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At the heart of general practice since 1960

Five-minute Practitioner: July 2007

Only got five minutes? Then just read these key points on: diabetes, thyrotoxicosis, adrenal disorders and sickle cell disease

Only got five minutes? Then just read these key points on: diabetes, thyrotoxicosis, adrenal disorders and sickle cell disease

Diabetes

Hyperglycaemia is the defining characteristic of all the diabetes syndromes and carries the same risks for microvascular and macrovascular complications irrespective of its cause.

Minimising hyperglycaemic exposure reduces the risk of complications and is a key goal of diabetes management.

Glucose control is improving, but it is clearly proving more difficult to achieve the QOF glucose control target than the blood pressure and lipid targets.

The treatment choices in type 2 diabetes are becoming more varied. They offer both patients and healthcare professionals a range of options that should reap significant long-term health benefits by enabling more patients to achieve and maintain target glucose control.

Thyrotoxicosis

The prevalence of hyperthyroidism in the UK is approximately 2%. It is ten times more common in women than men and is self-limiting in 40% of cases.

The typical presentation of thyrotoxicosis is a young woman with weight loss despite increased appetite, heat intolerance and mood changes.

There are four major causes of hyperthyroidism: a generalised enlargement of the thyroid (Graves' disease); an overactive solitary lump in the thyroid (Plummer's disease); overactivity in a multinodular goitre (toxic multinodular goitre); and inflammation of the thyroid resulting in release of excess thyroid hormone (thyroiditis).

Factitious or iatrogenic thyrotoxicosis is common and it is frequently seen in women who are trying to lose weight. Diagnosis is made by detection of grossly elevated thyroid hormone levels associated with a suppressed TSH. Long-term administration of thyroxine results in atrophy of the gland and serum thyroglobulin will be almost undetectable.

Adrenal disorders

In a GP practice of 2,000 patients there will be 1-3 cases of Addison's disease. The cause is autoimmune in approximately 70% of cases.

Most patients with adrenal insufficiency present with fatigue, poor appetite, dizziness, frequent infections, weight loss and nausea, and may have evidence of other autoimmune conditions. Physical examination may elicit low blood pressure, postural hypotension, hyperpigmentation of the buccal mucosa or scars.

Adrenal crisis, once suspected, is a life-threatening emergency that requires immediate treatment in a hospital setting.

Cushing's syndrome is characterised by excess adrenocortical hormone production. In approximately 70% of cases of spontaneous overproduction of cortisol the cause is a pituitary tumour secreting ACTH. Hypertension, easy bruising and myopathy are found in more than 90% of patients with Cushing's syndrome. More »47

Sickle cell disease

An estimated 12,500 people in the UK have sickle cell disease. Patients whose origins can be traced to Africa, the Carribean, the Mediterranean, South East Asia and the Middle East are at highest risk.

Carriers of the sickle cell trait and neonates with large amounts of HbF are usually asymptomatic.

The sickle solubility test is the preferred screening test. A positive test confirms the presence of HbS, but fails to distinguish between asymptomatic carriers and those with sickle cell disease. Diagnosis is confirmed by haemoglobin electrophoresis.

Sickle cell disease is characterised by reduced red cell survival due to haemolysis. This results in anaemia and often jaundice; functional hyposplenism, leading to an increased susceptibility to infection; and microvascular occlusion, causing tissue ischaemia and/or necrosis.

The most common clinical manifestation of the disease is pain caused by vaso-occlusion. Patients should be taught to use an analgesic ladder.

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