondary (<10%)

Dysfunction ofHypothalamus

Decreased TRHProduction

Tertiary (Rare)

HYPOTHYROIDISM

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Serum T4 or fT4

Below Normal

Primary HypothyroidismSecondary HypothyroidismTertiary Hypothyroidism

DIAGNOSIS

HYPOTHYROIDISM

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Serum TSH

Above Normal

Primary Hypothyroidism Secondary HypothyroidismTertiary Hypothyroidism

Below Normal

DIAGNOSIS

HYPOTHYROIDISM

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Thyroxin replacementGoal:

Primary hypothyroidism:Normalized TSH

Secondary hypothyroidism:T4 in upper half of normal limit

HYPOTHYROIDISM

Treatment

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Highly successful in bringing patients back to normal metabolic stateTherapy continues for lifeCaution when commencing treatment- risk of MI

Patients observed for signs of• Angina• ECG changes• Dyspnoea• Palpitations• Arrythmias

HYPOTHYROIDISM

Treatment

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Weight loss (but normal appetite)

Sweating; heat intoleranceFatiguePalpitation; sinus

tachycardia or atrial fibrilationAngina; Heart failure (high

output)Agitation; tremor

THYROTOXICOSIS

Generalised muscle weakness

DiarrhoeaRapid bounding pulseShortness of breathWarm moist skinInsomnia

Signs & Symptoms :-

Excess of the thyroid hormone resulting in an hypermetabolic state

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THYROTOXICOSIS

Hyperthyroidism Other causes ofthyrotoxicosis

-Graves’ disease-Toxic multinodular goiter

Increase uptake

Antithyroid drug+Ablative treatment

-Subacute thyroiditis-Excessive iodine intake-Thyrotoxicosis factitious-Struma ovarii

Decrease uptake

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Definition:-

"Excessive secretion of the thyroid hormone resulting in an hypermetabolic state.....".

Incidence:-

2 - 5% of all females between age of 30-50 yrsMale / female: 1 : 7Can be precipitated by a life 'crisis'

HYPERTHYROIDISM

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Aetiology

HYPERTHYROIDISM

Secondary (Rare)

Over Secretion by Pituitary Tumor

Increased TSHProduction

Increased ThyroxinProduction

Thyroid TissueDisease

Autoimmune(Graves’ Disease)

Thyroid Stimulating Antibodies

IncreasedStimulation of TSH Receptors

Increased ThyroxinProduction

Primary (99%)

Thyroid nodule(Toxic adenoma)

Autonomous

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HyperthyroidismHyperthyroidism

Weight loss (but normal appetite)

Sweating; heat intoleranceFatiguePalpitation; sinus

tachycardia or atrial fibrilationAngina; Heart failure (high

output)Agitation; tremor

Generalised muscle weakness

DiarrhoeaRapid bounding pulseShortness of breathWarm moist skinInsomnia

Signs & Symptoms :-

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Thyroid Acropachy

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Lid Lag

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GravesGraves’’ Disease Disease -- EyesEyes

ExopthalmosProptosisSIRIRA

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Periorbital MyxoedemaSIRIRA

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Pretibial Myxedema

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Serum T3, T4 and free T3,T4

Above Normal

Primary HyperthyroidismSecondary Hyperthyroidism

Diagnosis

HYPERTHYROIDISM

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Serum TSH

Below Normal

Primary Hyperthyroidism

Secondary Hyperthyroidism

Above Normal

Diagnosis

HYPERTHYROIDISM

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Treatment :-

Highly successful in bringing patients back to normal metabolic state

Long term follow-upTreatment:

Anti-Thyroid drugsRadioiodineThyroidectomy

PartialTotal

HYPERTHYROIDISM

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Treatment :-

Anti-Thyroid drugsDose:

Start: PTU 150-300 mg/day or Methimazole 15-30 mg/day

Maintain: taper dose as clinical and laboratory results

Duration: 1 ½ - 2 yearsSide effects

Minor: RashMajor: Agranulocytosis, hepatitis

HYPERTHYROIDISM

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Treatment :-

Ablative treatmentIndication:

Failure to medicationRelapse or recurrentMajor drug adverse reactionPatient with underlying heart diseaseToxic adenoma

