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Endocrine Med 2010 Step2

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Endocrine Disease J IRA SIR RAJ IRI JS IRA Apiradee Sriwijitkamol, MD SIR Division of Endocrinology and Metabolism Department of Medicine Faculty of Medicine Siriraj Hospital
Topic J IRA Thyroid disease SIR DM RAJ IRI JS IRA SIR
Topic J IRA Thyroid disease SIR DM RAJ IRI JS IRA SIR
SIR IRA JS IRI RAJ SIR IRA J
+ Hypothalamus J IRA - TRH SIR Pituitary RAJ TSH IRI JS Thyroid IRA SIR T4-TBG T4 T3 T3-TBG
Case 1 J IRA • 66 year old lady SIR • Presents with: • Depression RAJ • Myalgia IRI • Weight gain • On Examination: JS • Slow relaxing reflexes IRA • Sinus bradycardia SIR • BMI 32 • Swelling on the anterior aspect of the neck
SIR IRA JS IRI RAJ SIR IRA J
Case 1 J IRA • What is the diagnosis? SIR RAJ IRI JS IRA SIR
Case 2 J IRA • 36 year old lady SIR • Presents with: • RAJ Weight loss • Dyspnea on exertion For 6 months • IRI Palpitation JS • On Examination: IRA • Diffuse thyroid enlargement • SIR Sinus tachycardia, warm moist skin • Exophthalmos
SIR IRA JS IRI RAJ SIR IRA J
Case 2 J IRA • What is the diagnosis? SIR RAJ IRI JS IRA SIR
Case 3 J IRA • 36 year old lady SIR • Presents with: • RAJ Weight loss • Dyspnea on exertion For 2 months • IRI Palpitation JS • On Examination: IRA • Thyroid nodule 2 cm at right lobe • SIR Sinus tachycardia, warm moist skin • No exophthalmos, no pretibial myxedmea
SIR IRA JS IRI RAJ SIR IRA J
Case 3 J IRA • What is the diagnosis? SIR RAJ IRI JS IRA SIR
HYPOTHYROIDISM J IRA Signs & Symptoms :- SIR Tiredness / malaise Change in appearance RAJ Mental slowness Anaemia Reduced appetite Heart failure IRI Constipation JS Hypertension Sensitivity to drugs Bradycardia Cold intolerance Dyspnoea IRA / Hypothermia SIR
HYPOTHYROIDISM J Aetiology IRA SIR Primary (90%) Secondary (<10%) Tertiary (Rare) Thyroid Tissue Dysfunction of Dysfunction of RAJ Loss or Atrophy Pituitary Gland Hypothalamus Tumour or IRI Autoimmune Decreased TRH surgery Post Surgery Production JS Post Irradiation Decreased TSH Infiltration Production IRA Decreased Hormone SIR Synthesis Decreased Thyroxin Production
HYPOTHYROIDISM J IRA DIAGNOSIS SIR Serum T4 or fT4 RAJ Below Normal IRI Primary Hypothyroidism JS Secondary Hypothyroidism Tertiary Hypothyroidism IRA SIR
HYPOTHYROIDISM J IRA DIAGNOSIS SIR Serum TSH RAJ Above Normal Below Normal IRI Primary Hypothyroidism JS Secondary Hypothyroidism Tertiary Hypothyroidism IRA SIR
HYPOTHYROIDISM J IRA Treatment SIR Thyroxin replacement Goal: RAJ Primary hypothyroidism: Normalized TSH IRI Secondary hypothyroidism: JS T4 in upper half of normal limit IRA SIR
HYPOTHYROIDISM J IRA Treatment SIR Highly successful in bringing patients back to normal metabolic state RAJ Therapy continues for life Caution when commencing treatment - risk of MI IRI JS Patients observed for signs of • Angina IRA • ECG changes SIR • Dyspnoea • Palpitations • Arrythmias
THYROTOXICOSIS Excess of the thyroid hormone resulting J IRA in an hypermetabolic state Signs & Symptoms :- SIR Weight loss (but normal Generalised muscle RAJ appetite) weakness Sweating; heat intolerance Diarrhoea IRI Fatigue JS Rapid bounding pulse Palpitation; sinus Shortness of breath tachycardia or atrial fibrilation Warm moist skin IRA Angina; Heart failure (high Insomnia SIR output) Agitation; tremor
THYROTOXICOSIS J IRA Hyperthyroidism Other causes of thyrotoxicosis SIR -Graves’ disease -Subacute thyroiditis RAJ -Toxic multinodular goiter -Excessive iodine intake -Thyrotoxicosis factitious IRI JS -Struma ovarii Increase uptake Decrease uptake IRA SIR Antithyroid drug Treat cause +Ablative treatment
HYPERTHYROIDISM J IRA Definition:- SIR "Excessive secretion of the thyroid hormone resulting in an hypermetabolic state.....". RAJ IRI Incidence:- JS 2 - 5% of all females between age of 30-50 yrs Male / female: 1 : 7 IRA Can be precipitated by a life 'crisis' SIR
HYPERTHYROIDISM J IRA Aetiology SIR Primary (99%) Secondary (Rare) RAJ Thyroid Tissue Over Secretion Disease by Pituitary Tumor IRI Autoimmune Increased TSH (Graves’ Disease) Thyroid nodule JS Production Thyroid Stimulating Antibodies (Toxic adenoma) IRA Increased Autonomous Increased Thyroxin Stimulation of TSH Receptors Production SIR Increased Thyroxin Production
Hyperthyroidism J IRA Signs & Symptoms :- SIR Weight loss (but normal Generalised muscle appetite) weakness RAJ Sweating; heat intolerance Diarrhoea Rapid bounding pulse IRI Fatigue Palpitation; sinus JS Shortness of breath tachycardia or atrial fibrilation Warm moist skin Angina; Heart failure (high Insomnia IRA output) SIR Agitation; tremor
SIR IRA JS IRI RAJ Thyroid Acropachy SIR IRA J
SIR IRA JS IRI Lid Lag RAJ SIR IRA J
Graves’ Disease - Eyes J IRA SIR RAJ IRI JS IRA SIR Proptosis Exopthalmos
J IRA SIR RAJ IRI JS IRA SIR Periorbital Myxoedema
SIR IRA JS IRI RAJ Pretibial Myxedema SIR IRA J
HYPERTHYROIDISM J IRA Diagnosis SIR Serum T3, T4 and free T3,T4 RAJ Above Normal IRI Primary Hyperthyroidism JS Secondary Hyperthyroidism IRA SIR
HYPERTHYROIDISM J IRA Diagnosis SIR Serum TSH RAJ Below Normal Above Normal IRI PrimaryJS Secondary Hyperthyroidism Hyperthyroidism IRA SIR
