Endocrine

Question 1

Test for type 2 diabetes

Answer 1

1. fasting plasma glucose level (>126 mg/dL)
2. random plasma glucose level (>200 mg/dL)
3. oral glucose tolerance testing (2-hour blood glucose level >200 mg/dL) with a 75-g glucose load.
4. A1c 6.5% or over

Question 2

Primary adrenal insufficiency is characterized by…..

Answer 2

Low serum cortisol and a very high ACTH concentration.

Question 3

A patient has secondary (pituitary disease) or tertiary (hypothalamic disease) adrenal insufficiency when …

Answer 3

both the serum cortisol and the plasma ACTH concentrations are inappropriately low

Question 4

Risk factors for developing diabetes

Answer 4

1. High BMI
2. Giving birth to large gestational age baby

Question 5

Your 63-year-old female patient newly started on paroxetine after the death of her spouse presents to the urgent care with a lethargic state and a sodium of 125. Which of the following do you suspect?

Answer 5

Syndrome of inappropriate ADH (SIADH)

SIADH can be caused by initiation of SSRIs.

DI would likely have an elevated sodium and polyuria, polyphagia, and polydipsia as key symptoms. Serotonin syndrome would be more likely to have symptoms of muscle spasm, hypertension, diaphoresis, tachycardia. Takotsubo cardiomyopathy is broken-heart syndrome and may precipitate heart failure due to the loss of a spouse but does not explain a sodium of 125.

Question 6

Myxedema coma

Answer 6

Severe hypothyroidism with progression to decreased mental status, hypothermia, and other symptoms secondary to slowing of function in multiple organs

Question 7

Pheochromocytoma

Answer 7

Rare hormone-releasing adrenal tumor.

Random episodes of headache (can be mild to severe), diaphoresis, and tachycardia accompanied by hypertension (HTN). Episodes resolve spontaneously. In between attacks, patient’s vital signs are normal. Triggers include physical exertion, anxiety, stress, surgery, anesthesia, changes in body position, or labor and delivery.

Question 8

Addison’s Disease

Answer 8

Primary adrenal insufficiency. Failure of the body to release enough essential hormones, resulting in mineralocorticoid and glucocorticoid deficiency. Often the cause of autoimmune destruction of the adrenal gland

Question 9

S/S Addisons disease

Answer 9

Fatigue, weight loss (usually secondary to anorexia), GI side effects (nausea, vomiting, abdominal pain, diarrhea and/or constipation), amenorrhea, myalgia, and psychiatric changes (e.g., depression, psychosis). Other common findings include postural hypotension, salt craving, and hyperpigmentation (characteristic finding). Patients presenting in adrenal crisis will present in vasodilatory shock (dehydration, hypotension, acute abdomen, unexplained fever, tachycardia)

Hyponatremia, hyperkalemia, hypercalcemiaLa

Question 10

Labs for addison’s diease

Answer 10

ACTH
aldosterone
cortisol
CRH (differentiate between primary and secondary)

Question 11

Treatment plan for Addison’s disease

Answer 11

Replacement of glucocorticoids (e.g., hydrocortisone, dexamethasone, or prednisone) and mineralocorticoids (often fludrocortisone). Dehydroepiandrosterone (DHEA) therapy may be considered for some women with impaired mood or sense of well-being.

Question 12

Causes of Cushing’s Disease

Answer 12

Exogenous administration of glucocorticoids (treating for Addison’s).

Second most common form is Cushing’s disease, a subset of Cushing’s syndrome, which is pituitary hypersecretion of ACTH.

Question 13

Cushing’s disease

Answer 13

Condition that occurs when the body produces too much cortisol.

Question 14

Lab findings for Cushing’s disease

Answer 14

Hypernatremia
Hypokalemia
Hyperglycemia

Question 15

Diagnostics for Cushing’s

Answer 15

Labs:
ACTH
Cortisol
Aldosterone

• Late-night salivary cortisol (two measurements)
• 24-hour urinary free cortisol excretion (two measurements),
• overnight 1 mg dexamethasone suppression test

Question 16

S/S Cushing’s Disease

Answer 16

moon face with buffalo hump, acne, poor wound healing, purple striae, hirsutism, HTN, weakness, amenorrhea, impotence, headache, polyuria and thirst, labile mood, frequent infections

Question 17

S/S Addison’s Disease

Answer 17

hyperpigmentation in buccal mucosa and skin creases, diffuse tanning and freckles, orthostasis and hypotension, scant axillary and pubic hair

Question 18

Treatment for Cushing’s

Answer 18

Goal of therapy: Reverse signs, symptoms, and comorbidities of Cushing’s syndrome by reducing cortisol secretion to normal; eradicate any tumor; avoid permanent dependence on medication or hormone deficiency.

Acute management: Manage electrolyte balance and supportive care of symptoms.

Cushing’s disease: May require surgical intervention to excise pituitary tumor or pituitary irradiation. Medical management often is the primary treatment option if patient is not a surgical candidate or if symptoms do not resolve after excision.