Options:Radioactive iodineSurgery

HYPERTHYROIDISM

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THYROIDTHYROIDNODULENODULE

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FINE NEEDLE ASPIRATION

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Case 1Case 1


•• DepressionDepression•• MyalgiaMyalgia•• Weight gainWeight gain

•• On Examination:On Examination:•• Slow relaxing reflexesSlow relaxing reflexes•• Sinus Sinus bradycardiabradycardia•• BMI 32BMI 32•• Swelling on the anterior aspect of the neckSwelling on the anterior aspect of the neck

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Case 1Case 1


Hypothyroidism

FT4 and TSHThyroid antibodySIR

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Case 2Case 2



•• On Examination:On Examination:•• Diffuse thyroid enlargementDiffuse thyroid enlargement•• Sinus tachycardia, warm moist skinSinus tachycardia, warm moist skin•• ExophthalmosExophthalmos

For 6 months

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Case 2Case 2


Hyperthyroidism: Graves’ disease

T3, T4 and TSH

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Case 3Case 3



•• On Examination:On Examination:•• Thyroid nodule 3 cm at Thyroid nodule 3 cm at lefttleftt lobelobe•• Sinus tachycardia, warm moist skinSinus tachycardia, warm moist skin•• No No exophthalmosexophthalmos, no , no pretibialpretibial myxedmeamyxedmea

For 2 months

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Case 3Case 3


Thyrotoxicosis: Toxic adenomaExogenous thyroid

T3, T4 and TSHThyroid scanSIR

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Thyroid scanThyroid scan

Toxic adenomaSIRIRA

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TopicTopic

Thyroid diseaseThyroid diseaseDMDM

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Diagnostic criteria for diabetesDiagnostic criteria for diabetes

≥≥20020022--h post glucose loadh post glucose load

Symptom of DM + Casual plasma Symptom of DM + Casual plasma ≥≥200200GlucoseGlucose

≥≥126126FastingFasting**Diabetes mellitusDiabetes mellitus

VenousVenous Plasma Glucose Plasma Glucose concentration, mg dlconcentration, mg dl--11

*Repeat in different day

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Classification of DiabetesClassification of Diabetes

Type 1 DiabetesType 1 DiabetesType 2 DiabetesType 2 DiabetesGestational DiabetesGestational DiabetesOther typesOther types–– Endocrine diseaseEndocrine disease–– Chronic pancreatitisChronic pancreatitis–– MalnutritionMalnutrition--related diabetes mellitus related diabetes mellitus

(MRDM)(MRDM)

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Case 1Case 1

3939--year old woman came to year old woman came to see you because see you because polyuriapolyuria, , polydipsiapolydipsia and and nocturianocturia 4 4 times/night.times/night.PE BP 130/90 mmHg, other PE BP 130/90 mmHg, other as in figureas in figureYou ordered BG stat (11am) You ordered BG stat (11am) and it was 230 mg/dland it was 230 mg/dl

Diagnosis Diabetes

Cause of DiabetesCushing’s syndromeSIR

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Diabetes Control

Advice

Blood pressure

Cholesterol

DN screening

Eye Examination

Feet Care

Guardian Drugs

Diabetes Care:Diabetes Care:THE ALPHABET STRATEGYTHE ALPHABET STRATEGY

AlphabetStrategy

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Conclusion:Conclusion:The Modified Alphabet StrategyThe Modified Alphabet Strategy

•• AAdvicedvice Smoking , diet , exerciseSmoking , diet , exercise•• BBlood pressure lood pressure << 130/80130/80•• CCholesterol holesterol LDL LDL ≤≤ 100100•• DDiabetes control iabetes control HbA1c HbA1c ≤≤ 7%7%•• DDN screeningN screening Annual examination Annual examination •• EEye examination ye examination Annual examinationAnnual examination•• FFeet examination eet examination Annual examinationAnnual examination•• GGuardian drugs uardian drugs Aspirin, ACEI, Aspirin, ACEI, statinsstatinsSIR

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Case 2Case 2Mr. M,46Mr. M,46--yr old man came to you for check upyr old man came to you for check upHe had no underlying disease without any He had no underlying disease without any symptoms of hyperglycemiasymptoms of hyperglycemiaSmoking and drinking occasionallySmoking and drinking occasionallyOn physical examination, his blood pressure On physical examination, his blood pressure was 130/90 mmHg and his BMI was 31 kg/m2, was 130/90 mmHg and his BMI was 31 kg/m2, others were unremarkableothers were unremarkableHis lab investigation were followed, FPG 155 His lab investigation were followed, FPG 155 mg/dl, CH 250 mg/dl, TG 200 mg/dl, HDL 40 mg/dl, CH 250 mg/dl, TG 200 mg/dl, HDL 40 mg/dl, LDL 170 mg/dlmg/dl, LDL 170 mg/dl1 week later, his FPG was 150 mg/dl, HbA1c 1 week later, his FPG was 150 mg/dl, HbA1c was 7.5%was 7.5%

