Adult Endocrine Flashcards
Guidelines for diagnosis of DM
- FPG (Fasting plasma glucose) values ≥126 mg/dL (7.0 mmol/L).
- Two-hour plasma glucose values of ≥200 mg/dL (11.1 mmol/L) during a 75 g OGTT (Oral Glucose Tolerance Test).
- HbA1C values ≥6.5 percent (48 mmol/mol).
What is the recommended monitering for long term care of DM
- Hemoglobin A1c
- HbA1c
- GHbA1c
- Glycosylated hemoglobin
Differential for mental status changes
AEIOUTIPS
- A – Alcohol
- E – Epilepsy with seizure activity
- I – Infection
- O – Overdose
- U- Uremia
- T – Trauma
- I – Insulin (high or low blood sugar)
- P – Poisoning/Psychosis
- S – Stroke
Differential for abdominal pain mnemonic
BAD GUT PAINS
BAD GUT in abdominal pain differential
B - Bowel obstruction A - Appendicitis, Adenitis (mesenteric) D - Diverticulitis Diabetic Ketoacidosis Dysentary/Diarrhea Drug withdrawal G - Gastroenteritis Gall bladder disease/stones/obstruction/infection U - Urinary tract obstruction or infection T - Testicular Torsion Toxins - Lead, black widow spider bite
PAIN in abdominal pain differential
P - Pneumonia/Pleurisy/Pancreatitis Perforated
bowel/Peptic ulcer/Porphyria
A - Abdominal aneurysm
IN - Infarcted bowel
Infarcted myocardium (AMI-Acute Myocardial Infarction)
Incarcerated hernia
Inflammatory bowel disease
S - Splenic rupture/infarction
Sickle cell pain crisis/Sickle sequestration crisis
High Anion gap acidosis differential
MUDPILES
- Methanol
- Uremia
- Diabetic Ketoacidosis
- Paraldehyde
- Isopropyl Alcohol, Iron, INH (Isoniazid)
- Lactic Acidosis
- Ethylene Glycol
- Salicylates
Treatment of DKA
•Intensive Care Unit • Frequent monitoring of general status, vital signs, glucose and other labs • Acid-base status • Renal function • Potassium and other electrolytes
What is the 123 rule of fluid replacement in DKA
- 2 – 3 liters NS (Normal Saline) (0.9 %) over first 1-3 hours (5-10 ml/kg/hr)
- Then, ½ strength saline (0.45%) at 150 ml/hr
- When glucose reaches 250 mg/dl, switch to D51/2 NS (5% dextrose and 0.45% saline) at 100 – 200 ml/hr
What is the fluid deficit in DKA
Fluid deficit is often 3 – 5 liters
Insulin administration in DKA
Regular Insulin
• 10 – 20 units IV or IM (or 0.15/kg)
• Then, 5-10 units/hr continuous IV (or 0.05 – 0.1/kg/hr
• Increase if no response in 1-2 hrs – orders can be written with guidelines to titrate
When do you consider replacing potassium in DKA
When serum K <5.5 mEQ/L
Initial monitering in DKA
- Bloodwork
- BSG at least hourly
- Electrolytes q 2 – 4 hrs +/- ABG’s
- Clinical status at least hourly
- Vital signs
- B/P, P, R
- Mental status
- Fluid I & O
When do you start intermediae or long acting insulin in the treatment of DKA
- When patient is able to eat as shown by the following:
- Mental status improved
- No nausea/vomiting
- No abdominal pain
- Anion gap normalized
- Allow overlap timing of IV with SQ insulin – usually by 30 – 60 minutes
Symptoms of NKHS
- Polyuria
- Thirst
- Altered mental state
- NOTE: Typically ABSENT are nausea, vomiting, abdominal pain and kussmaul respirations (these and acidosis & ketonemia are more typically seen in DKA)
Fluid replacement in NKHS
• 2 – 3 liters NS (Normal Saline) (0.9 %) over first 1-3 hours
(5-10 ml/kg/hr)
• Fluid deficit is often 8 – 10L
• Reverse over next 24 – 48 hrs using ½ strength saline (0.45%)
• When glucose reaches 250 mg/dl, switch to D51/2 NS (5%
dextrose and 0.45% saline) at 100 – 200 ml/h
What are the differences between DKA and HHS
- Fluid deficit is much greater in NKHS
- Some drugs can contribute to NKHS
- Nausea, vomiting, abdominal pain, ketoacidosis and kussmaul respirations typically absent in NKHS
What are the similarities between DKA and HHS
- Insulin deficiency – absolute or relative
- Glucagon excess – absolute or relative
- Volume depletion
- Mental status changes
- Both are critical conditions needing intensive monitoring
What is the earliest measurable sign of
proteinuria and diabetic effect of nephropathy
Microalbumin
What is done/checked in quarterly diabetes monitoring
- Hgb A1C
- Review SGM (Self Glucose Monitoring) log –download if possible
- Foot inspection for ulcerations etc
What is done/checked in annual diabetes monitoring
- Dilated eye exam
- Urine protein screening (microalbumin/creatinine ratio)
- Monofilament testing
Foot care in diabetes
• Daily inspection – often difficult for patient with dexterity
and visual problems
• Can use “plastic” (to avoid injury from glass) mirror on floor when
getting out of bed
• Family assistance
• Never go barefoot
• Moisturize – but NOT in between or under toes
• Prescription shoes – Medicare will pay for one pair per year
• Podiatry
Most important lifestyle modification in diabetes
physical activity
What is the singe most additive risk for vascular disease in diabetes
cigarette smoking
List TSH and Free T4 levels in
- primary hypothyroidism
- primary hyperthyroidism
- TSH producing tumor
- Central hypothyroidism
- High TSH, low FT4
- Low TSH, high FT4
- High TSH, High FT4
- Low TSH, Low FT4
What does EUthyroid sick look like
• Critically ill patient
• Lab results don’t fit a pattern for primary, secondary or tertiary
dysfunction
Classification of causes of hypercalcemia
- Parathyroid-related
- Malignancy-related
- Vitamin D-related
- Associated with High Bone Turnover
- Associate with Renal Failure
what is the first measure in the treatment of hypercalcemia of malignancy
aggressive volume expansion with isotonic saline
How do you test for bone density for osteoporosis and excessive bone turnover
• DEXA (aka DXA, Dual-Energy X-ray Absorptiometry) scan
- Central: lower spine and hip
- Peripheral (p-DEXA) used for screening only: wrist, heel, leg, fingers
