endocrine

Question 1

normal tsh levels

Answer 1

0.4 - 4.0 mIU/L
high levels indicate hypOthyroidism
low levels of tsh indicate hypERthyroidism

Question 2

graves disease soundbite and exclusive s/s, tx

Answer 2

autoimmune disease with hyper stimulation of TSH receptors autoantibodies causing hyperthyroidism
pretibial myxedema, exophthalmos
antithyroid drugs, radio iodine therapy, thyroidectomy

Question 3

multi nodular goiter (toxic) soundbite

Answer 3

thyroid nodules that do not respond to feedback systems and create high levels of T3/t4 causing hyperthyroidism

Question 4

subacute thyroiditis soundbite, and labs

Answer 4

thought to be caused by viral infection and inflammation, causing elevated levels of t3/t4 initially followed by low levels (hyperthyroidism followed by hypothyroidismm)
labs are high t4/t3, low tsh and ELEVATED ESR

Question 5

Propylthiouracil and methimazole mech

Answer 5

prevent production of t4 and conversion of t4 to t3

Question 6

beta blockers role in thyroid tx

Answer 6

block the s/s (peripheral effects of thyroid hormone) until underlying problem can be addressed

Question 7

radioactive iodine

Answer 7

radioactive iodine - 131 is an ablative treatment (goes to the thyroid gland and radioactive destroys) given orally
used in graves (an others?)

Question 8

thyroid storm s/s and tx

Answer 8

large release of thyroid secondary to stress of surgery or illness, dysrhythmias, hyperthermia, n/v diarrhea, elevated systolic, low diastolic.
less severe supportive
severe - beta blockers, propylthiouracil, hydrocortisone prevent conversion of t4 to t3, sodium iodide blocks the release of stored thyroid.

Question 9

hyperthyroidism and surgery management

Answer 9

elective cases - takes 8 weeks for Propylthiouracil and methimazole to work, several months before elective surgery
goal is 85 bpm and normal thyroid function tests
emergency surgeries: beta blockers, glucocorticoids to decrease hormone release and reduce the peripheral conversion of t4 to t3
avoid sympathomimetics like ketamine, epi, atropine, ephedrine
ocular protection for graves
ekg for dysrhythmias
continue all hyperthyroidism meds morning of the surgery.

Question 10

hypothyroidism soundbite, labs

Answer 10

decreased production from the thyroid gland of t4/t3,
low t4/t3 with high tsh levels

Question 11

Hashimoto’s thyroiditis soundbite, labs, tx

Answer 11

autoimmune disease caused by the destruction of the thyroid gland, causing decreased thyroid hormone production and despite normal tsh levels
(but tsh eventually will be high)
t3/t4 low
presence of antibodies against thyroid peroxidase (TPO)
tx: levothyroxine

Question 12

myxedema soundbite, s/s, and tx

Answer 12

decompensated hypothyroidism (existing inadequately treated/unknown?), this is an emergency with hypoglycemia, hypercapnia, hypoventilation, hypotension, hypothermia
tx with t3 first, then t4 and glucocorticoids and supportive measures as needed, admit to ICU

Question 13

how does hypothyroidism effect surgery?

Answer 13

1) retore to euthyroid, HOWEVER, can treat mild/moderate hypothyroid with elective surgery with little risk
2) increase NPO due to delayed gastric emptying
3) prone to hypotension (secondary to lack of myocardial response and lack of peripheral catecholamines)
4) increased upper airway obstruction: goiters, and obesity
5) increased sensitivity to drugs.

Question 14

diabetes, type 1 and type 2 soundbites

Answer 14

diabetes - metabolic disorder with defect in insulin secretion, action or both resulting in hyperglycemia
type 1 - autoimmune loss of insulin producing beta cells, with lack of insulin, resulting in hyperglycemia
type 2 - insulin resistance in the peripheral cells and relative lack of insulin.

Question 15

functions of insulin

Answer 15

1) uptake of glucose by cells, especially skeletal muscles
2) increase glycogen
3) decrease gluconeogenesis
4) increase potassium uptake
5) increase lipid synthesis

Question 16

diagnostic criteria for diabetes

Answer 16

1) fasting bg over 126 on 2 or more occasions, also over 100 is pre-diabetic
2) glucose tolerance test - give 75 g glucose the 200 mg/dl after 2 hours
3) hg A1c of 6.5 or greater
4) non-fasting plasma glucose over 200 and symptoms of DM

Question 17

s/s diabetes

Answer 17

1)polyuria, polydipsia, polyphagia
2) peripheral neuropathy
3) silent MI due to cardiac ischemia with cardiac neuropathy, and because of glycosylation of LDLs
4) nephropathy - secondary to prolonged intraglomerlar pressure - leads to renal insufficiency
5) diabetic retinopathy
6) stiff joints - something to do to skin

Question 18

lispro, aspart, NPH, lente, glargine, levemir

Answer 18

lispro, aspart - fast
regular insulin - short
NPH, lente - intermediate
glargine, levemir - prolonged
can be combo of above insulins

Question 19

metformin

Answer 19

biguanide - decreases hepatic gluconeogenesis, decreases intestinal glucose absorption
risk of lactic acidosis in the setting of renal insufficiency

Question 20

glipizide, glyburide

Answer 20

sulfonylureas - stimulates beta cells to produce insulin. risk of hypoglycemia

Question 21

rosiglitazone, pioglitazone (-glitazones)

Answer 21

thiazolidinediones - promotes insulin sensitivity in adipose. decreases triglycerides and increases HDL.
weight gain is a side effect

Question 22

repaglinide

Answer 22

meglitinides - increase beta cell secretion of insulin through binding tap dependent potassium channel.

