Endocrine Flashcards
Hypoglycemia
Blood glucose less than 50
sxs- weakness, feels like passing out, hand tremors, and anxiety, difficulty concentrating
Type I DM is more common in what group
school aged children
Type I DM sxs
onset of persistent thirst (polydipsia)
frequent urination (polyuria)
weight loss
feeling of hunger
may be accompanied by blurred vision
breath fruity odor
large amounts of ketones in urine
children may present with DKA (neurological sxs such as drowsiness and lethargy, which can progress to coma)
may report recent viral illness before onset of sxs
diagnosis peaks from ages 4-6 years and again from ages 10-14 years
primary hyperthyroidism (thyrotoxicosis)
very low TSH that is undetectable with elevations in both serum free T4 and T3 levels. Most common cause is graves disease
What is Grave’s disease?
(hyperthyroidism)
autoimmune causing hyper function and production of excess thyroid hormones (T3 and T4)
What autoimmune disease are women with Grave’s disease at risk for?
rheumatoid arthritis (RA) and pernicious anemia (PA) and for osteopenia/osteoporosis due to increased metabolism
Describe the classic signs for Grave’s disease
Middle-aged woman loses a large amount of weight rapidly with anxiety and insomnia.
Cardiac sxs- palpitations, hypertension, atrial fibrillation, premature atrial contractions
warm and moist skin with increased perspiration
ophthalmopathy and lid lag
frequent bowel movements (looser stools)
amenorrhea and heat intolerance
enlarged thyroid goiter/thyroid nodules
pretrial myxedema (thickening of the skin usually located in the shins giving an orange-peel appearance
Describe the OBJECTIVE findings for Grave’s disease
Thyroid: diffusely enlarged gland (goiter), toxic adenoma, or multi nodular goiter. May be tender to palpation or asymptomatic.
Extremities: Fine tremors on both hands, sweaty palms, pretrial myxedema
Eyes: lid lag, exophthalmos in one or both eyes
Cardiac: tachycardia, atrial fibrillation, congestive heart failure, cardiomyopathy
integumentary: fine hair, warm skin
neurological: brisk deep tendon reflexes
What labs are appropriator Grave’s disease
very low TSH <0.5 mU/L, elevated serum free T4 and T3
positive thyrotropin receptor antibodies (TRAb) aka thyroid-stimulating immunoglobulin (TSI)
positive thyroid antibody (TPO)
Drugs used for hyperthyroidism
Propylthiouracil (PTU)- shrinks thyroid gland/decrease hormone production
methimazole (tapazole)
SE: skin rash, granulocytopenia/aplastic anemia, thrombocytopenia (check CBC with platelets), hepatic necrosis (monitor CBC, LFTS)
What is the adjunctive treatment for hyperthyroidism
Usually given before thyroid under control to alleviate symptoms of hyperstimualtion (anxiety, tachycardia, palpitations)
Beta-blockers are effective (propranolol, metoprolol, atenolol)
Radioactive iodine tx for hyperthyroidism
Contraindicated in pregnancy-1st line treatment is PTU (propylthiouracil)
PTU is 1st line tx (can cause liver failure)
Hyperthyroidism complications
thyroid storm (thyrotoxicosis):
heart rate, blood pressure, and body temp can soar to dangerous high levels. Sx= Decreased LOC, fever, abdominal pain
what are the laboratory findings of thyroid disease
TSH-used for both screening and monitoring
Drug-induced thyroid disease
lithium, amiodarone, high doses of iodine, interferon-alfa, dopamine
Hypothyroidism
High TSH with low free T4 levels
most common cause-hashimoto’s thyroiditis, postpartum thyroiditis, and thyroid ablation with radioactive iodine
Hashimoto’s thyroiditis
chronic autoimmune disorder of the thyroid gland
no pain with thyroid swelling
Body produce destructive antibodies (TPO) against the thyroid gland that gradually destroy it
elevated TPOs
goiter present
Hashimoto’s classic case
middle-aged-to-older woman who is overweight c/o fatigue, weight gain, cold intolerance, constipation, & menstrual abnormalities
