Editor:  Linda Wu

Contributors:  Eddy Tabet, Kharis Burns, Matthew Luttrell

Reviewed:  Barbara Depczynski, Bruce Way

 

 

In a hurry? Make sure you know

Diabetes:

  • Type of diabetes
  • Regimen: oral hypoglycaemics, insulin and doses
  • BSL trend and HbA1c

 

Hyponatraemia:

  • Current sodium, trend
  • Fluid status
  • Serum osmolality, urine sodium and osmolality
  • Medications

 

Thyroid disorders:

  • Clinical examination findings
  • TSH, T3, T4
  • Medications

 

 

What history should JMOs know/collect?

  • The reason for admission
  • Patient’s age
  • Patient’s likely discharge date 

 

Diabetes:

  • Type of Diabetes (type 1 or type 2)
  • Duration of Diabetes and macro/microvascular complications
  • Current diabetes regimen include type of insulins and doses
  • Usual/at home medication regimen – orals, insulin (and doses are important)
  • HbA1c in the last 3 months?
  • Specialist or GP care
  • Pattern of BSaLs in hospital including any hypos
  • Current feeding regimen – NBM, EN, Parenteral feeds, and whether any changes planned
  • Steroids and what is likely regimen going forward
  • Any planned procedures e.g. surgery, angiogram
  • Renal or liver function impairment
  • Cognition – is the patient currently coping with DM at home and would they cope with insulin or do they have a carer. Brief social History – i.e. lives alone or has supports
  • Following up correspondence from relevant GP or specialist

 

Hyponatraemia:

  • Symptoms – to suggest a cause (e.g. vomiting/diarrhoea) or symptoms to suggest there is neurological compromise
  • Acute versus chronic – i.e. the trajectory of sodium; when was the cortisol last normal? (which may need getting bloods from LMO)
  • Past medical history
  • Medications

 

Cortisol deficiency:

  • Previous history of adrenal or pituitary disorder
  • History of recent infection, weight loss, postural dizziness, vomiting?
  • Setting: is this patient acutely unwell?
  • Any associated autoimmune conditions?

 

Thyroid disorder:

  • Symptoms
  • Past medical history
  • Recent TFTs
  • Medications – in particular thyroxine or carbimazole, amiodarone or IV contrast

 

What examinations and investigations should JMOs perform/collect results of?

Diabetes:

  • QID if eating or q4-q6h if NBM readings. Fasting glucose levels and some pre plus 2 hour post-meal paired tests
  • HbA1c (if not done in past 2-3 months and if no blood loss to confound result) or obtain from LMO
  • BP and fasting lipids useful
  • LFT and UEC useful in choosing medication regime
  • Patient weight, height
  • Referral to diabetes educator and dietitian if appropriate

 

Hyponatraemia:

  • Fluid status – including postural BP
  • Serum Na and osmolality
  • Urine Na and osmolality (paired with serum)
  • TSH
  • Cortisol
  • eGFR
  • Weight trend

 

Cortisol deficiency:

  • Morning cortisol and ACTH (paired) – but if haemodynamically unstable –  draw blood for cortisol and ACTH at any time, and start empirical GC without waiting for result, with discussion with senior colleagues – so this is related to setting.   
  • Blood pressure (including postural)
  • Medications – any GC exposure: oral, inhalers, eye drops, IA
  • Serum electrolytes

 

Thyroid disorders:

  • Clinical assessment of thyroid activity – is the thyroid palpable? Tender? Is there clinical evidence of hyper/hypothyroidism? Obstructive symptoms
  • TSH, T4 and T3 level
  • As appropriate TPO, TRab

 

What additional information would impress you?

  • Information sourced from the GP/ endocrinologist/ pharmacist
  • If the JMO had a formed a clinical impression and considered how they might manage the patient
  • Use ISBAR as initial structure; this is the situation (admission and current issue), and suggested management plan to discuss further guidance on that endocrine aspect of the case

 

What are common mistakes/omissions made by JMOs?

  • Not taking history themselves and relying on power chart notes
  • For BGL control – lack of HbA1c, no blood glucose readings, no history from GP, wrong insulin eg humalog vs humalog mix
  • For hyponatraemia – need to order paired urine and serum tests, not examining fluid status, ordering both FT4 and TSH – to exclude secondary hypothyroidism, ordering cortisol/ACTH
  • For thyroid disorders – not examining the patient clinically, not knowing the recent TFT results

 

Helpful resources

eTG – via Clinical Information Access Portal (CIAP)  [Available at:  https://www.ciap.health.nsw.gov.au/]

AMH – via Clinical Information Access Portal (CIAP)  [Available at:  https://www.ciap.health.nsw.gov.au/

 

Podcasts

Caterson, Ian. (2015). Type 2 Diabetes. [podcast].  Available at:  https://onthewards.org/type-2-diabetes/ [Accessed 9 October 2018] 

Depczynski, Barbara.  (2016).  Diagnosing diabetic ketoacidosis (DKA). [podcast].  Available at: https://onthewards.org/diagnosing-diabetic-ketoacidosis-dka/  [Accessed 9 October 2018]

Depczynski, Barbara.  (2016). Perioperative management of diabetic patients. [podcast].  Available at: https://onthewards.org/perioperative-management-diabetic-patients/ [Accessed 9 October 2018]

Caterson, Ian. (2016).  Thyroid Disease. [podcast].  Available at https://onthewards.org/thyroid-disease/ [Accessed 9 October 2018]

Ross, Glynis. (2018).  Part 1: Blood Glucose Monitoring – Hyperglycaemia. [podcast].  Available at:  https://onthewards.org/part-1-blood-glucose-monitoring-hyperglycaemia/ [Accessed 9 October 2018]

Ross, Glynis. (2018).  Part 2: Blood Glucose Monitoring – Hypoglycaemia. [podcast].  Available at:  https://onthewards.org/part-2-blood-glucose-monitoring-hypoglycaemia/ [Accessed 9 October 2018]

Ganda, Kirtan (2018).  Bone health.  [podcast].  Available at:  https://onthewards.org/bone-health/ [Accessed 9 October 2018]