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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:


Important conditions:

These are the common conditions that should be reviewed for this topic:

Topics

Important reading

Diabetes
Thyroid disorders
Parathyroid disorders
  • Primary hyperparathyroidism: Is vitamin D supplementation safe? AFP, November 2011.  (https://bit.ly/2tvRJZM)
Hyperprolactinaemia
Cushing syndrome
Adrenal insufficiency
Osteoporosis
Androgen disorders

Medication doses:

These are the medications and doses that should be learned for the exam:

Condition

Medication

Type 2 Diabetes Mellitus
  • Metformin immediate-release 500mg PO BD
  • Sulfonylureas – Gliclazide modified-release 30mg PO daily
  • DPP-4 inhibitors – Linagliptin 5mg PO daily
  • GLP-1 receptor agonists – exenatide modified-release 2mg subcutaneously, once weekly.
  • SGLT2 inhibitors – dapagliflozin 10mg PO daily
  • Long-acting insulin 0.2 units/kg once daily initially
Hypothyroidism
  • Thyroxine 50-100 mcg PO daily initally (aiming for TSH of 0.5-2mU/L)
Hyperthyroidism
  • Carbimazole 10-45mg daily in 2-3 divided doses

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:

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

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