HYPERTHYROIDISM J IRA Treatment :- SIR Highly successful in bringing patients back to RAJ normal metabolic state IRI Long term follow-up Treatment: JS Anti-Thyroid drugs IRA Radioiodine SIR Thyroidectomy Partial Total
HYPERTHYROIDISM J IRA Treatment :- SIR Anti-Thyroid drugs Dose: RAJ Start: PTU 150-300 mg/day or Methimazole 15- IRI 30 mg/day Maintain: taper dose as clinical and laboratory JS results IRA Duration: 1 ½ - 2 years Side effects SIR Minor: Rash Major: Agranulocytosis, hepatitis
HYPERTHYROIDISM J IRA Treatment :- SIR Ablative treatment Indication: RAJ Failure to medication IRI Relapse or recurrent Major drug adverse reaction JS Patient with underlying heart disease IRA Toxic adenoma Options: SIR Radioactive iodine Surgery
SIR IRA JS IRI RAJ SIR IRA J NODULE THYROID
FINE NEEDLE ASPIRATION J IRA SIR RAJ IRI JS IRA SIR
FINE NEEDLE ASPIRATION J IRA SIR RAJ IRI JS IRA SIR
FINE NEEDLE ASPIRATION J IRA SIR RAJ IRI JS IRA SIR
Case 1 J IRA • 66 year old lady SIR • Presents with: • Depression RAJ • Myalgia IRI • Weight gain • On Examination: JS • Slow relaxing reflexes IRA • Sinus bradycardia SIR • BMI 32 • Swelling on the anterior aspect of the neck
SIR IRA JS IRI RAJ SIR IRA J
Case 1 J IRA • What is the diagnosis? SIR RAJ Hypothyroidism IRI JS FT4 and TSH IRA Thyroid antibody SIR
Case 2 J IRA • 36 year old lady SIR • Presents with: • RAJ Weight loss • Dyspnea on exertion For 6 months • IRI Palpitation JS • On Examination: IRA • Diffuse thyroid enlargement • SIR Sinus tachycardia, warm moist skin • Exophthalmos
SIR IRA JS IRI RAJ SIR IRA J
Case 2 J IRA • What is the diagnosis? SIR RAJ Hyperthyroidism: Graves’ disease IRI JS T3, T4 and TSH IRA SIR
Case 3 J IRA • 36 year old lady SIR • Presents with: • RAJ Weight loss • Dyspnea on exertion For 2 months • IRI Palpitation JS • On Examination: IRA • Thyroid nodule 3 cm at leftt lobe • SIR Sinus tachycardia, warm moist skin • No exophthalmos, no pretibial myxedmea
SIR IRA JS IRI RAJ SIR IRA J
Case 3 J IRA • What is the diagnosis? SIR RAJ Thyrotoxicosis: IRI Toxic adenoma JS Exogenous thyroid IRA T3, T4 and TSH SIR Thyroid scan
Thyroid scan J IRA SIR RAJ IRI JS IRA SIR Toxic adenoma
Topic J IRA Thyroid disease SIR DM RAJ IRI JS IRA SIR
Diagnostic criteria for diabetes J IRA Venous Plasma Glucose SIR concentration, mg dl-1 Diabetes mellitus RAJ Fasting* ≥126 Symptom of DM + Casual plasma ≥200 IRI Glucose JS 2-h post glucose load ≥200 IRA *Repeat in different day SIR
Classification of Diabetes J IRA Type 1 Diabetes SIR Type 2 Diabetes Gestational Diabetes RAJ Other types IRI – Endocrine disease JS – Chronic pancreatitis IRA – Malnutrition-related diabetes mellitus (MRDM) SIR
Case 1 J IRA 39-year old woman came to SIR see you because polyuria, polydipsia and nocturia 4 RAJ times/night. IRI PE Diagnosis mmHg, other BP 130/90 Diabetes JS as in figure IRA You ordered BG stat (11am) and it was 230 mg/dl SIR Cause of Diabetes Cushing’s syndrome
Diabetes Care: J THE ALPHABET STRATEGY IRA SIR Advice RAJ Blood pressure Cholesterol IRI Diabetes Control JS Alphabet DN screening Eye Examination Strategy IRA Feet Care Guardian Drugs SIR
Conclusion: The Modified Alphabet Strategy J IRA SIR • Advice Smoking , diet , exercise • Blood pressure < 130/80 RAJ • Cholesterol LDL ≤ 100 IRI • Diabetes control JS HbA1c ≤ 7% • DN screening Annual examination IRA • Eye examination Annual examination • Feet examination Annual examination SIR • Guardian drugs Aspirin, ACEI, statins
Case 2 J IRA Mr. M,46-yr old man came to you for check up SIR He had no underlying disease without any symptoms of hyperglycemia RAJ Smoking and drinking occasionally Type 2 diabetes, HT, On physical examination, his blood pressure IRI Combined dyslipidemia, was 130/90 mmHg and his BMI was 31 kg/m2, Obesity others were unremarkable JS His lab investigation were followed, FPG 155 IRA mg/dl, CH 250 mg/dl, TG 200 mg/dl, HDL 40 mg/dl, LDL 170 mg/dl SIR 1 week later, his FPG was 150 mg/dl, HbA1c was 7.5%
Diabetes Care: J THE ALPHABET STRATEGY IRA SIR Advice RAJ Blood pressure Cholesterol IRI Diabetes Control JS Alphabet DN screening Eye Examination Strategy IRA Feet Care Guardian Drugs SIR
Initiation of antihypertensive treatment Other risk Normal High normal Grade 1 HT Grade 2 HT Grade 3 HT factors, OD SBP 120-129 or SBP 130-139 SBP 140-159 or SBP 160-179 or SBP ≥180 or or disease DBP 80-84 or DBP 85-89 DBP 90-99 DBP 100-109 DBP ≥110 J IRA Lifestyle Lifestyle Lifestyle changes for changes for changes + No other risk No BP No BP several months several weeks immediate SIR factors intervention intervention then drug then drug drug treatment if BP treatment if BP treatment uncontrolled uncontrolled Lifestyle Lifestyle RAJ Lifestyle changes for changes for changes + 1-2 risk Lifestyle Lifestyle several weeks several weeks factors changes changes immediate then drug then drug drug IRI treatment if BP treatment if BP treatment uncontrolled uncontrolled 3 or more Lifestyle JS risk factors, Lifestyle changes and Lifestyle MS, OD or changes consider drug Lifestyle Lifestyle changes + diabetes treatment changes + drug changes + drug immediate IRA Lifestyle treatment treatment drug Diabetes Lifestyle treatment changes changes + drug treatment SIR Lifestyle Lifestyle Lifestyle Lifestyle Lifestyle Established changes + changes + changes + changes + changes + CV or renal immediate disease immediate drug immediate immediate drug immediate drug treatment drug treatment treatment treatment drug treatment