Type 2 diabetes, HT, Combined dyslipidemia, Obesity

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Advice

Blood pressure

Cholesterol

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AlphabetStrategy

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Initiation of antihypertensive treatment

Lifestyle changes + drug treatment

Lifestyle changesDiabetes

Lifestyle changes + immediate drug treatment





Established CV or renal disease




Lifestyle changes and consider drug treatment

Lifestyle changes

3 or more risk factors, MS, OD or diabetes


Lifestyle changes for several weeks then drug treatment if BP uncontrolled


Lifestyle changes

Lifestyle changes

1-2 risk factors



Lifestyle changes for several months then drug treatment if BP uncontrolled

No BP intervention

No BP intervention

No other risk factors

Grade 3 HT SBP ≥180 or DBP ≥110

Grade 2 HTSBP 160-179 or DBP 100-109

Grade 1 HTSBP 140-159 or DBP 90-99

High normal SBP 130-139 or DBP 85-89

Normal SBP 120-129 or DBP 80-84

Other risk factors, OD or disease

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Antihypertensive Treatment: Preferred DrugsAntihypertensive Treatment: Preferred DrugsGeneral rules: lower SBP and DBP to goal. Use any effective agent at adequate doses, if useful in combination. Use long acting agents to lower BP throughout 24 hours. Avoid or minimize adverse effects.

Subclinical organ damage Left ventricular hypertrophy ACE inhibitors, calcium antagonists,

angiotensin receptor antagonists Asymptomatic atherosclerosis Calcium antagonists, ACE inhibitors Microalbuminuria ACE inhibitors, angiotensin receptor antagonists Renal dysfunction ACE inhibitors, angiotensin receptor antagonists

Clinical event Previous stroke Any BP lowering agent Previous MI β-blockers, ACE inhibitors, angiotensin receptor antagonistsAngina pectoris β-blockers, calcium antagonists

Heart failure diuretics, β-blockers, ACE inhibitors, angiotensin receptor antagonists, antialdosterone agents

Atrial fibrillation Recurrent ACE inhibitors, angiotensin receptor antagonists Continuous β-blockers, non-dihydropiridine calcium antagonists

Renal failure/proteinuria ACE inhibitors, angiotensin receptor antagonists, loop diureticsPeripheral artery disease Calcium antagonists

Condition Isolated systolic hypertension (elderly) Duretics, calcium antagonists Metabolic syndrome ACE inhibitors, angiotensin receptor antagonists, calcium

antagonists Diabetes mellitus ACE inhibitors, angiotensin receptor blockerPregnancy calcium antagonists, methyldopa, β-blockers Blacks diuretics, calcium antagonistsSIR

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NCEP ATP III: LDLNCEP ATP III: LDL--C GoalsC Goals(2004 Modifications)(2004 Modifications)

Grundy SM et al. Circulation 2004;110:227-239.

High Risk

CHD or CHD risk equivalents

(10-yr risk >20%)

LD

L-C

level

100

160

130

190

Lower Risk

< 2 risk factors

Moderately High Risk

≥ 2 risk factors

(10-yr risk 10-20%) goal

160mg/dL

goal

130mg/dL

70 -

goal

100 mg/dL

Moderate Risk

≥ 2 risk factors

(10-yr risk <10%)

goal

130 mg/dL

Existing LDL-C goals

Proposed LDL-C goals

*CHD risk equivalents = DM, PAD, Stroke, CKD

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Major Risk FactorsMajor Risk Factors

Cigarette smokingCigarette smokingHT: BP HT: BP ≥≥140/90 mmHg or on antihypertensive agent140/90 mmHg or on antihypertensive agentLow HDLLow HDL--C (<40 mg/C (<40 mg/dLdL))††

Family history of premature CHDFamily history of premature CHD–– CHD in male first degree relative <55 yearsCHD in male first degree relative <55 years–– CHD in female first degree relative <65 yearsCHD in female first degree relative <65 years

Age (men Age (men ≥≥45 years; women 45 years; women ≥≥55 years)55 years)

