Endo SAQ Flashcards
1
Q
- A 7 year old girl is being treated for meningitis with acyclovir and antibiotics. Her urine output is 5-6 cc/kg/h. She has sunken eyes and no visible JVP impulse. serum Na is 127, K 3.8, Serum osm 264, Urine Na 80, urine K Normal (forget value), urine Osm 860.
A. Describe her volume status?(1)
B. What is the cause of low serum sodium and low serum osmolality
C. Management?
A
A. Intravascularly volume depleted depleted
B. **Cerebral salt wasting
- SIADH is normal/increased intravascular status
- DI is decreased intravascular status but has dilute urine and high serum osmol
C.
- Sodium replacement with hypertonic saline bolus, then infusion of NS
- Strict ins + outs, frequent onitoring of serum Na
- Tx underlying condition
2
Q
- Adolescent girl with T1DM presenting with DKA. Glu 32.4, pH 7.08, Na 132, K 4.3, HCO3 8
a. What is the reason for hyponatremia?
b. She is started on insulin 0.1U/kg/h, and 4 hours after, she has the following labs: Glu 6.0, pH 7.18, Na 138, K 3.6, HCO3 9. what are two things to do to her current management?
A
A. Dilutional effect of hyperglycemia pulling in intracellular fluids into the vasculature (causing cellular dehydration), which causes dilutional hyponatremia. For every 3.5mmol/L increase of glucose, there is a 1mmol/L decrease of Na
B. Add dextrose to her fluids. Add 40mEq/L KCl (if urinated)
3
Q
- A 14 year old boy presents with 3-6 month history of gynecomastia, with mild tenderness. He is otherwise well and is Tanner stage 3.
a. What is his most likely diagnosis?
b. What 2 items would you include in his management/follow-up plan?
A
A. Pubertal gynecomastia
- Imbalance between estrogen + androgen in breast tissue (not deteted in blood)
- 70% of boys early to mid puberty develop various degrees of subareolar hyperplasia of breasts
- Incidence peaks at 14yo, Tanner 3-4, testicular volume 5-10mL
- Asymmetric breast dvlpt, tenderness is common but transient
- Spontaneous regression within a few mo, rarely >2y
B.
- Reassurance
- F/U (should not persist >2y)
4
Q
- A mother calls because her child has diabetes and is sick today, but has good oral intake. Her glucose is 15 and her ketones are moderate. It’s supper time now. Her baseline short acting insulin is 3 units, but according to her sliding scale, she should receive 5 units. Her morning rapid is 4U, morning NPH 5U, and night NPH 8U.
a. How much insulin should she give now? Show calculation (2)
b. What advice would you give for further management (2)
A
A. Sick day protocol
- TDD = 4+3+5+8 = 20 units
- ISF = 100/TDD = 5 units
- Expect 1 unit of fast acting insulin to drop BG by 5
- Use 5-10-15-20 Rule to determine % of extra insulin needed if BG >=15
- For our case, moderate ketones with BG 15 -> give 10% of TDD
- Give 20 units x 10% = 2 units of rapid (Humalog, Novorapid) or short-acting (Regular or Toronto)
B. Sick day advice to prevent DKA
- Supervise child during illness (even adolescents)
- Check BG + ketones often
- Never skip an insulin dose! Even if child is not eating well. Illness usually increases glucose, unless vomiting or diarrhea.
- If BG is low and child is vomiting, consider mini-dose glucagon
- Give insulin Q2-3H PRN. Use the 5-10-15-20 Rule for BG >=15 and if ketones present
- Make sure child gets plenty of rest. Exercise will raise BG + cause body to make more ketones
- Give lots of fluids. May sure child eas some carbohydrate (juice, Jello, chicken noodle soup, crackers)
- Call diabetes on call if you have treated a severe low BG, cannot get BG or ketones down with 1-2 doses of extra insulin, need to adjust insulin
5
Q
- A 9 year old boy presents after he has been sick for a few days with vomiting and fatigue. He looks unwell with a blood pressure of 85/55 and tachycardia. His skin is bronzed. His mother mentions that he always gets really sick with any cold/flu.
a. What are 3 important steps in your acute management of this patient?
b. What is the diagnostic test for his underlying condition?
A
A.