Antihypertensive Treatment: Preferred Drugs General rules: lower SBP and DBP to goal. Use any effective agent at adequate doses, if useful in combination. Use long J acting agents to lower BP throughout 24 hours. Avoid or minimize adverse effects. IRA Subclinical organ damage Left ventricular hypertrophy ACE inhibitors, calcium antagonists, angiotensin receptor antagonists SIR Asymptomatic atherosclerosis Calcium antagonists, ACE inhibitors Microalbuminuria ACE inhibitors, angiotensin receptor antagonists Renal dysfunction ACE inhibitors, angiotensin receptor antagonists RAJ Clinical event Previous stroke Any BP lowering agent Previous MI β-blockers, ACE inhibitors, angiotensin receptor antagonists Angina pectoris β-blockers, calcium antagonists IRI Heart failure diuretics, β-blockers, ACE inhibitors, angiotensin receptor antagonists, antialdosterone agents Atrial fibrillation Recurrent ACE inhibitors, angiotensin receptor antagonists Continuous JS β-blockers, non-dihydropiridine calcium antagonists Renal failure/proteinuria ACE inhibitors, angiotensin receptor antagonists, loop diuretics Peripheral artery disease Calcium antagonists IRA Condition Isolated systolic hypertension (elderly) Duretics, calcium antagonists Metabolic syndrome ACE inhibitors, angiotensin receptor antagonists, calcium antagonists SIR Diabetes mellitus ACE inhibitors, angiotensin receptor blocker Pregnancy calcium antagonists, methyldopa, β-blockers Blacks diuretics, calcium antagonists
Diabetes Care: J THE ALPHABET STRATEGY IRA SIR Advice RAJ Blood pressure Cholesterol IRI Diabetes Control JS Alphabet DN screening Eye Examination Strategy IRA Feet Care Guardian Drugs SIR
NCEP ATP III: LDL-C Goals (2004 Modifications) J IRA High Risk Moderately Moderate Lower High Risk Risk Risk CHD or CHD risk ≥ 2 risk ≥ 2 risk < 2 risk SIR equivalents factors factors factors 190 (10-yr risk (10-yr risk (10-yr risk >20%) 10-20%) <10%) goal 160 RAJ mg/dL 160 LDL-C level goal goal IRI 130 130 mg/dL mg/dL 130 goal JS 100 mg/dL IRA 100 Existing LDL-C goals SIR Proposed LDL-C goals 70 - *CHD risk equivalents = DM, PAD, Stroke, CKD Grundy SM et al. Circulation 2004;110:227-239.
Major Risk Factors J IRA Cigarette smoking SIR HT: BP ≥140/90 mmHg or on antihypertensive agent Low HDL-C (<40 mg/dL)† RAJ Family history of premature CHD IRI – CHD in male first degree relative <55 years JS – CHD in female first degree relative <65 years Age (men ≥45 years; women ≥55 years) IRA SIR † HDL-C ≥60 mg/dL counts as a “negative” risk factor
NCEP ATP III: 2004 Modifications High Risk Moderately Moderate Lower High Risk Risk Risk J CHD or CHD risk ≥ 2 risk ≥ 2 risk < 2 risk IRA equivalents factors factors factors 190 (10-yr risk (10-yr risk (10-yr risk >20%) 10-20%) <10%) goal SIR 160 mg/dL 160 LDL-C level goal goal RAJ 130 130 mg/dL mg/dL 130 IRI goal or 100 optional mg/dL 100 mg/dL* JS 100 or Existing LDL-C goals optional 70 IRA Proposed LDL-C mg/dL* goals 70 - SIR * 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.
Diabetes Care: J THE ALPHABET STRATEGY IRA SIR Advice RAJ Blood pressure Cholesterol IRI Diabetes Control JS Alphabet DN screening Eye Examination Strategy IRA Feet Care Guardian Drugs SIR
Oral hypoglycemic drugs J IRA Insulin secretagogue SIR – Sulfonylurea: glibenclamide, glipizide, gliclazide RAJ – Glinide group IRI Biguanide: metformin α-Glucosidase Inhibitor: acarbose, JS voglibose IRA Thiazolidinediones: Rosiglitazone, SIR plioglitazone Incretin
Primary sites of action of oral anti-diabetic agents J IRA Biguanides Thiazolidinediones SIR DPP-4 RAJ inhibitors IRI DPP-4 Insulin JS Glucose GLP-1 IRA Sulphonylureas α-glucosidase inhibitors SIR GLP-1 and meglitinides analogues
J IRA SIR RAJ IRI JS IRA SIR ITC-1. Annals of Int Med. 2007
Insulin J IRA Intermediate acting: NPH, Humulin N, SIR Insulatard Short acting: RI, Humulin R, Actrapid RAJ Premixed insulin: Humulin 70/30, IRI Mixtard 30 JS Rapid acting: Insulin lispro, aspart IRA Long acting insulin: Insulin glargine, determir SIR
การออกฤทธิ์ของอินซูลิน J IRA Aspart Lispro SIR Regular NPH RAJ Glargine Detemir IRI JS 4 8 12 16 20 24 IRA ระยะเวลาหลังฉีดยาอินซูลิน (ชั่วโมง) SIR
ADA/EASD 2008 guideline Tier 1: Well-validated core therapies J Lifestyle + metformin Lifestyle + metformin IRA + + At diagnosis basal insulin Intensify insulin *HbA1c >8.5% SIR Lifestyle modification + metformin Lifestyle + metformin + RAJ sulfonylurea Step 1 Step 2 Step 3 IRI Tier 2: Less Lifestyle + metformin Lifestyle + metformin well-validated + JS + therapies Pioglitazone Pioglitazone No hypoglycemia + IRA CHF, Bone loss sulfonylurea Lifestyle + metformin SIR Lifestyle + metformin + + GLP-1 agonist basal insulin No hypogly, Wt loss Nausea vomitting Nathan DM, et al. Diabetes care 2008; 31:1-11.