† HDL-C ≥60 mg/dL counts as a “negative” risk factorSIRIRA

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or optional

70 mg/dL*

or optional

100 mg/dL*

NCEP ATP III: NCEP ATP III: 2004 Modifications2004 ModificationsHigh Risk

CHD or CHD risk equivalents

(10-yr risk >20%)

LD

L-C

level

100

160

130

190

Lower Risk

< 2 risk factors

Moderately High Risk

≥ 2 risk factors

(10-yr risk 10-20%) goal

160mg/dL

goal

130mg/dL

70 -

goal

100 mg/dL

Moderate Risk

≥ 2 risk factors

(10-yr risk <10%)

goal

130 mg/dL

Existing LDL-C goals

Proposed LDL-C goals

* And other clinical forms of atherosclerotic disease.# very high risk category = established CVD plus multiple major risk factors (especially diabetes), severe and poorly controlled risk factors (e.g. cigarette smoking), metabolic syndrome (TG > 200 mg/dL + non-HDL-C >130 mg/dL with HDL-C < 40 mg/dL]), and acute coronary syndromes.

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AlphabetStrategy

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Oral hypoglycemic drugsOral hypoglycemic drugsInsulin Insulin secretagoguesecretagogue–– Sulfonylurea: Sulfonylurea: glibenclamideglibenclamide, , glipizideglipizide, ,

gliclazidegliclazide–– GlinideGlinide groupgroupBiguanideBiguanide: : metforminmetforminαα--GlucosidaseGlucosidase InhibitorInhibitor: : acarboseacarbose, , voglibosevogliboseThiazolidinedionesThiazolidinediones: : RosiglitazoneRosiglitazone, , plioglitazoneplioglitazoneIncretinIncretin

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Glucose

Biguanides

Insulin

α-glucosidase inhibitors

Thiazolidinediones

Sulphonylureas and meglitinides

DPP-4

GLP-1

DPP-4 inhibitors

GLP-1 analogues

Primary sites of action of oral Primary sites of action of oral antianti--diabetic agentsdiabetic agents

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ITC-1. Annals of Int Med. 2007

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InsulinInsulinIntermediate actingIntermediate acting: NPH, : NPH, HumulinHumulin N, N, InsulatardInsulatardShort actingShort acting: RI, : RI, HumulinHumulin R, R, ActrapidActrapidPremixed insulinPremixed insulin: : HumulinHumulin 70/30, 70/30, MixtardMixtard 3030Rapid actingRapid acting: Insulin : Insulin lisprolispro, , aspartaspartLong acting insulinLong acting insulin: Insulin : Insulin glargineglargine, , determirdetermir

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ระยะเวลาหลังฉีดยาอินซูลิน (ชั่วโมง)4 8 12 16 20 24

RegularNPH

GlargineDetemir

AspartLispro

การออกฤทธิ์ของอินซูลินการออกฤทธิ์ของอินซูลิน

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ADA/EASD 2008 guidelineADA/EASD 2008 guideline

Nathan DM, et al. Diabetes care 2008; 31:1-11.

At diagnosisLifestyle

modification + metformin

Lifestyle + metformin+

basal insulin*HbA1c >8.5%


PioglitazoneNo hypoglycemiaCHF, Bone loss


Intensify insulin


GLP-1 agonistNo hypogly, Wt loss

Nausea vomitting


sulfonylurea

Step 1 Step 2 Step 3


basal insulin


Pioglitazone+

sulfonylurea

Tier 1: Well-validated core therapies

Tier 2: Lesswell-validatedtherapies

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ThaiThai’’s guideline for management of T2DMs guideline for management of T2DM

FPG <200 mg/dl orHbA1c <8%

FPG 200-300 mg/dl

FPG 250-350 mg/dl orHbA1c >9%

FPG >300 mg/dl orHbA1c >11% or

Symptomatic hyperglycemia

Lifestyle modification1-3 months

Life

styl

e m

odifi

catio

nC

oncu

rren

t with

med

icat

ion Monotherapy

Combination OHA

Insulin therapy

Metformin or SulfonylureaOther: TZDs, Glinide, AGI

or DPP-IV inhibitor

Basal or Premixed or MDI

Insulin resistance phenotype

Insulin defiiciencyphenotype

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Approach to patient with poor Approach to patient with poor glycemicglycemic controlcontrol

