Endocrinology

Clinical Practice of Medicine

  • Presenter: Sai Sreenija Dukkipati, MD, ABOM

  • Position: PGY IV Endocrinology Fellow at UMKC.

Learning Objectives

  • The ability to perform a thorough thyroid examination and articulate both normal and abnormal findings.

  • Competence in taking a focused history and conducting a focused examination on patients with the following conditions:

    • Type 2 Diabetes: Including examination for complications.

    • Type 1 Diabetes: Including recognition of presenting symptoms.

    • Hypothyroidism.

    • Hyperthyroidism.

    • Secondary Hypertension.

  • Proficiency in performing and interpreting the microfilament examination results.

  • Familiarity with examinations for diabetic complications and proper documentation practices.

Endocrine Disorders and Historical Context

  • Marshall Josip “Broz” Tito:

    • President of Yugoslavia.

    • Died in 1980 due to complications from type 2 diabetes, a situation which significantly influenced socio-political changes in the region, including the break-up of Yugoslavia.

  • John F. Kennedy:

    • Had Addison’s disease which contributed to his year-round “tan” that positively impacted his presidential campaign.

Diabetes Assessment

Risk Factor Assessment

  • CDC Prediabetes Screening Test:

    • Risk Scoring:

      • Scores from 3 to 8 indicate low risk.

      • Scores of 9 or higher indicate high risk.

    • Definitions:

      • Prediabetes: Blood glucose levels higher than normal, but not yet classified as diabetes.

      • Significant risk of serious diseases such as heart attack, stroke, blindness, kidney failure, or limb loss associated with untreated diabetes.

    • Lifestyle Programs: Effective in delaying or preventing type 2 diabetes for those identified as prediabetic.

Screening Questions

  • Detailed self-assessment questions regarding:

    1. History of giving birth to large babies (over 9 pounds).

    2. Family history of diabetes (parents or siblings).

    3. Personal weight issues relevant to height, assessed with a weight chart indicating at-risk weights.

    4. Age range implications for risk (under age 65 with low exercise vs. age 65 or older).

Clinical Guidelines & Standards

  • American Diabetes Association (ADA) 2018:

    • Guidelines are published annually in a supplement to the journal "Diabetes Care".

    • Standards cover best practices for diabetes care, including updated A1C, blood pressure, and LDL cholesterol levels.

    • Patient-centered communication strategies enhance health outcomes and quality of life.

Comprehensive Medical Evaluation

  • At the initial visit, essential evaluations include:

    • Confirmation and classification of the diabetes diagnosis.

    • Detection of complications and comorbid conditions.

    • Review of prior treatments and risk factor management.

    • Development of a management and continuing care plan.

Classification of Diabetes

  • Type 1 Diabetes: Characterized by beta-cell destruction.

  • Type 2 Diabetes: Involves a progressive insulin secretory defect.

  • Other Specific Types:

    • Genetic defects in beta-cell function or insulin action.

    • Diseases of the exocrine pancreas.

    • Drug or chemical-induced diabetes.

  • Gestational Diabetes Mellitus (GDM).

Components of Comprehensive Diabetes Evaluation

Medical History

  1. Key details regarding:

    • Age and characteristics of diabetes onset.

    • Personal and family eating patterns and nutritional status.

    • Presence of comorbidities (neuropathy, etc.) and psychosocial barriers.

    • Previous treatments and responses, including history of complications (DKA, hypoglycemia).

  2. Essential Screening Features:

    • Blood pressure history, abnormal lipids.

    • Examination for microvascular (retinopathy, nephropathy, neuropathy) and macrovascular complications (coronary heart disease).

    • Evaluation of pregnancy-related issues in women of childbearing potential.

Diabetes Symptoms

  • Common symptoms include:

    • Weight loss or gain.

    • Frequent urination (polyuria).

    • Excessive thirst (polydipsia).

    • Increased hunger (polyphagia).

    • Fatigue, blurred vision, and numbness.

Diabetes Review of Symptoms (ROS)

  • General: Fatigue, weight changes, “polys”.

  • HEENT: Vision changes, dental issues.

  • Cardiovascular: Chest pain, dyspnea, orthostasis.

  • Gastrointestinal: Nausea, vomiting, diarrhea.

  • Genitourinary: Sexual dysfunction, menstrual history (women).

  • Neurological: Numbness, pain.

  • Skin: Rashes, dryness.

  • Extremities: Edema, foot care evaluation.

Assessment of Glycemic Control

  • Main techniques:

    • Self-Monitoring of Blood Glucose (SMBG).

    • A1C level checking.

    • Continuous glucose monitoring (CGM) may aid in evaluating safety and effectiveness of treatment.

Diabetes Evaluation and Physical Examination

  • Essential Physical Exam Components:

    • Measurements of height, weight, BMI, and growth status in children.

    • Blood pressure assessment including orthostatic measurements.

    • Fundoscopic examination for retinopathy.

    • Thyroid palpation and skin examination for other complications.

    • Comprehensive foot examination required annually.

Diabetes Foot Exam Recommendations

  • Key Components:

    • Full inspection of feet post shoe/sock removal.

    • Vascular assessment including pulses, and ABI if indicated.

    • Neurological assessment using the 10-g monofilament test plus additional sensations (e.g., vibration, pinprick).

  • Risk Factors for Foot Ulcers:

    • Previous ulceration or amputation, peripheral neuropathy, foot deformity, vascular disease, visual impairment, and smoking history are essential in determining foot health risk.

Foot Care Recommendations

  • Annual comprehensive foot evaluation is crucial for early identification of ulcer risk.

  • All patients advised to inspect feet regularly and have them evaluated at each visit.

  • Education on appropriate footwear and nonsurgical interventions if necessary.

Conditions and Complications in Hyperthyroidism

Symptoms & Signs

  • Common clinical symptoms of hyperthyroidism:

    • Fatigue, nervousness, weight loss, increased appetite, heat intolerance, and palpitations.

  • Notable clinical signs include hyperkinesis, warm skin, goiter, tachycardia, and tremor.

  • Graves’ Disease:

    • Eye conditions like ophthalmopathy or eyelid retraction.

Complications of Hyperthyroidism

  • Graves' Ophthalmopathy:

    • Symptoms include eye irritation, gaze abnormalities, retraction, and possibly vision loss.

Hypothyroidism Overview

Clinical Symptoms

  • Bradycardia, dry skin, weight gain, cold intolerance, muscle weakness, fatigue, depression.

Clinical Signs

  • Hypothermia, goiter presence, slow relaxation of deep tendon reflexes, coarse features, and periorbital edema.

Secondary Hypertension

  • Causes include:

    • Renal diseases, medications (e.g., OCP, steroids), illicit drugs, and endocrine disorders (e.g., pheochromocytoma, primary hyperaldosteronism).

Case Studies

  1. Case #1: A 24-year-old male with unexplained weight loss; differential diagnosis includes type 1 DM or hyperthyroidism.

  2. Case #2: A 45-year-old female presents with fatigue and weight gain; differential diagnosis includes type 2 DM or hypothyroidism.

Summary Checklists

  • Diabetes and Thyroid evaluations include history, physical examination, and assessments targeting potential complications.