Thai’s guideline for management of T2DM J IRA FPG <200 mg/dl or Lifestyle modification HbA1c <8% 1-3 months SIR Insulin resistance Insulin defiiciency phenotype phenotype Monotherapy Concurrent with medication FPG 200-300 mg/dl RAJ Metformin or Sulfonylurea Lifestyle modification Other: TZDs, Glinide, AGI IRI or DPP-IV inhibitor FPG 250-350 mg/dl or HbA1c >9% JS Combination OHA IRA FPG >300 mg/dl or Insulin therapy HbA1c >11% or SIR Symptomatic hyperglycemia Basal or Premixed or MDI
Approach to patient with poor glycemic control J IRA Diet history SIR Exercise history RAJ Compliance history Concurrent medication IRI – Herbal medicine JS – Steroid IRA – Diuretics, beta-blocker SIR Occult infection
Diabetes Care: J THE ALPHABET STRATEGY IRA SIR Advice RAJ Blood pressure Cholesterol IRI Diabetes Control JS Alphabet DN screening Eye Examination Strategy IRA Feet Care Guardian Drugs SIR
Screening for Diabetic Nephropathy J IRA SIR Test When Normal Range RAJ Blood Each office visit <130/80 mm/Hg 1 Pressure GFR = ([140-age] X weight in kg) X 0.85 (if female) IRI Creatinine Annually >90 ml/min per 1.73 Clearance1 JS m2 BSA (serum creatinine X 72) Urinary Type 2: Annually <30 mg/day IRA 1 Albumin beginning at diagnosis <30 μg/mg creatinine Type 1: Annually, 5 -years SIR post -diagnosis 1American Diabetes Association: Nephropathy in Diabetes (Position Statement). Diabetes Care 27 (Suppl.1): S79-S83, 2007
Definitions of abnormalities in albumin secretion J IRA SIR Category Spot collection μg/mg creatinine RAJ Normal <30 IRI Microalbuminuria 30-299 JS IRA Macroalbuminuria >300 SIR 1American Diabetes Association: Nephropathy in Diabetes (Position Statement). Diabetes Care 28 (Suppl.1): S3-41, 2008
Stage of CKD J IRA SIR Stage GFR ml/min per 1.73m2 BSA RAJ 1 >90 IRI 2 60-89 3 30-59 JS 4 15-29 IRA 5 <15 or dialysis SIR 1American Diabetes Association: Nephropathy in Diabetes (Position Statement). Diabetes Care 28 (Suppl.1): S3-41, 2008
Diabetes Care: J THE ALPHABET STRATEGY IRA SIR Advice RAJ Blood pressure Cholesterol IRI Diabetes Control JS Alphabet DN screening Eye Examination Strategy IRA Feet Care Guardian Drugs SIR
Diabetic foot J IRA Inspection: SIR – Deformity – Dryness or cracks in RAJ the skin – Wound IRI – Gangrene JS – Callus IRA – Toe nail SIR Hallux valgus
Diabetic foot J IRA SIR Pulse – Dorsalis pedis pulse RAJ – Posterior tibial pulse – IRI Popliteal – Femoral JS IRA SIR
Diabetic foot J IRA Monofilament – โดยใหผูปวยหลับตา กดปลาย SIR monofilament ที่แขนผูปวยกอน เพื่อใหผูปวยรูวาจะรูสึกอยางไร RAJ – ใหผูปวยหลับตา กดปลาย IRI monofilament ใหตั้งฉากกับฝาเทา ให monofilament โคงงอเล็กนอย JS ประมาณ 1-1.5 วินาที IRA Loss of protective sense ==จากการตรวจ10 จุด ดังรูป โดยตรวจ Loss of protective sense ตรวจครบ monofilament ผูปววยไม – จากการตรวจ monofilament ผูป ยไม รูรูสึกถึงแรงกดมากกวา44จุจุดในา10จุจุดทีตรวจ ครั้ง (ถาตอบถูก 2 ใน 3 สึกถึงแรงกดมากกวา ดใน 10 ดทีง่ละ 3 ตํ แหน ตรวจ SIR ่ ครั้ง = OK) – ถามวาผูปวยรูสกหรือไม ึ
Diabetic foot J IRA Vibration – เลือกใชสอมเสียงขนาด 128 Hz SIR – แสดงใหผูปวยทราบวาอาการสั่นเปนอยางไร โดยวาง สอมเสียงที่ถูกทําใหสั่นที่กระดูก sternum RAJ – ตรวจผูปวยขณะที่ผูปวยหลับตา IRI – วางสอมเสียงที่ปุมกระดูก distal interpharyngeal joint ของนิ้วหัวแมเทา ตรวจทั้ง 2 ขาง JS – ถามผูปวยวารูสึกสั่นหรือไม และใหบอกทันทีเมื่อหยุด  IRA สั่น จะได 2 คําตอบ ทําขางละ 2 ครั้ง นับเปน 1 รอบ เมื่อ ทําครบ 1 รอบ ใหทําซ้ําใหครบ 2 รอบ SIR – ถาตอบผิดมากกวา 5 ใน 8 ครั้งของแตละขางแสดงวา ขางนั้นมี peripheral neuropathy
Advice foot care J IRA Daily feet inspection, including areas between the toes SIR If vision is impaired, people with diabetes should not attempt their own foot care RAJ Regular washing of feet with careful drying, especially between the toes IRI Water temperature – always below 37C Do not use a heater or a hot-water bottle to warm JS your feet IRA Use of lubricating oils or creams for dry skin - but not between the toes SIR
Advice foot care J IRA Avoidance of barefoot walking indoors or outdoors and of wearing of shoes without SIR socks Daily inspection and palpation of the inside of RAJ the shoes Do not wear tight shoes or shoes with rough IRI edges Daily change of socks JS Wearing of stocking with seams inside out or IRA preferably without any seams Never wear tight or knee-high socks SIR
Advice foot care J IRA Cutting nails straight across SIR Chemical agents or plasters to remove corns and calluses - should not be used RAJ Corns and calluses - should be cut IRI by a healthcare provider Patient awareness of the need to JS ensure that feet are examined IRA regularly by a healthcare provider Notifying the healthcare provider at SIR once if a blister, cut, scratch or sore has developed
Conclusion J IRA What type of diabetes he/she has? SIR What is the goal for this patient? We should correct and take care everything RAJ according to alphabet strategy Which medication suitable for this patient? IRI According to guideline JS Does she/he have any contra-indication for this IRA medication? Lifestyle modification is the fundamental SIR management of diabetes
Diabetes Care: J THE ALPHABET STRATEGY IRA SIR Advice RAJ Blood pressure Cholesterol IRI Diabetes Control JS Alphabet DN screening Eye Examination Strategy IRA Feet Care Guardian Drugs SIR
Topic J IRA Thyroid disease SIR DM RAJ Endocrine emergency IRI JS IRA SIR
