Adult Endocrine Cases Kirila Flashcards
Methods of Capillary Glucose monitory
FSG - Fingerstick glucose
BSG - Bedside glucose
“Accucheck” - most common glucose monitor
Outpatient setting:
HGM - Home glucose monitoring
GSM - Glucose self-monitoring
SBGM - Self blood glucose monitoring
Basal Insulin
Long acting insulin that achieves a steady state of glucose control
“Bolus” Insulin
Used to adjust insulin levels at mealtimes based on FSG and carbohydrate count in meal
Signs and Symptoms of Diabetes Mellitus
Polyuria Polydipsia Nocturia Blurred vision Weight loss Frequent recurring infections
Guidelines for DM Diagnosis
Fasting plasma glucose > 126 mg/dL (7 mmol/L)
Two-hour plasma glucose values >200 mg/dL (11 mmol/L) during a 75 OGTT
HbA1C > 6.5 (48 mmol/mol)
Recommendations for long-term care of DM
Schedule appointment to check patient’s A1C every 3-4 months
Differential Diagnosis for a DM patient with Mental Status Change
AEIOU TIPS
A - Alcohol E - Epilepsy I - Infection O - Overdose U - Uremia T - Trauma I - Insulin P - Poisoning/Psychosis S - Stroke
Differential Diagnosis for a DM patient with Abdominal Pain
BAD GUT PAINS
B - Bowel Obstruction
A - Appendicitis, Adenitis (mesenteric)
D - Diabetic ketoacidosis, Diverticulitis, Dysentary/Diarrhea, Drug withdraw
G - Gastroenteritis, Gallbladder disease/stones/obstruction/infection
U - Urinary tract infection or obstruction
T - Testicular Torsion, Toxins (lead, black widow spider bite)
P - Pneumonia/Pleurisy/Pancreatitis, Perforated bowel/Peptic Ulcer/Polyphyria
A - Aortic aneurysm
IN - Infarcted bowel, MI, incarcerated hernia, IBD
S - Splenic rupture/infarction, Sickle cell pain/crisis, Sickle sequestration crisis
Acute Complications of DM
Diabetic Ketoacidosis (DKA) - more common in Type 1 DM
Non-ketotic Hyperosmolar State (NKHS) - most commonly seen in Type 2 DM
Common Causes of DKA
Inadequate insulin administration Infections (Pneumonia, UTI, Gastroenteritis, Sepsis) Infarction Surgery Drugs (Cocaine)
Initial Symptoms of DKA
Anorexia Nausea Vomiting Polyuria Thirst
Progressive Symptoms of DKA
Abdominal Pain
Altered mental status
Coma
Signs of DKA
Kussmaul respirations - rapid and deep Acetone (fruity) odor breat Dry mucous membranes Poor skin turgor Tachycardia Hypotension Fever Abdominal tenderness
Differential Diagnosis with High Anion Gap Acidosis
MUDPILES
Methanol Uremia Diabetic Ketoacidosis Paraldehyde Isopropyl alcohol, Iron, INH (isoniazid) Lactic acidosis Ethylene Glycol Salicylated
Treatment for DKA
ICU admission
Frequent monitoring of general status, vital signs, glucose and other labs
Acid-base status, renal function, potassium and other electrolytes
Fluid Replacement in DKA
1-2-3 rule
2-3 liters of normal saline over 1-3 hours
Then 1/2 NS at 150 ml/hr
When glucose reaches 250 mg/dl switch to D5 1/2 NS at 100-200 ml/hr
Fluid deficit is usually 3-5 L
Initial Insulin Administration during DKA
10-20 units IV or IM
Then give 5-10 units/hour via continuous IV
Increase if no response in 1-2 hrs
Evaluation for Underlying Cause of DKA
Cultures EKG CXR Drug screen Seek additional history
Initial Monitoring in DKA
Bloodwork
BSG hourly if not more
Electrolytes q2-4 hour +/- ABG
Check status
Vitals
Mental Status
Fluid in and out
Potassium Replacement in DKA
Consider K+ replacement if K< 5.5 mEq/L
Monitor renal function
Baseline EKG with continuous cardiac monitoring
Measure urine output
Goals of Treatment for DKA
Increase the rate of glucose utilization in insulin-dependent tissues - 150-250 meq/dL
Reverse ketonemia and acidosis
Correct depletion of H2O and electrolytes
When do you start to give long-acting or intermediate insulin and allow to eat
When patient is able to eat and has improved mental status, no nausea/vomiting, and no abdominal pain
Normal anion gap
Allow overlap timing of IV with SQ insulin - usually 30-60 min
Causes of Non-ketotic Hyperosmolar State
Insulin deficiency
Inadequate fluid intake
Osmotic diuresis induced by hyperglycemia
Sepsis MI Glucocorticoids Phenytoin Thiazide diuretics Impaired access to H2O
Symptoms of NKHS
Polyuria
Thirst
Altered mental status
Typically doesn’t have abdominal pain, nausea, vomiting, or Kussmaul respirations
