endocrine Flashcards
(122 cards)
1
Q
diabetes mellitus: pathophysiology
A
metabolic disease
- inability to produce/utilize insulin = causes hyperglycemia
2
Q
diabetes type 1: pathophys
A
total DESTRUCTION of beta cells; thought to result from infectious/toxic environmental insult to beta cells in genetically prediposed
- d/t islet cell antibodies found in 90% w/in 1 year
- ketone development occurs
Insulin DEPENDENT.
3
Q
DM1: s/s
A
P olyphagia
P olydypsia
P olyuria
W eight loss
4
Q
diabetes mellitus (either 1 or 2): diagnostics x5
A
- random BG: gt 200 mg/dL (+ uria/dips/wt loss)
- fasting BG: gt 126 mg/dL x2 diff occasions
- HgbA1c: gt 7%
- ↑ ↑ BUN/Cr d/t dehydration
- DM1 only: ketonemia/uria
5
Q
What pharmacological therapy is indicated if patient presents with ketones and DM1?
A
insulin therapy @ 0.5 units/kg/day
split: give ⅔ AM & ⅓ PM
6
Q
What are the Conventional Split Dose Mixtures of insulin administration for DM1?
A
AM: ⅔ NPH; + ⅓ Regular
PM: ½ NPH + ½ Regular
7
Q
What are 3 insulin analogs?
A
RAPID ACTING
aspart (NovoLog)
lispro (Humalog): rapid onset
LONG-ACTING
glargine (Lantus): prolonged duration
8
Q
DM2: pathophysiology
A
circulating insulin insufficient to meet body’s needs but IS enough to prevent ketoacidosis
causes:
- tissue insensitivity
- insulin secretion defect leading to resistance and/or impaired insulin production
9
Q
What are the diagnostic criteria for Metabolic Syndrome?
A
3+ of... WAIST: M 40+ & F 35+ BP: over 130/85 TRIGS: 150+ FBG: 100+ HDL: less than 40(M) or 50(F)
10
Q
40 yo. F presents to ED with complaints of four UTIs in the past 6 months and chronic skin infection with increasing pruritus. What is most likely differential?
A
DM Type II. Women often first present with recurring vaginitis, plus chronic skin infections are associated with DM2.
11
Q
What is the initial therapy indicated for DM Type II management? x3
A
weight loss (obese pts)
consider early use of oral agent
dietary tx & exercise
12
Q
What pharmacological intervention is considered the standard of care upon diagnosis of DM2?
A
metformin (Glucophage)
13
Q
What is a major AE of metformin (Glucophage)?
A
LACTIC ACIDOSIS
If patient complains of muscle cramps/pain - think LA.
14
Q
glipizide (Glucotrol)
glyburide (Diabeta)
glimepiride (Amaryl)
These fall in what class? What is the mechanism of action?
A
diabetic oral agents: sulfonylureas
MOA: stimulate pancreas to release more insulin
15
Q
A key feature of DM Type II is Metabolic Syndrome. To make this diagnosis, you need three of the following EXCEPT:
a. Waist circumference M 40, F 35
b. BP 140/90
c. Fasting BG t100
d. HDL M 40, F 50
A
B. The BP in Metabolic Syndrome is greater than 135/85.
16
Q
What is the function of incretins in diabetes pathophysiology?
A
incretins signal pancreas to increase insulin secretion and liver to stop producing glucagon
17
Q
60 yo. F with PMH significant for DM Type II is being discharged. Lipid acting drug therapy should be especially considered for this patient with the following:
a. triglycerides 140
b. HDL 40
c. cholesterol 200
d. LDL 90
A
D. Goal LDL is less than 60
18
Q
What is the Somogyi Effect?
A
Nocturnal hypoglycemia stimulates surge of counter regulatory hormones that raise blood sugar. Hypoglycemia @ 0300 results in rebound causing hyperglycemia @ 0700
SOMOGYI SURGE
19
Q
What is the treatment for Somogyi Effect?
A
reduce /omit bedtime dose of insulin
20
Q
What is the Dawn Phenomenon?
A
Tissue DESENSITIZED to insulin nocturnally. BG progressively elevates through night resulting in hyperglycemia @ 0700.
DAWN IS RISING
21
Q
What is the treatment for Dawn Phenomenon?