SIR IRA JS IRI RAJ Thank you SIR IRA J

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Endocrine Med 2010 Step2

  • 1. Endocrine Disease J IRA SIR RAJ IRI JS IRA Apiradee Sriwijitkamol, MD SIR Division of Endocrinology and Metabolism Department of Medicine Faculty of Medicine Siriraj Hospital
  • 2. Topic J IRA Thyroid disease SIR DM RAJ IRI JS IRA SIR
  • 3. Topic J IRA Thyroid disease SIR DM RAJ IRI JS IRA SIR
  • 4. SIR IRA JS IRI RAJ SIR IRA J
  • 5. + Hypothalamus J IRA - TRH SIR Pituitary RAJ TSH IRI JS Thyroid IRA SIR T4-TBG T4 T3 T3-TBG
  • 6. Case 1 J IRA • 66 year old lady SIR • Presents with: • Depression RAJ • Myalgia IRI • Weight gain • On Examination: JS • Slow relaxing reflexes IRA • Sinus bradycardia SIR • BMI 32 • Swelling on the anterior aspect of the neck
  • 7. SIR IRA JS IRI RAJ SIR IRA J
  • 8. Case 1 J IRA • What is the diagnosis? SIR RAJ IRI JS IRA SIR
  • 9. Case 2 J IRA • 36 year old lady SIR • Presents with: • RAJ Weight loss • Dyspnea on exertion For 6 months • IRI Palpitation JS • On Examination: IRA • Diffuse thyroid enlargement • SIR Sinus tachycardia, warm moist skin • Exophthalmos
  • 10. SIR IRA JS IRI RAJ SIR IRA J
  • 11. Case 2 J IRA • What is the diagnosis? SIR RAJ IRI JS IRA SIR
  • 12. Case 3 J IRA • 36 year old lady SIR • Presents with: • RAJ Weight loss • Dyspnea on exertion For 2 months • IRI Palpitation JS • On Examination: IRA • Thyroid nodule 2 cm at right lobe • SIR Sinus tachycardia, warm moist skin • No exophthalmos, no pretibial myxedmea
  • 13. SIR IRA JS IRI RAJ SIR IRA J
  • 14. Case 3 J IRA • What is the diagnosis? SIR RAJ IRI JS IRA SIR
  • 15. HYPOTHYROIDISM J IRA Signs & Symptoms :- SIR Tiredness / malaise Change in appearance RAJ Mental slowness Anaemia Reduced appetite Heart failure IRI Constipation JS Hypertension Sensitivity to drugs Bradycardia Cold intolerance Dyspnoea IRA / Hypothermia SIR
  • 16. HYPOTHYROIDISM J Aetiology IRA SIR Primary (90%) Secondary (<10%) Tertiary (Rare) Thyroid Tissue Dysfunction of Dysfunction of RAJ Loss or Atrophy Pituitary Gland Hypothalamus Tumour or IRI Autoimmune Decreased TRH surgery Post Surgery Production JS Post Irradiation Decreased TSH Infiltration Production IRA Decreased Hormone SIR Synthesis Decreased Thyroxin Production
  • 17. HYPOTHYROIDISM J IRA DIAGNOSIS SIR Serum T4 or fT4 RAJ Below Normal IRI Primary Hypothyroidism JS Secondary Hypothyroidism Tertiary Hypothyroidism IRA SIR
  • 18. HYPOTHYROIDISM J IRA DIAGNOSIS SIR Serum TSH RAJ Above Normal Below Normal IRI Primary Hypothyroidism JS Secondary Hypothyroidism Tertiary Hypothyroidism IRA SIR
  • 19. HYPOTHYROIDISM J IRA Treatment SIR Thyroxin replacement Goal: RAJ Primary hypothyroidism: Normalized TSH IRI Secondary hypothyroidism: JS T4 in upper half of normal limit IRA SIR
  • 20. HYPOTHYROIDISM J IRA Treatment SIR Highly successful in bringing patients back to normal metabolic state RAJ Therapy continues for life Caution when commencing treatment - risk of MI IRI JS Patients observed for signs of • Angina IRA • ECG changes SIR • Dyspnoea • Palpitations • Arrythmias
  • 21. THYROTOXICOSIS Excess of the thyroid hormone resulting J IRA in an hypermetabolic state Signs & Symptoms :- SIR Weight loss (but normal Generalised muscle RAJ appetite) weakness Sweating; heat intolerance Diarrhoea IRI Fatigue JS Rapid bounding pulse Palpitation; sinus Shortness of breath tachycardia or atrial fibrilation Warm moist skin IRA Angina; Heart failure (high Insomnia SIR output) Agitation; tremor
  • 22. THYROTOXICOSIS J IRA Hyperthyroidism Other causes of thyrotoxicosis SIR -Graves’ disease -Subacute thyroiditis RAJ -Toxic multinodular goiter -Excessive iodine intake -Thyrotoxicosis factitious IRI JS -Struma ovarii Increase uptake Decrease uptake IRA SIR Antithyroid drug Treat cause +Ablative treatment
  • 23. HYPERTHYROIDISM J IRA Definition:- SIR "Excessive secretion of the thyroid hormone resulting in an hypermetabolic state.....". RAJ IRI Incidence:- JS 2 - 5% of all females between age of 30-50 yrs Male / female: 1 : 7 IRA Can be precipitated by a life 'crisis' SIR
  • 24. HYPERTHYROIDISM J IRA Aetiology SIR Primary (99%) Secondary (Rare) RAJ Thyroid Tissue Over Secretion Disease by Pituitary Tumor IRI Autoimmune Increased TSH (Graves’ Disease) Thyroid nodule JS Production Thyroid Stimulating Antibodies (Toxic adenoma) IRA Increased Autonomous Increased Thyroxin Stimulation of TSH Receptors Production SIR Increased Thyroxin Production
  • 25. Hyperthyroidism J IRA Signs & Symptoms :- SIR Weight loss (but normal Generalised muscle appetite) weakness RAJ Sweating; heat intolerance Diarrhoea Rapid bounding pulse IRI Fatigue Palpitation; sinus JS Shortness of breath tachycardia or atrial fibrilation Warm moist skin Angina; Heart failure (high Insomnia IRA output) SIR Agitation; tremor
  • 26. SIR IRA JS IRI RAJ Thyroid Acropachy SIR IRA J
  • 27. SIR IRA JS IRI Lid Lag RAJ SIR IRA J
  • 28. Graves’ Disease - Eyes J IRA SIR RAJ IRI JS IRA SIR Proptosis Exopthalmos
  • 29. J IRA SIR RAJ IRI JS IRA SIR Periorbital Myxoedema
  • 30. SIR IRA JS IRI RAJ Pretibial Myxedema SIR IRA J
  • 31. HYPERTHYROIDISM J IRA Diagnosis SIR Serum T3, T4 and free T3,T4 RAJ Above Normal IRI Primary Hyperthyroidism JS Secondary Hyperthyroidism IRA SIR