alopecia on the outer one third on both eyebrows
serum cholesterol is elevated
could have hx of another autoimmune disorder
Hypothyroidism labs
TSH 1st>elevated>TSH with free T4
TSH is elevated and serum T4 is low-confirmed diagnosis
then order TPO to confirm Hashimoto’s thyroiditis
Subclinical hypothyroidism
TSH is greater than 5mu/L, serum free T4 is within normal range
Hypothyroidism
Starting dose of levothyroxine(Synthroid) from 25-50 mcg/day
start with lowest dose for elderly or patients with hx of heart disease (watch for angina, acute MI, atrial fib)
increase Synthroid dose every few weeks until TSH is normalized <5.0
Recheck TSH every 6-8 weeks until TSH is normalized <5.0
once under control every 12 months
Patient education: advise patient to report if palpitations, nervousness, or tremors because this means that Synthroid dose is too high (decrease dose until symptoms are gone and TSH in normal range)
Synthroid
start elderly at low dose (12.5-25 mcg) and gradually increase to avoid adverse cardiac effects
When not to treat hypothyroidism
patient with normal free T4 but with elevated TSH (subclinical hypothyroidism)
Radioactive iodine treatment
results in hypothyroidism for life, supplement thyroid hormone for life
TSH is suppressed
Hyperthyroidism
TSH 0.1
workup needed for hyperthyroidism
Tx for chronic amenorrhea and hyper metabolism
Cause osteoporosis
tx with calcium with vitamin D 1200 mg
weight bearing exercise
Recommendations for Diabetic patients
CDC recommends adults older than 50 be given SHINGRID in two doses, 2-6 months apart
Influenza immunization every year
Pneumococcal polysaccharide vaccine: if vaccinated before 65 years of age; give one-time revaccination in 5 years; if age 65 years, give one dose of the vaccine only
ASA 81 mg if high risk for MI, stroke
TYPE II DM every at diagnosis; Type I eye exam 5 years after diagnosis
podiatrist 1-2 twice a year
Bp goal is 130/80
Dawn Phenomenon
a hormonal surge in all people causing an elevation in the FBG occurs daily, early in the morning between 4:00 and 8:00 am. Without normal insulin responses, diabetics experience rising FBG levels.
Somogyi effect
severe nocturnal hypoglycemia
high levels of glucagon in the systemic circulation result in high fasting blood glucose by 7am. Condition is due to over treatment with the evening and/or bedtime insulin (dose is too high)
Tx: check blood glucose very early in the morning around 3 am for 1-2 weeks
Eat a snack before bedtime, or eliminate dinnertime intermediate-acting insulin (NPH) dose or lower the bedtime dose for both NPH and regular insulin
Rapid acting insulin
Covers one meal at a time
regular insulin
last from meal to meal
NPH insulin
last from breakfast to dinner
Lantus
once a day
What is 1st line treatment for type 2 DM
metformin (glucophage)
If patient on metformin 500 mg daily and A1C is high (>7%), increase dose to metformin 500 mg BID.
If A1C is still high (>7%) and on metformin 500 mg BID, increase dose to 1000 mg BID
If taking maximum dose of metformin (1g BID), add sulfonylurea like glipizide (glucotrol XL), 5mg PO daily (do not exceed maximum dose of 20mg, DPP-4 inhibitor (Januvia, Onglyza), TZD (ACTOs)
A1C >/= 9
Start on basal insulin
Diabetic retinopathy
cotton wool spots (soft exudates), neovascularization, micro aneurysms with dot and blot hemorrhages
hypertensive retinopathy
silver wire/copper wire arterioles, arteriovenous nicking
what can ACTOS cause
water retention>CHF
these meds are contraindicated in h/o heart failure, NYHA class III or IV (moderate to severe heart failure)
Insulin pump education
disconnect if swimming, bathing, or showering
wrestling
what are microvascular complications oF DM
retinopathy, nephropathy, or neuropathy
what are microvascular complications of DM
coronary artery disease, peripheral arterial disease, or stroke
Charcot’s foot & ankle
common in diabetics
