Read week
Hi everyone!
How are your energy levels going? If you’re entering a period of study and you’re feeling completely depleted it’s sometimes useful to run on the spot for a minute, have a brief 15 minute nap, have a quick wander outside on the grass, do some stretching, or if those fail, to have a coffee or some chocolate. There’s nothing worse than feeling tired when you’re really needing to do something. So take some time to monitor your energy levels through the day, measure it out and use it where it’s needed. Don’t get stuck wasting your energy on rude patients, discouraging consultations or arguments with your family/colleagues.
This article is about endocrinology.
One of my difficult endocrine patients came to me when I was in GPT1. Before calling in the patient for the first time, I looked at his background medical history and saw Addison’s disease and my heart sank. I’ve always thought that endocrinology was such a mystery to me, and Addison’s disease particularly was so confusing to get my head around. A quick glance through the eTG just made my anxiety about this consultation heighten. So much to know! The patient himself was a concerned, well-informed, micro-manager of his condition which made me feel like I knew nothing. Over the next 18 months, I got to know this patient quite well – I learned about Addison, I knew the eTG posting on this condition back to front, and build a solid relationship with the endocrinologist. It goes to show that difficult patients and conditions can really spur you on to grow and learn.
A common endocrine issue that requires management by the GP is hypothyroidism – sometimes Hashimoto’s or sometimes secondary to definitively treated Graves. Titration of thyroxine is not as stressful as you may think. It has a long half life and the prescriber shouldn’t worry about trying to achieve equal daily dosing. For example, if a patient is on 100mcg daily, to increase the dose the doctor can recommend increasing by 100mcg over the entire week with either 1x 100mcg tablet extra on a Saturday, or half a 100mcg tablet each on Saturday or Sunday. Keeping the same dose tablet makes it much easier for the patient to cope with.
Patient’s with diabetes require a lot of chronic disease management to ensure their disease is well controlled. Each patient should have a care plan with clearly listed goals that are general to the condition (such as understanding of condition, target lipids and BP levels) but also targeted goals (such as realistic weight loss goals, HbA1c targeted to suit their age, and exercise goals that are achievable). It is my common practice to create a Team care arrangement (TCA) to refer these patients to a dietitian, exercise physiologist and diabetes educator. They should have an ECG each year, and see the nursing staff regularly to complete a diabetes cycle of care. It’s important for GPs to understand the medical item billing codes for all of these services.
Be kind to yourself, and remember to choose your battles!
Dr Andrew Harris
Director of Amadeus Education.
Did you know?
According to BEACH data, 5.7% of all encounters in General Practice were specifically related to the endocrine and metabolic issues. Consider this as you are preparing for your exams. (Source: General practice activity in Australia: 2015-16. https://bit.ly/2c4d8Em)
Presenting complaints:
These are the common presenting complaints that should be covered for this topic:
- Confusion, acute in adults (https://bit.ly/2MeZ8Fk)
- Eye, gradual loss of vision (https://bit.ly/2VXnFmL)
- Neck lumps (https://bit.ly/2SVIDkg)
- Paresthesia and numbness (https://bit.ly/2AMSu4K)
- Weight gain (https://bit.ly/2McoLXA)
- Weight loss (https://bit.ly/2DfidV9)
Important conditions:
These are the common conditions that should be reviewed for this topic:
Topics | Important reading |
| Diabetes | – General practice management of type 2 diabetes. RACGP, 2016-2018. (https://bit.ly/3RsXYqO) – Management of type 2 diabetes: A handbook for general practice (https://bit.ly/3BoQ4Ja) – Charcot osteoarthropathy of the foot. AFP, March 2010. (https://bit.ly/2tseBcH) HbA1c, blood glucose monitoring and insulin therapy. AFP, September 2014. (https://bit.ly/2S9tcDX) – Early and tight glycaemic control: The key to managing type 2 diabetes. AFP, September 2012. (https://bit.ly/2BIBP2J) – HbA1c and monitoring glycaemica. AFP, January/February 2012. (https://bit.ly/2GAejJu) – AUSDRISK: Application in general practice. AFP, July 2011. (https://bit.ly/2SQX7pt) – Dietary management in diabetes. AFP, August 2010. (https://bit.ly/2GAeBjy) – Type 1 diabetes in children: Emergency management. AFP, May 2010. (https://bit.ly/2SNItza) – Type 1 diabetes: Still the commonest form of diabetes in children. AFP, September 2009. (https://bit.ly/2NgbUnI) – Children get type 2 diabetes too. AFP, September 2009. (https://bit.ly/2XbAScu) |
| Thyroid disorders | – Evaluating and managing patients with thyrotoxicosis. AFP, August 2012. (https://bit.ly/2GX5dpg) – Goitre: Causes, investigation and management. AFP, August 2012. (https://bit.ly/2NfMDdn) – Thyroid disease in the perinatal period. AFP, August 2012. (https://bit.ly/2T2TETZ) – Thyroid therapy: Tips and traps. AFP, August 2012. (https://bit.ly/2Negu5Q) |
| Parathyroid disorders | – Primary hyperparathyroidism: Is vitamin D supplementation safe? AFP, November 2011. (https://bit.ly/2tvRJZM) |
| Hyperprolactinaemia | – Hyperprolactinaemia. Australian Prescriber, Dec 2017. (https://bit.ly/2TXtcsl) |
| Cushing syndrome | – Evaluation of adrenocortical function in adults. AFP, December 2007. (https://bit.ly/2EjPDCv) – Skin and Cushing syndrome. AFP, July 2007. (https://bit.ly/2EkQLGe) – The short Synacthen test and laboratory assay interference. AFP, March 2017. (https://bit.ly/2vkFocp) |
| Adrenal insufficiency | – Addison disease: Diagnosis and initial management. AFP, November 2010. (https://bit.ly/2AHKqVg) |
| Osteoporosis | – Vitamin D: And the musculoskeletal health of older adults. AFP, March 2012. (https://bit.ly/2GRWTY3) – Osteoporosis: Prevention and detection in general practice. AFP, March 2012. (https://bit.ly/2SKMuET) – Osteoporosis: Pharmacological prevention and management in older people. AFP, March 2012. (https://bit.ly/2IppHtq) |
| Androgen disorders | – Assessment and management of male androgen disorders: an update. AFP, May 2014. (https://bit.ly/2EkwIYn) – Andrology: Reproductive years and beyond. AFP, October 2012. (https://bit.ly/2NhhplT) – Androgen deficiency in the aging man. AFP, October 2010. (https://bit.ly/2GvxgNe) |
Medication doses:
These are the medications and doses that should be learned for the exam:
Condition | Medication |
| Type 2 Diabetes Mellitus |
|
| Hypothyroidism |
|
| Hyperthyroidism |
|
Mnemonics:
These are some important mnemonics relevant to this topic:
- AUSDRISK (risk for developing Type 2 diabetes)
CHECKS:
Here are the list of recommended Checks that would be useful in your study for GP exams (accessed via subscription from http://gplearning.racgp.org.au):
- Type 2 Diabetes, October 2015
- Diabetes and obesity, October 2014
- Fatigue, June 2014
Focus on clinical skills:
Here is a brief focus on some OSCE preparation related to this topic:
- Endocrine examination playlist by GP Synergy: https://bit.ly/2CrYDDx
Focus on medicolegal:
Here is a brief focus on the medicolegal issues covered in Australian Family Physician:Failure to diagnose: diabetic ketoacidosis. AFP, November 2010 (https://bit.ly/2FNrPYW)
Copyright © 2021 Andrew Harris