A
add/increase bedtime dose of insulin
22
Q
DKA: pathophysiology
A
intracellular dehydration as a result of hyperglycemia, often acute complication of DM1 (may be presenting sign)
23
Q
DKA: hallmark s/s x6
A
Kussmaul breathing
altered LOC
fruity breath
dehydration - poor skin turgor, orthostatic hypotension with tachycardia
24
Q
DKA: diagnostics x6
A
BG over 250 mg/dL keton-emia/-uria metabolic acidosis: pH less than 7.3 + ↑AG hyperkalemia leukocytosis hyperosmolality
25
DKA: mgmt x7
- protect airway; oxygen
- 1st hour: min 1L NS IVF then 500 mL/hr
- - if glucose 500+ use ½NS after 1st hr (water exceeds Na loss)
- - when glucose under 250 give D5 ½NS (prevent hypoglycemia)
- 0.1u/kg regular insulin IV bolus then 0.1u/kg/hr
- - if glucose doesn't fall after 1 hr, repeat bolus
- severe acidosis lt 7.1: correct w bicarb drip (44-48mEq in 900 mL ½NS) until gt 7.1
- do not treat initial hyperkalemia
- UOP monitored hourly
- supportive
26
HHNK: pathophysiology
also intracellular dehydration d/t elevated blood glucose
- usually complication of DM2
- insulin production impaired, not sufficient to prevent severe hyperglycemia, osmotic diuresis, extracellular fluid depletion.
27
HHNK: hallmark s/s
NO KETONES IN URINE!
- dehydration (poor turgor, tachycardia, orthostatic hypotension)
- changes in LOC
28
HHNK: diagnostics x4
- BG gt 600 mg/dL; often 1000+
- hyperosm: gt 310 mOsm/L
- ↑ ↑ BUN/Cr r/t dehydration
- NORMAL pH & anion gap + NO KETONES
29
HHNK: mgmt x4
- protect airway; O2.
- fluid deficit 6 - 10L: massive fluid replacement, NS IVF then ½NS then D5½NS
- 15u regular insulin IV bolus followed by 10 - 15u SQ STAT (additional insulin depends on severity/response)
- supportive care
30
hyperthyroidism: classic s/s
```
↑ sweating, smooth/warm/moist skin
tachycardia, a fib
hyperthermia/heat intolerance
weight loss
exopthalmos
emotional lability, fatigue
hyperreflexia
thinning hair
```
31
What is the most sensitive test in diagnosing hyperthyroidism?
TSH assay
| Hyperthyroidism: ↓TSH + ↑T3
32
hyperthyroidism: T3
↓T3 (80 - 230 ng/dL)
33
A low thyroid radioactive iodine uptake is associated with what etiology of hyperthyroidism?
subacute thyroiditis
34
What is the pharmacological management of a patient with small goiter; mild cases of hyperthyroidism; or fear of isotopes?
Thiourea drugs
Methimazole (Tapazole) 30-60 mg TID daily
Propulthiouracil 300-600 mg QID daily
35
What drug class is used for symptomatic relief in hyperthyroidism?
Beta Blockers - Propanolol (Inderal) 10 mg PO and titrate up to max 80 mg PO QID daily.
36
What is used to destroy goiters in hyperthyroidism?
Radioactive iodine-131
37
What medication is contraindicated during a thyroid crisis and why?
ASA - it can exacerbate storm.
38
What is the most common cause of hypothyroidism?
Hashimoto's thyroiditis
39
hypothyroidism: hallmark s/s
```
extreme weakness, arthralgias, cramps
cold intolerance
weight gain
edematous hands, face
constipation
dry skin, hair loss, brittle nails
```
40
hypothyroidism: TSH presentation assay
↑ TSH, ↓ T4
| T3 is not a reliable test
41
In addition to TSH assay, what two lab values are of note when diagnosing hypothyroidism?
Hyponatremia
| Hypoglycemia
42
What pharmaceutical intervention is the standard of care in treating hypothyroidism?
levothyroxine (Synthroid) 50 - 100 mcg QD
- ↑ dose 25 mcg QD for 1 - 2 wks until stable
- elderly: start low go slow
- @ 60, decrease dose
43
Considerations for levothyroxine in older adults? x2
60+ = decrease dose
| if new dx, start low & go slow
44
What lab value is used to monitor the effectiveness of levothyroxine (Synthroid)?
TSH
45
What AE is most responsible for decreased compliance with levothyroxine (Synthroid)?
Alopecia. Hair falls out in clumps - it is temporary but distressing.
46
What is the most common cause of hyponatremia?
Hyperglycemia (as with HHNK).
47
What is Cushing's Syndrome and what are 3 causes?
