Adult Endocrine Flashcards
What are the guidelines for diagnosing DM based on
Fasting Plasma glucose:
Two hour plasma glucose:
HbA1C:
FPG: >126
OGTT: >200
HbA1C: >6.5%
What test should be ordered every three months on diabetic patients that is a measure of the “average” glucose levels
HbA1C
(aka hemoglobin A1c, glycosylated hemoglobin)
What are three common presenting signs and symptoms that may be caused by DM?
Mental status change
Abdominal Pain
Dehydration
Why could DM present with altered mentation?
Due to high or low glucose levels
Why could DM present with abdominal pain?
due to diabetic ketoacidosis
What are the possible etiologies of DKA?
Inadequate Insulin
Infection
Infarction
Surgery
Drugs
What are the initial signs of DKA?
anorexia
n/v
polyuria/polydipsia
What are some serious signs and symptoms of DKA?
Coma
AMS
Kussmaul respirations
Acetone breath
Dehydration
Tachycardia
Hypotension
Fever
Which type of metabolic disturbance will be seen with DKA?
HAGMA
What is the treatment for DKA?
ICU admit
monitor status, vitals, glucose, renal fxn, a/b status, K and other electrolytes
What is one method of fluid replacement in DKA?
1-2-3 rule
2-3L if NS over the first 1-3 hours
then, 1/2 strength saline at 150ml/h
fluid deficit is usually 3-5L
what is the insulin dosing for DKA?
10-20 units IV or IM
then, 5-10 units/hr cont. IV
increase if no response in 1-2hrs, can be written to titrate
What labs/imaging are ordered to look for the cause of DKA?
Cx
EKG
CXR
Drug screen
hx from family/pt
What is the monitoring protocol for DKA?
BSG hourly
Electrolytes q2-4hrs +/- ABG
Vitals, mental status, and fluids hourly
When should K be replaced in DKA?
when serum K drops below <5.5
monitor renal fxn, EKG, and urinary output (hourly)
What are the three main goals of treating DKA?
increase rate of glucose utilization (gluc: 120-250)
reverse ketonemia and acidosis
correct depletion of water and electrolytes
When DKA is resolving, and pt is able to tolerate food, when should intermediate or long-acting insulin be added?
once anion gap has normalized and overlap IV and SQ insulin by about 30-60min
What is Non-Ketotic Hyperosmolar State (NKHS)?
Insulin def.
Inadequate fluid inake
Osmostic diuresis induced by hyperglycemia
NO KETONES
What are some precipitating factors for NKHS?
sepsis
MI
glucocorticoids
Phenytoin
thiazides
dehydration
What are the sypmtoms of NKHS?
polyuria/polydipsia
AMS
What is the fluid replacement protocol for NKHS?
2-3L of NS over first 1-3hrs
correct the deficit of 8-10L over the next 24-48hrs with 1/2NS
when glucose reaches 250, switch to D5 1/2NS at 100-200ml/hr
What is the insulin administration for NKHS?
regular insulin at 5-10u IV
3-7u cont.
transition when able to tolerate PO
monitor, replace K, investigate cause as with DKA
What are the main differences between NKHS and DKA?
fluid deficit is much greater in NKHS
drugs can contribute to NKHS
N/v, abdominal pain, ketoacidosis and kussmail resp. are absent in NKHS
What are the similiarities between NKHS and DKA?
insulin def. and glucagon excess (absolute or relative)
volume depletion
AMS
critical conditions
What are some of the long term complications of DM?
cardiovascular disease (main cause or mortality)
coronary artery disease
What HbA1C value indicates good control?
6.5 or less
lower is usually better, but consider hypoglycemia contributing to syncope and falls, esp. in elderly
What is a form of autonomic neuropathy?
Diabetic Gastropathy
variable stomach emptying can require varying amounts of insulin
How can nephropathy be screened for?
random urine sample
protein should be <300mg/24hr
What is the earliest measurable sign of proteinuria and nephropaty?
microalbuminuria
30-300mg
can do a random urine sample or a microalbumin/creatinine ratio which is more accurate
When is a 24hr urine collection used?
Not routinely, only in screening/monitoring for more advanced kidney disease
can measure large amounts of protein, but need to obtain a serum creatinine at same time to determine creatinine clearance
can be difficult to remember to collect urine/difficult to preform
What should be ordered quarterly on diabetic patients?
HbA1C
Revire SGM log
Foot inspection
What should be done annually for diabetic monitoring?
dilated eye exam
urine protein screening (microalbumin/cr ratio)
monofilament testing
What are some general foot care recomendations?
Daily inspection
Wear prescription shoes
Moisturize but avoid under/between toes
See podiatry
What behavior is the single most additive risk for vascular disease?
Smoking
What are the major characteristics of type I DM?
Absolute insulin def
Absolute glucagon excess
Volume depletion
AMS
autoimmune dz
What are the characteristics of type 2 DM?
Relative Insulin def.
Relative Glucagon excess
Volume depletion
AMS
obesity/inactivity
What are the s/s of hyperthyroidism?
“Hyped”
lid lag/exophthalmos
bruits
tachycardia
tremor
diaphoresis
gynecomastia
heat intolerance
weight loss
diarrhea
What is the source of dysfunction in 1’, 2’, and 3’ thyroid disorders
1’: thyroid itself is dysfunctional
2’: pituitary dysfunction
3’: central/hypothalamic dysfunction
Name the Condition:
Increased TSH
Decreased FT4
Primary Hypothyroid
Name the Condition?
Decreased TSH
Increased FT4
Primary Hyperthyroidism
Name the condition
Increased TSH
Increased FT4
TSH producing tumor
Name the condition
Decreased TSH
Decreased FT4
Central hypothyroidism
What should be done if thyroid labs are abnormal in critically ill patients?
Be cautious diagnosing thyroid conditions in critically ill patients as protein shifts, metabolism and maladaptive processes can be contributing to the abnormal results
Are thyroid nodules typically benign or malignant?
benign (even the “cold” ones)
Are cold or hot nodules more likley to be malignant?
When compared, cold nodules are more likely to be malignant than warm or hot nodules
What nerve can be damaged with thyroid surgery?
Recurrent laryngeal nerve
What other endocrine structure can be damaged with thyroid surgery?
Parathyroids
What are the factors that affect calcium and vitamin D homeostasis?
bon, kidney and intestines respond to low Ca levels by increasing PTH
PTH increases tubular reabsorption of Ca and stimulates renal 1,25(OH)2D production which helps intestinal absorption of Ca
If Ca and PO4 are moving in opposite directions, what is the issue?
PTH imbalance
If Ca and Po4 are moving in the same direction, what is the issue?
Vitamin D issue
What are five causes of hypercalcemia?
parathyroid related
malignancy related
vitamin d related
associated with high bone turnover
associated with renal failure
What EKG change may be seen on hypercalcemia?
shortened QT interval
What is the treatment for hypercalcemia of malignancy?
When presenting with AMS and/or EKG changes, treat with aggressive volume expansion with isotonic saline
