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endocrine Flashcards

1
Q

diabetes mellitus: pathophysiology

A

metabolic disease

- inability to produce/utilize insulin = causes hyperglycemia

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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.

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3
Q

DM1: s/s

A

P olyphagia
P olydypsia
P olyuria
W eight loss

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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
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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

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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

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7
Q

What are 3 insulin analogs?

A

RAPID ACTING
aspart (NovoLog)
lispro (Humalog): rapid onset

LONG-ACTING
glargine (Lantus): prolonged duration

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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

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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)
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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.

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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

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12
Q

What pharmacological intervention is considered the standard of care upon diagnosis of DM2?

A

metformin (Glucophage)

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13
Q

What is a major AE of metformin (Glucophage)?

A

LACTIC ACIDOSIS

If patient complains of muscle cramps/pain - think LA.

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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

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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.

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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

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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

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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

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19
Q

What is the treatment for Somogyi Effect?

A

reduce /omit bedtime dose of insulin

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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

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21
Q

What is the treatment for Dawn Phenomenon?

A

add/increase bedtime dose of insulin

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22
Q

DKA: pathophysiology

A

intracellular dehydration as a result of hyperglycemia, often acute complication of DM1 (may be presenting sign)

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23
Q

DKA: hallmark s/s x6

A

Kussmaul breathing
altered LOC
fruity breath
dehydration - poor skin turgor, orthostatic hypotension with tachycardia

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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
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25
Q

DKA: mgmt x7

A
  • 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
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26
Q

HHNK: pathophysiology

A

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.
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27
Q

HHNK: hallmark s/s

A

NO KETONES IN URINE!

  • dehydration (poor turgor, tachycardia, orthostatic hypotension)
  • changes in LOC
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28
Q

HHNK: diagnostics x4

A
  • BG gt 600 mg/dL; often 1000+
  • hyperosm: gt 310 mOsm/L
  • ↑ ↑ BUN/Cr r/t dehydration
  • NORMAL pH & anion gap + NO KETONES
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29
Q

HHNK: mgmt x4

A
  • 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
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30
Q

hyperthyroidism: classic s/s

A 
↑ sweating, smooth/warm/moist skin
tachycardia, a fib
hyperthermia/heat intolerance
weight loss
exopthalmos
emotional lability, fatigue
hyperreflexia
thinning hair
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31
Q

What is the most sensitive test in diagnosing hyperthyroidism?

A

TSH assay

Hyperthyroidism: ↓TSH + ↑T3

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32
Q

hyperthyroidism: T3

A

↓T3 (80 - 230 ng/dL)

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33
Q

A low thyroid radioactive iodine uptake is associated with what etiology of hyperthyroidism?

A

subacute thyroiditis

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34
Q

What is the pharmacological management of a patient with small goiter; mild cases of hyperthyroidism; or fear of isotopes?

A

Thiourea drugs
Methimazole (Tapazole) 30-60 mg TID daily
Propulthiouracil 300-600 mg QID daily

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35
Q

What drug class is used for symptomatic relief in hyperthyroidism?

A

Beta Blockers - Propanolol (Inderal) 10 mg PO and titrate up to max 80 mg PO QID daily.

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36
Q

What is used to destroy goiters in hyperthyroidism?

A

Radioactive iodine-131

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37
Q

What medication is contraindicated during a thyroid crisis and why?

A

ASA - it can exacerbate storm.

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38
Q

What is the most common cause of hypothyroidism?

A

Hashimoto’s thyroiditis

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39
Q

hypothyroidism: hallmark s/s

A 
extreme weakness, arthralgias, cramps
cold intolerance
weight gain
edematous hands, face
constipation
dry skin, hair loss, brittle nails
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40
Q

hypothyroidism: TSH presentation assay

A

↑ TSH, ↓ T4

T3 is not a reliable test

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41
Q

In addition to TSH assay, what two lab values are of note when diagnosing hypothyroidism?

A

Hyponatremia

Hypoglycemia

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42
Q

What pharmaceutical intervention is the standard of care in treating hypothyroidism?