Diet historyDiet historyExercise historyExercise historyCompliance historyCompliance historyConcurrent medicationConcurrent medication–– Herbal medicineHerbal medicine–– SteroidSteroid–– Diuretics, betaDiuretics, beta--blockerblockerOccult infectionOccult infectionSIR

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Screening for Diabetic Screening for Diabetic NephropathyNephropathy

1American Diabetes Association: Nephropathy in Diabetes (Position Statement). Diabetes Care 27 (Suppl.1): S79-S83, 2007

Test When Normal Range

BloodPressure 1

Each office visit <130/80 mm/Hg

UrinaryAlbumin 1

Type 2: Annuallybeginning at diagnosisType 1: Annually, 5 -yearspost -diagnosis

<30 mg/day<30 μg/mg creatinine

CreatinineClearance1

Annually >90 ml/min per 1.73m2 BSA

GFR = ([140-age] X weight in kg) X 0.85 (if female)

(serum creatinine X 72)

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Definitions of abnormalities in Definitions of abnormalities in albumin secretionalbumin secretion

1American Diabetes Association: Nephropathy in Diabetes (Position Statement). Diabetes Care 28 (Suppl.1): S3-41, 2008

Category Spot collection

Normal <30

μg/mg creatinine

Microalbuminuria

Macroalbuminuria

30-299

>300

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Stage of CKDStage of CKD

1American Diabetes Association: Nephropathy in Diabetes (Position Statement). Diabetes Care 28 (Suppl.1): S3-41, 2008

Stage GFR

1

2

3

4

5

ml/min per 1.73m2 BSA

>90

60-89

30-59

15-29

<15 or dialysis

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AlphabetStrategy

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Diabetic footDiabetic foot

Inspection:Inspection:–– DeformityDeformity–– Dryness or cracks in Dryness or cracks in

the skinthe skin–– WoundWound–– GangreneGangrene–– CallusCallus–– Toe nail Toe nail

Hallux valgusSIRIRA

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Diabetic footDiabetic foot

PulsePulse–– DorsalisDorsalis pedispedis pulse pulse –– Posterior Posterior tibialtibial pulsepulse–– PoplitealPopliteal–– FemoralFemoral

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Diabetic footDiabetic footMonofilament Monofilament –– โดยใหผูปวยหลับตาโดยใหผูปวยหลับตา กดปลายกดปลาย

monofilament monofilament ที่แขนผูปวยกอนที่แขนผูปวยกอนเพื่อใหผูปวยรูวาจะรูสึกอยางไรเพื่อใหผูปวยรูวาจะรูสึกอยางไร

–– ใหผูปวยหลับตาใหผูปวยหลับตา กดปลายกดปลาย monofilament monofilament ใหตั้งฉากกับฝาเทาใหตั้งฉากกับฝาเทา ใหให monofilamentmonofilament โคงงอเล็กนอยโคงงอเล็กนอยประมาณประมาณ 11--1.5 1.5 วินาทีวินาที

–– ตรวจครบตรวจครบ 10 10 จุดจุด ดังรูปดังรูป โดยตรวจโดยตรวจตําแหนงละตําแหนงละ 33 ครั้งครั้ง ((ถาตอบถูกถาตอบถูก 2 2 ในใน 3 3 ครั้งครั้ง == OKOK))

–– ถามวาผูปวยรูสกึหรือไมถามวาผูปวยรูสกึหรือไม

Loss of protective sense = จากการตรวจ monofilament ผูปวยไม

รูสึกถงึแรงกดมากกวา 4 จดุใน 10 จดุทีต่รวจ

Loss of protective sense = จากการตรวจ monofilament ผูปวยไม

รูสึกถงึแรงกดมากกวา 4 จดุใน 10 จดุทีต่รวจ SIRIRA

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Diabetic footDiabetic footVibrationVibration–– เลือกใชสอมเสียงขนาดเลือกใชสอมเสียงขนาด 128 Hz128 Hz

–– แสดงใหผูปวยทราบวาอาการสั่นเปนอยางไรแสดงใหผูปวยทราบวาอาการสั่นเปนอยางไร โดยวางโดยวางสอมเสียงที่ถูกทําใหสั่นที่กระดูกสอมเสียงที่ถูกทําใหสั่นที่กระดูก sternumsternum