  • 32. HYPERTHYROIDISM J IRA Diagnosis SIR Serum TSH RAJ Below Normal Above Normal IRI PrimaryJS Secondary Hyperthyroidism Hyperthyroidism IRA SIR
  • 33. HYPERTHYROIDISM J IRA Treatment :- SIR Highly successful in bringing patients back to RAJ normal metabolic state IRI Long term follow-up Treatment: JS Anti-Thyroid drugs IRA Radioiodine SIR Thyroidectomy Partial Total
  • 34. HYPERTHYROIDISM J IRA Treatment :- SIR Anti-Thyroid drugs Dose: RAJ Start: PTU 150-300 mg/day or Methimazole 15- IRI 30 mg/day Maintain: taper dose as clinical and laboratory JS results IRA Duration: 1 ½ - 2 years Side effects SIR Minor: Rash Major: Agranulocytosis, hepatitis
  • 35. HYPERTHYROIDISM J IRA Treatment :- SIR Ablative treatment Indication: RAJ Failure to medication IRI Relapse or recurrent Major drug adverse reaction JS Patient with underlying heart disease IRA Toxic adenoma Options: SIR Radioactive iodine Surgery
  • 36. SIR IRA JS IRI RAJ SIR IRA J NODULE THYROID
  • 37. FINE NEEDLE ASPIRATION J IRA SIR RAJ IRI JS IRA SIR
  • 38. FINE NEEDLE ASPIRATION J IRA SIR RAJ IRI JS IRA SIR
  • 39. FINE NEEDLE ASPIRATION J IRA SIR RAJ IRI JS IRA SIR
  • 40. Case 1 J IRA • 66 year old lady SIR • Presents with: • Depression RAJ • Myalgia IRI • Weight gain • On Examination: JS • Slow relaxing reflexes IRA • Sinus bradycardia SIR • BMI 32 • Swelling on the anterior aspect of the neck
  • 41. SIR IRA JS IRI RAJ SIR IRA J
  • 42. Case 1 J IRA • What is the diagnosis? SIR RAJ Hypothyroidism IRI JS FT4 and TSH IRA Thyroid antibody SIR
  • 43. Case 2 J IRA • 36 year old lady SIR • Presents with: • RAJ Weight loss • Dyspnea on exertion For 6 months • IRI Palpitation JS • On Examination: IRA • Diffuse thyroid enlargement • SIR Sinus tachycardia, warm moist skin • Exophthalmos
  • 44. SIR IRA JS IRI RAJ SIR IRA J
  • 45. Case 2 J IRA • What is the diagnosis? SIR RAJ Hyperthyroidism: Graves’ disease IRI JS T3, T4 and TSH IRA SIR
  • 46. Case 3 J IRA • 36 year old lady SIR • Presents with: • RAJ Weight loss • Dyspnea on exertion For 2 months • IRI Palpitation JS • On Examination: IRA • Thyroid nodule 3 cm at leftt lobe • SIR Sinus tachycardia, warm moist skin • No exophthalmos, no pretibial myxedmea
  • 47. SIR IRA JS IRI RAJ SIR IRA J
  • 48. Case 3 J IRA • What is the diagnosis? SIR RAJ Thyrotoxicosis: IRI Toxic adenoma JS Exogenous thyroid IRA T3, T4 and TSH SIR Thyroid scan
  • 49. Thyroid scan J IRA SIR RAJ IRI JS IRA SIR Toxic adenoma
  • 50. Topic J IRA Thyroid disease SIR DM RAJ IRI JS IRA SIR
  • 51. Diagnostic criteria for diabetes J IRA Venous Plasma Glucose SIR concentration, mg dl-1 Diabetes mellitus RAJ Fasting* ≥126 Symptom of DM + Casual plasma ≥200 IRI Glucose JS 2-h post glucose load ≥200 IRA *Repeat in different day SIR
  • 52. Classification of Diabetes J IRA Type 1 Diabetes SIR Type 2 Diabetes Gestational Diabetes RAJ Other types IRI – Endocrine disease JS – Chronic pancreatitis IRA – Malnutrition-related diabetes mellitus (MRDM) SIR
  • 53. Case 1 J IRA 39-year old woman came to SIR see you because polyuria, polydipsia and nocturia 4 RAJ times/night. IRI PE Diagnosis mmHg, other BP 130/90 Diabetes JS as in figure IRA You ordered BG stat (11am) and it was 230 mg/dl SIR Cause of Diabetes Cushing’s syndrome
  • 54. Diabetes Care: J THE ALPHABET STRATEGY IRA SIR Advice RAJ Blood pressure Cholesterol IRI Diabetes Control JS Alphabet DN screening Eye Examination Strategy IRA Feet Care Guardian Drugs SIR
  • 55. Conclusion: The Modified Alphabet Strategy J IRA SIR • Advice Smoking , diet , exercise • Blood pressure < 130/80 RAJ • Cholesterol LDL ≤ 100 IRI • Diabetes control JS HbA1c ≤ 7% • DN screening Annual examination IRA • Eye examination Annual examination • Feet examination Annual examination SIR • Guardian drugs Aspirin, ACEI, statins
  • 56. Case 2 J IRA Mr. M,46-yr old man came to you for check up SIR He had no underlying disease without any symptoms of hyperglycemia RAJ Smoking and drinking occasionally Type 2 diabetes, HT, On physical examination, his blood pressure IRI Combined dyslipidemia, was 130/90 mmHg and his BMI was 31 kg/m2, Obesity others were unremarkable JS His lab investigation were followed, FPG 155 IRA mg/dl, CH 250 mg/dl, TG 200 mg/dl, HDL 40 mg/dl, LDL 170 mg/dl SIR 1 week later, his FPG was 150 mg/dl, HbA1c was 7.5%
  • 57. Diabetes Care: J THE ALPHABET STRATEGY IRA SIR Advice RAJ Blood pressure Cholesterol IRI Diabetes Control JS Alphabet DN screening Eye Examination Strategy IRA Feet Care Guardian Drugs SIR
  • 58. Initiation of antihypertensive treatment Other risk Normal High normal Grade 1 HT Grade 2 HT Grade 3 HT factors, OD SBP 120-129 or SBP 130-139 SBP 140-159 or SBP 160-179 or SBP ≥180 or or disease DBP 80-84 or DBP 85-89 DBP 90-99 DBP 100-109 DBP ≥110 J IRA Lifestyle Lifestyle Lifestyle changes for changes for changes + No other risk No BP No BP several months several weeks immediate SIR factors intervention intervention then drug then drug drug treatment if BP treatment if BP treatment uncontrolled uncontrolled Lifestyle Lifestyle RAJ Lifestyle changes for changes for changes + 1-2 risk Lifestyle Lifestyle several weeks several weeks factors changes changes immediate then drug then drug drug IRI treatment if BP treatment if BP treatment uncontrolled uncontrolled 3 or more Lifestyle JS risk factors, Lifestyle changes and Lifestyle MS, OD or changes consider drug Lifestyle Lifestyle changes + diabetes treatment changes + drug changes + drug immediate IRA Lifestyle treatment treatment drug Diabetes Lifestyle treatment changes changes + drug treatment SIR Lifestyle Lifestyle Lifestyle Lifestyle Lifestyle Established changes + changes + changes + changes + changes + CV or renal immediate disease immediate drug immediate immediate drug immediate drug treatment drug treatment treatment treatment drug treatment
