Ch 17. Endocrine

Question 1

Criteria for the diagnosis of diabetes (4)


Answer 1

1. HGBA1C >6.5%
   
2. Fasting Glc >7.0

2. Random Glc >11.1

3. 2hr Glc >11.1

Question 2

Complications of diabetes (6)


Answer 2

3 microvascular and 3 macrovascular

1. Retinopathy

2. Neuropathy

3. Nephropathy

4. CAD

5. PVD

6. CVD

Question 3

Types of foot ulcers (3)


Answer 3

1. Venous ulcer – malleolus. Painless.
   
2. Arterial ulcer – toes or shins. Pale, punched out, painful

2. Diabetic ulcer – areas of pressure. Probe it to see if you hit bone! AKA osteomyelitis


Question 4

Anti-diabetes agents (5), drug example, and adverse effects (15)


Answer 4

1. Biguanides – metformin – beware diarrhea, lactic acidosis
   
2. Secretagogues/sulfonylurea – glyburide – beware hypoglycemia, weight gain

2. Thiazolidinediones – pioglitazone – beware CHF, weight gain

3. Insulin – insulin – beware weight gain, hypoglycemia

4. Alpha-glucosidase inhibitors – acarbose – beware the flatculence and diarrhea

5. SGLT2 – empagliflozen – beware UTI, normoglycemia DKA

6. Incretins/GLP-1 agonist – Liraglutide(Victoza) – beware thyroid cancer,pancreatitis


Question 5

Three drugs for Tm of hypoglycemia (3)?


Answer 5

1. Glucose

2. Octreotide (consider with sulfonylurea overdose)
   
3. Glucagon


Question 6

Causes of DKA (3)


Answer 6

1. Infection

2. Infarction (ACS, CVA, PE, pancreatitis)
   
3. Insulin – lack thereof
-
   Also trauma, substance abuse, pregnancy

Question 7

Dx of DKA (3)


Answer 7

1. Diabetes (Glc >14)
   
2. Ketones present (urine, blood)

2. Acidosis (pH <7.3)


Question 8

Dx of HHS (3)


Answer 8

1. Hyperglycemia (Glc > 30)

2. Hyperosmolar (Osmolality >320)

3. pH >7.30

4. Bicarb >15

5. Small or negative ketones


Question 9

Ketones in DKA (3)


Answer 9

1. BHB

2. Acetoacetic acid (AcAc) *The only one detected in our assays!

3. Acetone


Question 10

Euglycemia DKA is a known complication of (1)


Answer 10

SGLT2 inhibitors (Canagliflozin)


Question 11

DDx of DKA (5)


Answer 11

1. Alcoholic ketoacidosis

2. Starvation ketoacidosis

3. Lactic acidosis

4. Renal failure

5. Ingestions: salicylates, ethylene glycol, methanol


Question 12

Treatment DKA (3)


Answer 12

1. Normal saline (20mL/kg over the first hour
   
2. Potassium – monitor closely

2. Insulin 0.1units/kg/hour after the first fluid bolus


Question 13

The feared complication of DKA corrections in peds (1)


Answer 13

Cerebral edema


Question 14

What is alcoholic ketoacidosis? (1)


Answer 14

WAGMA from alcohol cessation in the context of NAD and glycogen depletion. 
EtOH Acetaldehyde Acetate Acetyl CoA Ketones
Nausea, vomiting, abdo pain
*Test for ketones and a WAGMA

Question 15

What is starvation ketoacidosis? (1)


Answer 15

Ketone production from no carbohydrate intake. Ketones appear after 3 days of fasting. 


Question 16

Causes of hypothyroidism (8)


Answer 16

1. Autoimmune (Hashimoto’s)

2. Thyroiditis
   
3. Iodine deficiency

3. Surgical/radiation ablation

4. Infiltrative disease (lymphoma, amyloid, sarcoid)

5. Hypopituitarism (secondary hypothyroid)

6. Congenital

7. Drugs – lithium, amiodarone, iodine


Question 17

Signs of thyroid myxedema crisis (5)


Answer 17

1. Characteristic hypothyroid habitus (facial swelling, edema, myxedema, obese)

2. Bradycardia

3. Hypotension

4. Hypothermia <35.5 *** Very common

5. Hypoventilation

6. Altered mental status / coma


Question 18

Treatment of myxedema crisis (1)


Answer 18

IV levothyroxine 4mcg/kg.. and other supportive measures! Don’t expect anything to work until they get thyroxine. 


Question 19

Causes of hyperthyroidism (7)


Answer 19

1. Grave’s disease (85%)

2. Toxic multinodular goitre
   
3. Thyroiditis
   
4. Hasimoto’s thyroiditis

3. Secondary hyperthyroid (excess thyrotropin from pituitary adenoma)
   
6. Iodine induced
   
7. Amiodarone, excess thyroid hormone, or PO cow thyroid


Question 20

Hyperthyroid/thyroid storm Sx (4)


Answer 20

1. Fever

2. CV – tachycardia, pulm edema, pedal edema, AFib

3. CNS – agitated, delirium, psychosis, seizures, coma

4. GI – nausea, vomiting, diarrhea, abdo pain, jaundice
* In more mild cases of hyperthyroidism, ask about weakness, heat intolerance, weight loss, anxiety, palpitations, fine tremor, diarrhea, and eye changes (exopthalamus) 


Question 21

Treatment of thyroid storm (5)


Answer 21

1. Supportive (O2, fluids, glucose)
   
2. Inhibit new thyroid hormone synthesis: thionamides (Methimazole)

2. Inhibit thyroid release (Iodone – at least 1 hour after methimazole)

3. Beta blocker: propranolol

4. Prevent peripheral thyroid conversion: dexamethasone
   
6. Definitive care = radiactive iodine ablation



Question 22

Adrenal gland hormones (3)


Answer 22

1. Mineralcorticoids - Aldosterone
   
2. Glucocorticoids - Cortisol
   
3. Sex hormones

   *Salt, sugar, sex

Question 23

Difference between Primary adrenal insufficiency and Secondary adrenal insufficiency? Causes? (4)


Answer 23

Primary adrenal insufficiency (Addison’s disease) = deficient in all 3 – no ACTH (from autoimmune or TB). Primary has hyperkalemia, hyponatremia, + skin pigmentation (from ACTH)


Secondary adrenal insufficiency = deficient in cortisol (from exogenous corticosteroids, CNS infx). Secondary has hypokalemia, +/- Cushing appearance


Question 24

Clinical features and treatment of adrenal crisis (3)


Answer 24

1. Adrenal crisis: severe hypotension refractory to vasopressors. Severe abdo pain, N+V, confusion. Consider in anyone on long-term glucocorticoids, HIV, head trauma, TB

2. IV fluids, hydrocortisone 100mg (or Dex 4mg if you need an ACTH test)
   
3. Consider norepi and underlying sepsis


Question 25

What is a stress dose of glucocorticoids (1)?


Answer 25

1. Three times the daily dose of glucocorticoid