- Give fluid bolus NS 20mL/kg for decompensated shock
- Measure cortisol and give IV hydrocortisone 100mg/m2
- BCx and start empiric ABx
- Measure and correct glucose + lytes
B. ACTH stimulation (to look for adrenal insufficiency) or adrenal antibodies (Addison’s)
6
Q
- You have a 16 year old with type 1 diabetes in your clinic.
a. What are 5 ways that you can begin to plan for his transition to adult care?
A
A. Transition MUSIC
- M - Include teen in MANAGEMENT decisions
- Do glucose checks + insulin adjustments
- U - Help teen develp UNDERSTANDING of conditions
- S - Foster SELF-ESTEEM + SELF-CONFIDENCE
- I - INDEPENDENCE (completion of adolescent development tasts)
- Visits on their own
- C - Encourage teen to understand their CAREER/personal potential
7
Q
6-year-old with newly diagnosed type 1 diabetes.
a. At what age should she start to receive screening for retinopathy?
b. At what age should she start to receive screening for nephropathy?
c. What would you test in the urine to screen for nephropathy?
A
A. Screen at 15yo and 5y of illness
B. Screen at 12yo and 5y of illness
C. First AM albumin:Cr (preferred) or random urine ACR
8
Q
- 15 year old female with no menarche yet. Tanner stage I across the board. Height less than 3rd percentile. Parents are concerned.
What 3 most important investigations would you do for the amenorrhea?
A
- BHCG, LH, FSH, estrodiol, TSH, prolactin
- AUS to assess for ovaries
- Karyotype
- Bone age
Delayed puberty
- Girls
- No breast development by 12-13Y
- No menarche 2-3Y after breast development OR by 15-16y
- Boys
- No testicular enlargement by 14Y
- Delay in dvlpt for >=5Y after onset of genitalia
Amenorrhea
- Primary: absence by 15yo with normal sexual dvlpt or by 13yo with no secondary sexual characteristics
- Secondary: absence of menses for >3 cycle intervals or 6mo in women who were previously menstruating
9
Q
- 9-month old Boy with Ca of 0.7 and phosphate 1.1.
a. What is the most likely cause?
b. What are three other things to test for?
A
a) Vitamin D deficiency rickets
b)
- 25 Vitamin D
- PTH
- X-ray knees + wrist (rickets survey) - metaphyseal fraying and cupping of distal radius + ulna
10
Q
- Baby boy with hyperpigmentation of the scrotum with Na 121, K 6.1
a) Name one test for diagnosis
b) Name 3 treatment
A
A. 17 OHP
B.
- Hydrocortisone - physiologic dosing when well, stress dosing when sick
- Fludrocortisone
- Salt
11
Q
- 18d old male is brought to the ER with vomiting and decreased urine output. He is listless and has a weak cry. HR is 184, RR 54. On exam he has pigmentation of the genitalia. Labs show Na 118, K 6.8, glu 2.8, BUN 8, Cr elevated (? In the 70s).
a. What is the most important test for diagnosis?
b. List 3 things for emergency management.
A
a. 17 OHP
b. Salt, sugar, steroids, support, search
- Fluid bolus shock and Na
- Start dextrose in maintenance fluids
- Draw cortisol and start hydrocortisone 100mg/m2
- Support: BP, BW, Endo, PICU
- Search for etiology: FSWU and start antibiotics
12
Q
- Growth chart given of child with constitutional growth delay. Given bone age.
a. Determine mid-parental height
b. Determine expected height of child
A
a. MPH
- Boy = (mother + father +13)/2
- Girl = (mother + father - 13)/2
b. expected height of child
* Plot height at the bone age then track along that percentile to 18yo on growth chart
13
Q
- Girl started menarche 10 months ago, irregular every 1-3 months and heavy flow. No dysmennorhea.
a. What is the most likely cause
b. name 2 suggestions for management. (2 points)
A
A. Anovulatory cycles
B.
- Observe/reasure
- OCP if bothersome or impacting QoL
14
Q
- An 8 month old infant is taken to the ER, very lethargic. Had just started sleeping through the night, and fasted about 7-8 hours overnight. BG is 1.1, and there are no ketones in the urine.
a. Name 2 things on your differential diagnosis?
A
A.
- FAOD
- Hyperinsulinism
15
Q
- An adopted child is brought to your office. You note on exam enlarged costro-condral junctions and bowed legs.
a. What 4 investigations would you do?
A
A
- 25-OH-Vit D
- Ca, phos, ALP
- PTH
- Xray hand + wrist