Adrenal glands gone haywire. THINK: TOO MUCH STEROID
ACTH hypersecretion by pituitary
Adrenal tumor
Chronic glucocorticoid use
48
Cushing's Syndrome: hallmark s/s
```
moon face, buffalo hump, central obesity
hypertension
acne, purple striae, poor wound healing/freq infection
hirsutism
amenorrhea, impotence
```
49
Which 2 adrenal-related labs are elevated in Cushing's Disease?
AM cortisol
| Serum ACTH
50
Cushing's Syndrome: glucose, Na, K
hyperglycemia
hypernatremia
hypokalemia
51
Cushing's Syndrome: mgmt x5
DEPENDS ON CAUSE!
- d/c glucocorticoids
- transphenoidal resection of pituitary adenoma
- resection of ACTH secreting or adrenal tumors
- manage electrolyte imbalance
52
Addison's Disease: pathophysiology
adrenal insufficiency ∴ deficiency in androgens, cortisol, aldosterone
53
Addison's Disease: hallmark s/s
```
hyperpigmentation: buccal mucosa & skin creases (nipples, nail beds, knuckles, palms, neck)
diffuse tanning/freckles
orthostasis, hypotension
scant axillary, pubic hair
acute: fever, worsening of sx, Δ LOC
```
54
Addison's Disease: glucose, Na, K
hypoglycemia
hyponatremia
hyperkalemia
55
What lab is ordered to rule out Addison's Disease?
Cosytropin - measures how well adrenal glands respond to ACTH
56
Addison's Disease: outpatient mgmt x3
- specialist referral
| - replace glucocorticoid (hydrocortisone) & mineralcorticoid (fludrocortisone)
57
SIADH: pathophys
release of ADH occurs independent of osmolality or volume-dependent stimulation
INAPPROPRIATE WATER RETENTION
58
SIADH: hallmark s/s
neuro changes r/t hyponatremia: HA, seizures, coma
weight gain/edema
↓ UOP
59
SIADH: diagnostics
hyponatremia but EUVOLEMIC
* ↓ serum osm lt 280
* ↑ urine osm gt 100
urine Na gt 20
60
Patient has been diagnosed with SIADH with serum Na gt 120 mEq/L. Treatment plan?
restrict total fluids to 1000 mL/24 hrs
61
Patient has been diagnosed with SIADH and is having neuro symptoms with serum Na less than 110 mEq/L. Treatment plan? x3
can use iso or hyper: NS or 3% NS IVF - SLOW admin
+ furosemide (Lasix) 1 - 2 mEq/hr.
monitor Na/K losses hourly + replete as needed
62
Patient has been diagnosed with SIADH, has no neuro symptoms, and has serum Na 115 mEq/L. Treatment plan? x2
restrict fluids to 500 mL/24hrs
| monitor
63
What is central diabetes insipidus and what are the causes x4?
pituitary or hypothalamus damage → ADH deficiency
causes:
- surgical damage
- trauma
- infection
- metastatic carcinoma
64
What is nephrogenic diabetes insipidus and what are the causes x5?
renal tubule defect → renal insensitivity to ADH
causes:
- familial X-linked
- pyelonephritis
- K depletion
- sickle cell anemia
- meds
65
diabetes insipidus: hallmark s/s
```
thirst, fluid intake: 5 - 20 L/day
polyuria: 6 - 20 L/day
nocturia
tachycardia, hypotension, dizziness
AMS, fatigue
weight loss, poor turgor
```
66
diabetes insipidus: diagnostics x5
hypernatremia
↑ serum osm gt 290
↑ BUN/Cr
these two go together;
- ↓ urine osm lt 100
- ↓ urine specific gravity lt 1.005
67
Patient has diabetes insipidus and serum Na of gt 150 mEq/L. Treatment plan?
Give D5W IV to replace 1/2 FVD in 12-24 hours
68
What is a major complication associated with rapid lowering of serum sodium?
Cerebral edema.
69
diabetes insipidus: acute mgmt
DDAVP 1-4 ug IV or SQ q 12-24 hrs
70
diabetes insipidusL maintenance treatment
maintenance dose: DDAVP 10 ug q 12-24 hrs INTRANASALLY
71
pheochromocytoma: pathophys
excess catecholamine (epi + NE) release characterized by paroxysmal or sustained HTN
most commonly caused by TUMOR of the adrenal MEDULLA
72
Pheochromocytoma is often associated with what hallmark symptom?