–– ตรวจผูปวยขณะที่ผูปวยหลับตาตรวจผูปวยขณะที่ผูปวยหลับตา

–– วางสอมเสียงที่ปุมกระดูกวางสอมเสียงที่ปุมกระดูก distal distal interpharyngealinterpharyngeal joint joint ของนิ้วหัวแมเทาของนิ้วหัวแมเทา ตรวจทั้งตรวจทั้ง 22 ขางขาง

–– ถามผูปวยวารูสึกสั่นหรือไมถามผูปวยวารูสึกสั่นหรือไม และใหบอกทันทีเมื่อหยุดและใหบอกทันทีเมื่อหยุดสั่นสั่น จะไดจะได 2 2 คําตอบคําตอบ ทําขางละทําขางละ 2 2 ครั้งครั้ง นับเปนนับเปน 1 1 รอบรอบ เมื่อเมื่อทําครบทําครบ 1 1 รอบรอบ ใหทําซ้ําใหครบใหทําซ้ําใหครบ 2 2 รอบรอบ

–– ถาตอบผิดมากกวาถาตอบผิดมากกวา 5 5 ในใน 8 8 ครั้งของแตละขางแสดงวาครั้งของแตละขางแสดงวาขางนั้นมีขางนั้นมี peripheral neuropathyperipheral neuropathy

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Advice foot careAdvice foot care

DailyDaily feetfeet inspectioninspection,, includingincluding areasareas betweenbetween thethetoestoesIfIf visionvision isis impairedimpaired,, peoplepeople withwith diabetesdiabetes shouldshould notnotattemptattempt theirtheir ownown footfoot carecareRegularRegular washingwashing ofof feetfeet withwith carefulcareful dryingdrying,, especiallyespeciallybetweenbetween thethe toestoesWaterWater temperaturetemperature –– alwaysalways belowbelow 37C37CDoDo notnot useuse a a heaterheater oror a a hothot--waterwater bottlebottle toto warmwarmyour feetyour feetUseUse ofof lubricatinglubricating oilsoils oror creamscreams forfor drydry skinskin -- butbut notnotbetweenbetween thethe toestoes

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Advice foot careAdvice foot care

AvoidanceAvoidance ofof barefootbarefoot walkingwalking indoorsindoors ororoutdoorsoutdoors andand ofof wearingwearing ofof shoesshoes withoutwithoutsockssocksDailyDaily inspectioninspection andand palpationpalpation ofof thethe insideinside ofofthethe shoesshoesDoDo notnot wearwear tighttight shoesshoes oror shoesshoes withwith roughroughedgesedgesDailyDaily changechange ofof sockssocksWearingWearing ofof stockingstocking withwith seamsseams insideinside outout ororpreferablypreferably withoutwithout anyany seamsseamsNeverNever wearwear tighttight oror kneeknee--highhigh sockssocks

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Advice foot careAdvice foot careCuttingCutting nailsnails straightstraight acrossacrossChemicalChemical agentsagents oror plastersplasters totoremoveremove cornscorns andand callusescalluses -- shouldshouldnotnot bebe usedusedCornsCorns andand callusescalluses -- shouldshould bebe cutcutbyby a a healthcarehealthcare providerproviderPatientPatient awarenessawareness ofof thethe needneed totoensureensure thatthat feetfeet areare examinedexaminedregularlyregularly byby a a healthcarehealthcare providerproviderNotifyingNotifying thethe healthcarehealthcare providerprovider atatonceonce ifif a a blisterblister,, cutcut,, scratchscratch oror soresorehashas developeddeveloped

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ConclusionConclusion

What type of diabetes he/she has?What type of diabetes he/she has?What is the goal for this patient?What is the goal for this patient?We should correct and take care everything We should correct and take care everything according to alphabet strategyaccording to alphabet strategyWhich medication suitable for this patient?Which medication suitable for this patient?According to guidelineAccording to guidelineDoes she/he have any contraDoes she/he have any contra--indication for this indication for this medication?medication?Lifestyle modification is the fundamental Lifestyle modification is the fundamental management of diabetesmanagement of diabetesSIR

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Diabetes Control

Advice

Blood pressure

Cholesterol

DN screening

Eye Examination

Feet Care

Guardian Drugs


AlphabetStrategy

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TopicTopic

Thyroid diseaseThyroid diseaseDMDMEndocrine emergencyEndocrine emergency

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Thank youThank youSIRIRA

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Endocrine Med 2010 Step2

Health & Medicine

Transcript of Endocrine Med 2010 Step2