A

levothyroxine (Synthroid) 50 - 100 mcg QD

  • ↑ dose 25 mcg QD for 1 - 2 wks until stable
  • elderly: start low go slow
  • @ 60, decrease dose
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43
Q

Considerations for levothyroxine in older adults? x2

A

60+ = decrease dose

if new dx, start low & go slow

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44
Q

What lab value is used to monitor the effectiveness of levothyroxine (Synthroid)?

A

TSH

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45
Q

What AE is most responsible for decreased compliance with levothyroxine (Synthroid)?

A

Alopecia. Hair falls out in clumps - it is temporary but distressing.

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46
Q

What is the most common cause of hyponatremia?

A

Hyperglycemia (as with HHNK).

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47
Q

What is Cushing’s Syndrome and what are 3 causes?

A

Adrenal glands gone haywire. THINK: TOO MUCH STEROID

ACTH hypersecretion by pituitary
Adrenal tumor
Chronic glucocorticoid use

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48
Q

Cushing’s Syndrome: hallmark s/s

A 
moon face, buffalo hump, central obesity
hypertension
acne, purple striae, poor wound healing/freq infection
hirsutism
amenorrhea, impotence
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49
Q

Which 2 adrenal-related labs are elevated in Cushing’s Disease?

A

AM cortisol

Serum ACTH

50
Q

Cushing’s Syndrome: glucose, Na, K

A

hyperglycemia
hypernatremia
hypokalemia

51
Q

Cushing’s Syndrome: mgmt x5

A

DEPENDS ON CAUSE!

  • d/c glucocorticoids
  • transphenoidal resection of pituitary adenoma
  • resection of ACTH secreting or adrenal tumors
  • manage electrolyte imbalance
52
Q

Addison’s Disease: pathophysiology

A

adrenal insufficiency ∴ deficiency in androgens, cortisol, aldosterone

53
Q

Addison’s Disease: hallmark s/s

A 
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
Q

Addison’s Disease: glucose, Na, K

A

hypoglycemia
hyponatremia
hyperkalemia

55
Q

What lab is ordered to rule out Addison’s Disease?

A

Cosytropin - measures how well adrenal glands respond to ACTH

56
Q

Addison’s Disease: outpatient mgmt x3

A
  • specialist referral

- replace glucocorticoid (hydrocortisone) & mineralcorticoid (fludrocortisone)

57
Q

SIADH: pathophys

A

release of ADH occurs independent of osmolality or volume-dependent stimulation

INAPPROPRIATE WATER RETENTION

58
Q

SIADH: hallmark s/s

A

neuro changes r/t hyponatremia: HA, seizures, coma
weight gain/edema
↓ UOP

59
Q

SIADH: diagnostics

A

hyponatremia but EUVOLEMIC
* ↓ serum osm lt 280
* ↑ urine osm gt 100
urine Na gt 20

60
Q

Patient has been diagnosed with SIADH with serum Na gt 120 mEq/L. Treatment plan?

A

restrict total fluids to 1000 mL/24 hrs

61
Q

Patient has been diagnosed with SIADH and is having neuro symptoms with serum Na less than 110 mEq/L. Treatment plan? x3

A

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
Q

Patient has been diagnosed with SIADH, has no neuro symptoms, and has serum Na 115 mEq/L. Treatment plan? x2

A

restrict fluids to 500 mL/24hrs

monitor

63
Q

What is central diabetes insipidus and what are the causes x4?

A

pituitary or hypothalamus damage → ADH deficiency

causes:

  • surgical damage
  • trauma
  • infection
  • metastatic carcinoma
64
Q

What is nephrogenic diabetes insipidus and what are the causes x5?