Labile HTN and postural hypotension
73
** What are the four components of the urine assay that is diagnostic for a pheochromocytoma? **
!!!!
urine catecholimines
metanephrines
vanillylmandelic acid (VMA)
creatinine
74
What diagnostic confirms a pheochromocytoma?
adrenals CT to confirm and localize tumor
75
Expected TSH value given pheochromocytoma?
The TSH is normal with a pheo.
76
What is the treatment of choice for pheochromocytoma?
surgical removal of adrenal medulla tumor
77
What are 3 possible complications that should be monitored in patients who are s/p surgical removal of tumor that was causing pheochromocytoma?
hypotension (r/t depleted catecholamines)
adrenal Insufficiency
hemorrhage
78
The most common complication associated with diabetes is:
retinopathy
79
What is the most prevalent risk factor for type II DM?
Obesity
80
The two most common causes of hypercalcemia are:
Malignancy
| Hyperparathyroidism
81
Metabolic abnormalities seen in Addison's Disease include:
- hyponatremia s/t renal tubular loss of sodium ions
- hyperkalemia s/t decrease in cortisol which helps to regulate intracellular and extracellular potassium and sodium
- hypoglycemia
Metabolic Acidosis
82
30 yo. D with PMH of DM Type II is scheduled for a cardiac cath within the next 7 days. Home medications include Metformin (Glucophage) 500 mg TID. What instructions would you give her regarding her medications?
Instruct the patient to stop Metformin (Glucophage) at least 3 days before procedure. The use of Metformin (Glucophage) and contrast dye could cause ARF.
83
A patient with DM and HTN should be on which classification of medication and why?
ACE Inhibitors - to reduce proteinuria and the resulting diabetic nephropathy
84
HgbA1C: normal range + good control
normal 5.5 - 7
| good control @ 6 (given DM)
85
impaired glucose tolerance values
FBG 100 - 125
86
#1 reason for BUN fluctuation?
dehydration
87
normal range BUN & Cr?
10 - 20 & 0.5 - 1.5
88
lispro (Humalog): very important admin consideration
lispro (Humalog) has very rapid onset, must give food with it otherwise hypoglycemia will occur within 5 - 10 minutes
89
What is intensive therapy of insulin for DM1?
reduce/omit PM dose and add at bedtime
90
As waist circumference increases, risk for what increases?
risk of sudden cardioembolic death - above Metabolic Syndrome thresholds, this risk is substantive
91
What is the most widely prescribed oral antidiabetic?
sulfonylureas
92
What class of meds can be used as an adjunct to sulfonylureas but can also be used alone? When would you use it alone?
biguanides (metformin)
| use alone for obese pts
93
DKA vs HHNK
```
DKA / HHNK
DM1 / DM2
BG 250+ / 600 - 1000+
metabolic acidosis / normal anion gap
ketones / none
```
94
What diagnostic test is performed to establish etiology of hyperthyroidism?
thyroid radioactive iodine uptake
95
A high thyroid radioactive iodine uptake is associated with what etiology of hyperthyroidism?
Grave's Disease
96
```
normals:
TSH
Total T4
Free T4
T3
```
TSH: 0.4 - 5.0
Tot T4: 4.5 - 11.5
Free T4: 0.8 - 2.8
T3: 75 - 200
97
Most common presentation of hyperthyroidism?
Grave's Disease
98
5 potential causes of hyperthyroidism
```
Grave's Disease
subacute thyroiditis
toxic adenoma
TSH secreting pituitary tumor
high dose amiodarone
```
99
What cardiac med has the potential AE of hyperthyroidism?
amiodarone (at high doses)
100
6 causes of hypothyroidism
```
Hashimoto's thyroiditis
pituitary TSH deficiency
hypothalamic TRH deficiency
iodine deficiency
gland damage
idiopathic
```
101
hyperthyroidism: mgmt
- refer to specialist esp w comorbs
- propranolol (Inderal): sx relief - begin @ 10mg up to 80mg QID; subacute thyroiditis best treated symptomatically with this
- radioactive iodine 131-I: destroy goiter
- thyroid surgery
- lugol's solution: reduce gland vascularity, 2 - 3 gtt PO QD x10 days
- thiourea drugs: mild cases, small goiter, or isotope aversion
- - methimazole (Tapazole): 30 - 60mg QD across 3 doses
- - propylthiouracil 300 - 600mg QD across 4 doses
102
Thyroid disease indication + use for propranolol (Inderal)?