Adrenalectomy: Definitive treatment for ACTH-secreting pituitary or ectopic tumors

Question 19

HHS

Answer 19

hyperglycemia, severe dehydration, and obtundation, but without ketoacidosis

Question 20

Metabolic syndrome

Answer 20

Male waist circumference: >40 inches (102 cm); female waist circumference: >35 inches (88 cm)

HTN: Blood pressure [BP] ≥130/85 mmHg or drug treatment for elevated BP

Triglycerides: Level ≥150 mg/dL or drug treatment for elevated triglycerides

Serum high-density lipoprotein (HDL) cholesterol: <40 mg/dL in males and <50 mg/dL in females or drug treatment for low HDL cholesterol

Hyperglycemia: Fasting plasma glucose (FPG) ≥100 mg/dL or drug treatment for elevated blood glucose

Question 21

Diagnostic criteria for pre-DM

Answer 21

A1C) between 5.7% and 6.4%

OR

Fasting glucose of 100 to 125 mg/dL (impaired FPG)
OR

Two-hour oral glucose tolerance test (OGTT; 75 g load) of 140 to 199 mg/dL

Question 22

Diagnostic criteria for DM

Answer 22

A1C ≥6.5%
OR

FPG ≥126 mg/dL (fasting is no caloric intake for at least 8 hours)
OR

Classic symptoms of hyperglycemia (polyuria, polydipsia, polyphagia) plus random blood glucose ≥200 mg/dL
OR

Two-hour plasma glucose ≥200 mg/dL during an OGTT with a 75-g glucose load

Question 23

Recommendations for patients with DM

Answer 23

Blood pressure < 130/80 mmHg

LDL cholesterol < 70 mg/dL

A1C < 7% (although exceptions exist for certain populations)

Fasting blood glucose 80–130 mg/dL

Postprandial glucose (~2 hours after meal) < 180 mg/dL

Question 24

In diabetic patients with CVD and/or CKD, or heart failure with reduced ejection fraction (HFrEF) what medications should be considered?

Answer 24

An SGLT2 inhibitor and/or GLP-1 receptor agonist.

Question 25

Dawn Phenomenon

Answer 25

Proposed to result from diurnal secretion patterns of hormones, particularly increased GH at midnight to 2 a.m. This tends to antagonize the actions of insulin in the early morning hours. The result is high FBG concentrations. To determine if insulin dosing needs to be adjusted, examine glucose patterns at least 3 to 4 hours after the last meal or snack and insulin bolus, as well as at 3 a.m. Ask the patient about evening snacking and bedtime insulin bolusing for food. Inadequate correction can cause hyperglycemia

Question 26

Types of insulin and duration of effectiveness

Answer 26

Rapid-acting insulin covers “one meal at a time”
Regular insulin lasts “from meal to meal”
NPH insulin lasts “from breakfast to dinner”
Lantus is “once a day”

Question 27

Levels of hypoglycemia

Answer 27

Level 1 hypoglycemia (glucose alert): Blood glucose ≤70 and >54 mg/dL

Level 2 hypoglycemia: Blood glucose ≤54 mg/dL (severe hypoglycemia)

Level 3: Severe event characterized by altered mental and/or physical status requiring assistance for treatment of hypoglycemia

Question 28

Treatment for hyperthyroidism

Answer 28

Methimazole (Tapazole): Shrinks thyroid gland/decreases hormone production.

Propylthiouracil (PTU): Shrinks thyroid gland/decreases hormone production. PTU is preferred treatment for moderate to severe hyperthyroidism (can cause liver failure).
Side effects: Skin rash, granulocytopenia/aplastic anemia, thrombocytopenia (check CBC with platelets), hepatic necrosis (monitor CBC, LFTs).

Question 29

Thyroid storm

Answer 29

heart rate, BP, and body temperature can elevate rapidly to dangerously high levels. Acute worsening of symptoms due to stress or infection. Look for decreased LOC, fever, abdominal pain. Life-threatening. Immediate hospitalization is necessary.

Question 30

TSH goal for thyroid supplementation

Answer 30

Keep TSH between .4 and 4.0 mU/L.

Question 31

subclinical hypothyroidism

Answer 31

normal free T4 but with elevated TSH

Doesn’t necessarily need treatment

Question 32

myxedema coma

Answer 32

Medical emergency

Slowed thinking, poor short-term memory, depression (or dementia), hypotension, and hypothermia.

Question 33

Treatment for hypothyroidism

Answer 33

Start older patients at low dose of levothyroxine (Synthroid) (25–50 mcg/day) and gradually increase to avoid adverse cardiac effects from overstimulation (palpitations, angina, MI).

Average full replacement dose of synthetic thyroxine (T4, levothyroxine [Synthroid]) in adults is 1.6 mcg/kg body weight per day; dose ranges from 50 to >200 mcg/day.

Check TSH every 6 to 8 weeks to monitor treatment response to thyroid hormone replacement therapy. Aim to keep serum TSH within the normal reference range (about .4 to 4.0 mU/L).

Question 34

Hyperthyroidism managment

Answer 34

All hyperthyroid patients should be referred to an endocrinologist as soon as possible.