  • 59. Antihypertensive Treatment: Preferred Drugs General rules: lower SBP and DBP to goal. Use any effective agent at adequate doses, if useful in combination. Use long J acting agents to lower BP throughout 24 hours. Avoid or minimize adverse effects. IRA Subclinical organ damage Left ventricular hypertrophy ACE inhibitors, calcium antagonists, angiotensin receptor antagonists SIR Asymptomatic atherosclerosis Calcium antagonists, ACE inhibitors Microalbuminuria ACE inhibitors, angiotensin receptor antagonists Renal dysfunction ACE inhibitors, angiotensin receptor antagonists RAJ Clinical event Previous stroke Any BP lowering agent Previous MI β-blockers, ACE inhibitors, angiotensin receptor antagonists Angina pectoris β-blockers, calcium antagonists IRI Heart failure diuretics, β-blockers, ACE inhibitors, angiotensin receptor antagonists, antialdosterone agents Atrial fibrillation Recurrent ACE inhibitors, angiotensin receptor antagonists Continuous JS β-blockers, non-dihydropiridine calcium antagonists Renal failure/proteinuria ACE inhibitors, angiotensin receptor antagonists, loop diuretics Peripheral artery disease Calcium antagonists IRA Condition Isolated systolic hypertension (elderly) Duretics, calcium antagonists Metabolic syndrome ACE inhibitors, angiotensin receptor antagonists, calcium antagonists SIR Diabetes mellitus ACE inhibitors, angiotensin receptor blocker Pregnancy calcium antagonists, methyldopa, β-blockers Blacks diuretics, calcium antagonists
  • 60. Diabetes Care: J THE ALPHABET STRATEGY IRA SIR Advice RAJ Blood pressure Cholesterol IRI Diabetes Control JS Alphabet DN screening Eye Examination Strategy IRA Feet Care Guardian Drugs SIR
  • 61. NCEP ATP III: LDL-C Goals (2004 Modifications) J IRA High Risk Moderately Moderate Lower High Risk Risk Risk CHD or CHD risk ≥ 2 risk ≥ 2 risk < 2 risk SIR equivalents factors factors factors 190 (10-yr risk (10-yr risk (10-yr risk >20%) 10-20%) <10%) goal 160 RAJ mg/dL 160 LDL-C level goal goal IRI 130 130 mg/dL mg/dL 130 goal JS 100 mg/dL IRA 100 Existing LDL-C goals SIR Proposed LDL-C goals 70 - *CHD risk equivalents = DM, PAD, Stroke, CKD Grundy SM et al. Circulation 2004;110:227-239.
  • 62. Major Risk Factors J IRA Cigarette smoking SIR HT: BP ≥140/90 mmHg or on antihypertensive agent Low HDL-C (<40 mg/dL)† RAJ Family history of premature CHD IRI – CHD in male first degree relative <55 years JS – CHD in female first degree relative <65 years Age (men ≥45 years; women ≥55 years) IRA SIR † HDL-C ≥60 mg/dL counts as a “negative” risk factor
  • 63. NCEP ATP III: 2004 Modifications High Risk Moderately Moderate Lower High Risk Risk Risk J CHD or CHD risk ≥ 2 risk ≥ 2 risk < 2 risk IRA equivalents factors factors factors 190 (10-yr risk (10-yr risk (10-yr risk >20%) 10-20%) <10%) goal SIR 160 mg/dL 160 LDL-C level goal goal RAJ 130 130 mg/dL mg/dL 130 IRI goal or 100 optional mg/dL 100 mg/dL* JS 100 or Existing LDL-C goals optional 70 IRA Proposed LDL-C mg/dL* goals 70 - SIR * 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.
  • 64. Diabetes Care: J THE ALPHABET STRATEGY IRA SIR Advice RAJ Blood pressure Cholesterol IRI Diabetes Control JS Alphabet DN screening Eye Examination Strategy IRA Feet Care Guardian Drugs SIR
  • 65. Oral hypoglycemic drugs J IRA Insulin secretagogue SIR – Sulfonylurea: glibenclamide, glipizide, gliclazide RAJ – Glinide group IRI Biguanide: metformin α-Glucosidase Inhibitor: acarbose, JS voglibose IRA Thiazolidinediones: Rosiglitazone, SIR plioglitazone Incretin
  • 66. Primary sites of action of oral anti-diabetic agents J IRA Biguanides Thiazolidinediones SIR DPP-4 RAJ inhibitors IRI DPP-4 Insulin JS Glucose GLP-1 IRA Sulphonylureas α-glucosidase inhibitors SIR GLP-1 and meglitinides analogues
  • 67. J IRA SIR RAJ IRI JS IRA SIR ITC-1. Annals of Int Med. 2007
  • 68. Insulin J IRA Intermediate acting: NPH, Humulin N, SIR Insulatard Short acting: RI, Humulin R, Actrapid RAJ Premixed insulin: Humulin 70/30, IRI Mixtard 30 JS Rapid acting: Insulin lispro, aspart IRA Long acting insulin: Insulin glargine, determir SIR
  • 69. การออกฤทธิ์ของอินซูลิน J IRA Aspart Lispro SIR Regular NPH RAJ Glargine Detemir IRI JS 4 8 12 16 20 24 IRA ระยะเวลาหลังฉีดยาอินซูลิน (ชั่วโมง) SIR
  • 70. ADA/EASD 2008 guideline Tier 1: Well-validated core therapies J Lifestyle + metformin Lifestyle + metformin IRA + + At diagnosis basal insulin Intensify insulin *HbA1c >8.5% SIR Lifestyle modification + metformin Lifestyle + metformin + RAJ sulfonylurea Step 1 Step 2 Step 3 IRI Tier 2: Less Lifestyle + metformin Lifestyle + metformin well-validated + JS + therapies Pioglitazone Pioglitazone No hypoglycemia + IRA CHF, Bone loss sulfonylurea Lifestyle + metformin SIR Lifestyle + metformin + + GLP-1 agonist basal insulin No hypogly, Wt loss Nausea vomitting Nathan DM, et al. Diabetes care 2008; 31:1-11.