symptomatic relief for hyperthyroidism, also, subacute thyroiditis best treated symptomatically with it
begin @ 10mg up to 80mg QID;
103
Thyroid disease indication + use for lugol's solution?
in hyperthyroidism to reduce gland vascularity, 2 - 3 gtt PO QD x10 days
104
Thyroid disease indication + use + 2 examples of thiourea drugs?
mild cases of hyperthyroidism or with small goiters, or patient refuses isotope
methimazole (Tapazole): 30 - 60mg QD across 3 doses
propylthiouracil 300 - 600mg QD across 4 doses
105
thyroid storm: mgmt
propylthiouracil 150 - 250 g q6 hours
OR
methimazole (Tapazole) 15 - 25mg q6 hrs PLUS the following in 1 hour:
- Lugol's Sol'n 10 gtts TID
OR
- Na iodide 1g slow IV PLUS the following:
-- propranolol 0.5 - 2g IV q4 hrs or 20 - 120 mg PO q6 hrs WITH
-- hydrocortisone 50 mg q6 hrs with rapid reduction as situation improves
106
myxedema coma: what is it + mgmt x6
hypothyroid crisis
- protect airway (vent if needed)
- fluid replacement
- levothyroxine 400 mcg IV once, then 100 mcg QD
- hypotension support
- slow rewarming with blankets to avoid circulatory collapse
- symptomatic care
107
What is the dosage of levothyroxine in a myxedema coma?
IV !!!!!!!
levothyroxine 400 mcg IV once
THEN
100 mcg QD
108
Why do you see hypertension in Cushing's Syndrome?
steroids induce vasoconstriction
109
What 2 adrenal-related labs can be seen in Addison's Disease?
↓↓ plasma cortisol: less than 5 mcg/dL @ 0800
cosyntropin test
110
Addison's Disease x4
autoimmune destruction of adrenals
bilateral adrenal hemorrhage (ex: w anticoag tx)
pituitary failure = ↓ ACTH
metastatic cancer
111
Cushing's vs Addison's: glucose, Na, K
CUSHY:
hypergly, hyperNa, hypoK
ADDY:
hypogly, hypoNa, hyperK
112
Addison's Disease: inpatient mgmt
hydrocorisone (Solu-Cortef) 100 - 300 mg IV initially w NS
- replace volume with D5NS at 500 cc/hr x4 hours then taper as appropriate
- vasopressors usually ineffective
TREAT THE UNDERLYING CAUSE! (Often infection, sepsis)
113
What is often the underlying cause for Addison's Disease?
infection - sepsis
114
What is usually ineffective in the treatment of Addison's Disease requiring hospitalization?
vasopressors
115
The symptoms of SIADH are largely related to what imbalance?
hyponatremia
116
SIADH: mgmt for 3 different levels of acuity
serum Na gt 120
- restrict water to 1000 mL/24 hrs + monitor
serum Na 110 - 120 & no neuro symptoms
- restrict water to 500 mL/24 hrs + monitor
neuro symptoms +/- serum Na lt 120
- NS or 3%NS SLOWLY
- furosemide 1 - 2 mEq/h
- monitor Na/K losses hourly & replete
117
urine specific gravity normal
1.010 - 1.030
118
What is a vasopressin (Desmopressin) challenge test and when is it used?
use if central diabetes insipidus is suspected
give 0.05 - 0.1 mL nasally
OR
1 ug SQ or IV & measure urine volume
POSITIVE in central DI
NEGATIVE in nephrogenic DI
119
diabetes insipidus mgmt x 2 serum levels + acute + maintenance
serum Na 150+ give D5W** to replace ½ volume deficit in 12 - 24 hrs (SLOWWW)
serum Na under 150: give ½ or NS
acute: DDAVP 1 - 4 ug IV or SQ q 12 - 24 hrs
maintenance DDAVP: 10 ug q 12 - 24 hrs intranasally**
120
pheochromocytoma: diagnostic process x4
TSH: if normal...
then check
- plasma-free metanephrines
- assay of urine catecholamines
then CT of adrenal glands: confirms & localizes tumor
121
What is important to r/o if you suspect pheochromocytoma? How do you rule it out x3?
hyperthyroidism! r/o with
TSH level
observation of labile hypertension and postural hypotension
122
in suspected pheochromocytoma, 24 hour urine test expected findings **
2.2+ ug metanephrine / mg creat
AND
5.5+ ug VMA / mg creat
MICROGRAMS OF METANEPHRINE AND VMA