Question 23

exantide/byetta

Answer 23

GLP1 agonist - stimulates insulin and decreases glucagon secretion by being a synthetic peptide of glucagon like peptide

Question 24

sitagliptin aka januvia

Answer 24

increased insulin secretion via DPP4 inhibitor.

Question 25

what are some medications that increase insulin

Answer 25

sitagliptin aka Januvia (DPP4 inhibitor)
exantide aka byetta - glp1 agonist
repaglinide - meglitindes
glipizide, glyburide - sulfonylureas
not metformin, rosiglitazone, pioglitazone

Question 26

DKA Diabetic ketoacidosis soundbite, s/s, triggers, tx

Answer 26

secondary to insulin shortage resulting in hyperglycemia, ketonemia, and anion gap metabolic acidosis
2) s/s - 3 ps, severe dehydration, fruity breath, vomiting, abdominal pain, fruity breath, kussmaul breathing (look up)
3) triggers CVA, MI, infection, stress, cocaine
4) tx - fluids, insulin, mgmt of hyperkalemia, bicarb for metabolic acidosis, mgmt of underlying problem

Question 27

what is the postprandial goal for diabetics?

Answer 27

good question to gauge diabetic control. only really for people who administer insulin
120-200 mg/dl

Question 28

preoperative workup for diabetics?

Answer 28

1) recent ecg
2) labs - glucose, potassium, creatinine, urinalysis (look up the normal values of these labs)
3) ha1c
4) rule out thyroid, type 1 correlation to other autoimmune like graves and hashimoto’s

Question 29

HA1C levels correlate to average blood glucose (close, about

Answer 29

5- 100
6 - 126
7- 150
8-180
9-212 (boiling?)
10- 240
11-270
12 - 300

Question 30

preoperative hospital for diabetics

Answer 30

1) keep hydrated with. 100-200ml of 5% dextrose (which is 5-10 g/h) if NPO
2) SS insulin OR insulin pump (would have to look up the settings)

Question 31

preoperative (day before/day of surgery)

Answer 31

1) basal 1/2, hold short insulin
2) hold orals for t2dm except thiazolidinediones, which are rosiglitazone, pioglitazone, the tease being is the promote insulin sensitivity and will have minimal effect during NPO periods. Also, metformin can have lactic acidosis in setting of hypotension, poor derision, and hypoxia.
3) longer NPO due to delayed gastric emptying - is this secondary to neuropathy of the GI? look up.

Question 32

peri-operative management

Answer 32

1) pre/post op blood glucose levels taken
2) fluids - if greater than 130 mg/dl then NS
if less than 100 mg/dl the consider D5W with 0.45 NS
2.5) glucocorticoids only when lifesaving, will really mess with bs post op
3) monitor ekg, increased risk of MI
4) stiff joint syndrome, difficult to intubated because of atlantooccipital joint motion

Question 33

infections and diabetes, tell me the etiology and how to prevent

Answer 33

etiology is impaired chemotaxis and phagocytosis
prevent with pre and post op antibiotics
particularly when the fasting blood glucose is greater than 250

Question 34

cushings syndrome, tests

Answer 34

iatrogenic or endogenous
iatrogenic - lifters or people chronically on steroids
endogenous are typically a tumor somewhere.
not going to learn the tests - maybe if time later.
blood cortisol, 24 hour urine free cortisol level, dexamethasone suppression test (low and high) and acth level

Question 35

Addisons disease soundbite, s/s, dx,

Answer 35

1) insufficient adrenocortical synthesis of glucocorticoids and mineralcororticoids
2) thin and dark (anorexia and hyperpigmentation), hyponatremia and hyperkalemia (mineral problem)
3) dx - low morning cortisol - if less than 3mcg/dL no further testing, can do corticotropin stimulation test- would have to look up what the results of this mean.
4) check serum potassium pre op and 100mg of IV hydrocortisone

Question 36

adrenal crisis soundbite

Answer 36

life threatening state when adrenal can not respond to the stress, and causes circulatory collapse not responsive to vasopressors
need to look up tx?

Question 37

dosage for adrenal insufficiency

Answer 37

minor- usual dose
moderate (Ie orthographic) - hydrocortisone 50mg, then 25 mg every 8h for 24 h then regular dosage
major - hydrocortisone 100 mg or equivalent then 50 mg every 8h for first 24 hours then taper by half every day to usual dosage.

Question 38

if you have cgcg what do you need to rule out?

Answer 38

brown cell tumor of parathyroidism - get PTH levels and calcium levels. adenoma would have high pth

Question 39

primary hyperparathyroidism levels, signs

Answer 39

high pth and high calcium.
when remove adenoma pth levels should drop immediately.
signs are
stones - kidney
bones - pain
groans - abdominal (n/v)
and psychic overtones