  • 71. Thai’s guideline for management of T2DM J IRA FPG <200 mg/dl or Lifestyle modification HbA1c <8% 1-3 months SIR Insulin resistance Insulin defiiciency phenotype phenotype Monotherapy Concurrent with medication FPG 200-300 mg/dl RAJ Metformin or Sulfonylurea Lifestyle modification Other: TZDs, Glinide, AGI IRI or DPP-IV inhibitor FPG 250-350 mg/dl or HbA1c >9% JS Combination OHA IRA FPG >300 mg/dl or Insulin therapy HbA1c >11% or SIR Symptomatic hyperglycemia Basal or Premixed or MDI
  • 72. Approach to patient with poor glycemic control J IRA Diet history SIR Exercise history RAJ Compliance history Concurrent medication IRI – Herbal medicine JS – Steroid IRA – Diuretics, beta-blocker SIR Occult infection
  • 73. Diabetes Care: J THE ALPHABET STRATEGY IRA SIR Advice RAJ Blood pressure Cholesterol IRI Diabetes Control JS Alphabet DN screening Eye Examination Strategy IRA Feet Care Guardian Drugs SIR
  • 74. Screening for Diabetic Nephropathy J IRA SIR Test When Normal Range RAJ Blood Each office visit <130/80 mm/Hg 1 Pressure GFR = ([140-age] X weight in kg) X 0.85 (if female) IRI Creatinine Annually >90 ml/min per 1.73 Clearance1 JS m2 BSA (serum creatinine X 72) Urinary Type 2: Annually <30 mg/day IRA 1 Albumin beginning at diagnosis <30 μg/mg creatinine Type 1: Annually, 5 -years SIR post -diagnosis 1American Diabetes Association: Nephropathy in Diabetes (Position Statement). Diabetes Care 27 (Suppl.1): S79-S83, 2007
  • 75. Definitions of abnormalities in albumin secretion J IRA SIR Category Spot collection μg/mg creatinine RAJ Normal <30 IRI Microalbuminuria 30-299 JS IRA Macroalbuminuria >300 SIR 1American Diabetes Association: Nephropathy in Diabetes (Position Statement). Diabetes Care 28 (Suppl.1): S3-41, 2008
  • 76. Stage of CKD J IRA SIR Stage GFR ml/min per 1.73m2 BSA RAJ 1 >90 IRI 2 60-89 3 30-59 JS 4 15-29 IRA 5 <15 or dialysis SIR 1American Diabetes Association: Nephropathy in Diabetes (Position Statement). Diabetes Care 28 (Suppl.1): S3-41, 2008
  • 77. Diabetes Care: J THE ALPHABET STRATEGY IRA SIR Advice RAJ Blood pressure Cholesterol IRI Diabetes Control JS Alphabet DN screening Eye Examination Strategy IRA Feet Care Guardian Drugs SIR
  • 78. Diabetic foot J IRA Inspection: SIR – Deformity – Dryness or cracks in RAJ the skin – Wound IRI – Gangrene JS – Callus IRA – Toe nail SIR Hallux valgus
  • 79. Diabetic foot J IRA SIR Pulse – Dorsalis pedis pulse RAJ – Posterior tibial pulse – IRI Popliteal – Femoral JS IRA SIR
  • 80. Diabetic foot J IRA Monofilament – โดยใหผูปวยหลับตา กดปลาย SIR monofilament ที่แขนผูปวยกอน เพื่อใหผูปวยรูวาจะรูสึกอยางไร RAJ – ใหผูปวยหลับตา กดปลาย IRI monofilament ใหตั้งฉากกับฝาเทา ให monofilament โคงงอเล็กนอย JS ประมาณ 1-1.5 วินาที IRA Loss of protective sense ==จากการตรวจ10 จุด ดังรูป โดยตรวจ Loss of protective sense ตรวจครบ monofilament ผูปววยไม – จากการตรวจ monofilament ผูป ยไม รูรูสึกถึงแรงกดมากกวา44จุจุดในา10จุจุดทีตรวจ ครั้ง (ถาตอบถูก 2 ใน 3 สึกถึงแรงกดมากกวา ดใน 10 ดทีง่ละ 3 ตํ แหน ตรวจ SIR ่ ครั้ง = OK) – ถามวาผูปวยรูสกหรือไม ึ
  • 81. Diabetic foot J IRA Vibration – เลือกใชสอมเสียงขนาด 128 Hz SIR – แสดงใหผูปวยทราบวาอาการสั่นเปนอยางไร โดยวาง สอมเสียงที่ถูกทําใหสั่นที่กระดูก sternum RAJ – ตรวจผูปวยขณะที่ผูปวยหลับตา IRI – วางสอมเสียงที่ปุมกระดูก distal interpharyngeal joint ของนิ้วหัวแมเทา ตรวจทั้ง 2 ขาง JS – ถามผูปวยวารูสึกสั่นหรือไม และใหบอกทันทีเมื่อหยุด  IRA สั่น จะได 2 คําตอบ ทําขางละ 2 ครั้ง นับเปน 1 รอบ เมื่อ ทําครบ 1 รอบ ใหทําซ้ําใหครบ 2 รอบ SIR – ถาตอบผิดมากกวา 5 ใน 8 ครั้งของแตละขางแสดงวา ขางนั้นมี peripheral neuropathy
  • 82. Advice foot care J IRA Daily feet inspection, including areas between the toes SIR If vision is impaired, people with diabetes should not attempt their own foot care RAJ Regular washing of feet with careful drying, especially between the toes IRI Water temperature – always below 37C Do not use a heater or a hot-water bottle to warm JS your feet IRA Use of lubricating oils or creams for dry skin - but not between the toes SIR
  • 83. Advice foot care J IRA Avoidance of barefoot walking indoors or outdoors and of wearing of shoes without SIR socks Daily inspection and palpation of the inside of RAJ the shoes Do not wear tight shoes or shoes with rough IRI edges Daily change of socks JS Wearing of stocking with seams inside out or IRA preferably without any seams Never wear tight or knee-high socks SIR
  • 84. Advice foot care J IRA Cutting nails straight across SIR Chemical agents or plasters to remove corns and calluses - should not be used RAJ Corns and calluses - should be cut IRI by a healthcare provider Patient awareness of the need to JS ensure that feet are examined IRA regularly by a healthcare provider Notifying the healthcare provider at SIR once if a blister, cut, scratch or sore has developed
  • 85. Conclusion J IRA What type of diabetes he/she has? SIR What is the goal for this patient? We should correct and take care everything RAJ according to alphabet strategy Which medication suitable for this patient? IRI According to guideline JS Does she/he have any contra-indication for this IRA medication? Lifestyle modification is the fundamental SIR management of diabetes
  • 86. Diabetes Care: J THE ALPHABET STRATEGY IRA SIR Advice RAJ Blood pressure Cholesterol IRI Diabetes Control JS Alphabet DN screening Eye Examination Strategy IRA Feet Care Guardian Drugs SIR
  • 87. Topic J IRA Thyroid disease SIR DM RAJ Endocrine emergency IRI JS IRA SIR
  • 88. SIR IRA JS IRI RAJ Thank you SIR IRA J