A

renal tubule defect → renal insensitivity to ADH

causes:

  • familial X-linked
  • pyelonephritis
  • K depletion
  • sickle cell anemia
  • meds
65
Q

diabetes insipidus: hallmark s/s

A 
thirst, fluid intake: 5 - 20 L/day
polyuria: 6 - 20 L/day 
nocturia
tachycardia, hypotension, dizziness
AMS, fatigue
weight loss, poor turgor
66
Q

diabetes insipidus: diagnostics x5

A

hypernatremia
↑ serum osm gt 290
↑ BUN/Cr

these two go together;

  • ↓ urine osm lt 100
  • ↓ urine specific gravity lt 1.005
67
Q

Patient has diabetes insipidus and serum Na of gt 150 mEq/L. Treatment plan?

A

Give D5W IV to replace 1/2 FVD in 12-24 hours

68
Q

What is a major complication associated with rapid lowering of serum sodium?

A

Cerebral edema.

69
Q

diabetes insipidus: acute mgmt

A

DDAVP 1-4 ug IV or SQ q 12-24 hrs

70
Q

diabetes insipidusL maintenance treatment

A

maintenance dose: DDAVP 10 ug q 12-24 hrs INTRANASALLY

71
Q

pheochromocytoma: pathophys

A

excess catecholamine (epi + NE) release characterized by paroxysmal or sustained HTN

most commonly caused by TUMOR of the adrenal MEDULLA

72
Q

Pheochromocytoma is often associated with what hallmark symptom?

A

Labile HTN and postural hypotension

73
Q

** What are the four components of the urine assay that is diagnostic for a pheochromocytoma? **

!!!!

A

urine catecholimines
metanephrines
vanillylmandelic acid (VMA)
creatinine

74
Q

What diagnostic confirms a pheochromocytoma?

A

adrenals CT to confirm and localize tumor

75
Q

Expected TSH value given pheochromocytoma?

A

The TSH is normal with a pheo.

76
Q

What is the treatment of choice for pheochromocytoma?

A

surgical removal of adrenal medulla tumor

77
Q

What are 3 possible complications that should be monitored in patients who are s/p surgical removal of tumor that was causing pheochromocytoma?

A

hypotension (r/t depleted catecholamines)
adrenal Insufficiency
hemorrhage

78
Q

The most common complication associated with diabetes is:

A

retinopathy

79
Q

What is the most prevalent risk factor for type II DM?

A

Obesity

80
Q

The two most common causes of hypercalcemia are:

A

Malignancy

Hyperparathyroidism

81
Q

Metabolic abnormalities seen in Addison’s Disease include:

A
  • 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
Q

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?

A

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
Q

A patient with DM and HTN should be on which classification of medication and why?

A

ACE Inhibitors - to reduce proteinuria and the resulting diabetic nephropathy

84
Q

HgbA1C: normal range + good control

A

normal 5.5 - 7

good control @ 6 (given DM)

85
Q

impaired glucose tolerance values

A

FBG 100 - 125

86
Q

1 reason for BUN fluctuation?

A

dehydration

87
Q

normal range BUN & Cr?

A

10 - 20 & 0.5 - 1.5

88
Q

lispro (Humalog): very important admin consideration

A

lispro (Humalog) has very rapid onset, must give food with it otherwise hypoglycemia will occur within 5 - 10 minutes

89
Q

What is intensive therapy of insulin for DM1?

A

reduce/omit PM dose and add at bedtime

90
Q

As waist circumference increases, risk for what increases?

A

risk of sudden cardioembolic death - above Metabolic Syndrome thresholds, this risk is substantive

91
Q

What is the most widely prescribed oral antidiabetic?

A

sulfonylureas

92
Q

What class of meds can be used as an adjunct to sulfonylureas but can also be used alone? When would you use it alone?

A

biguanides (metformin)

use alone for obese pts

93
Q

DKA vs HHNK

A 
DKA / HHNK
DM1 / DM2
BG 250+ / 600 - 1000+
metabolic acidosis / normal anion gap
ketones / none
94
Q

What diagnostic test is performed to establish etiology of hyperthyroidism?

A

thyroid radioactive iodine uptake

95
Q

A high thyroid radioactive iodine uptake is associated with what etiology of hyperthyroidism?

A

Grave’s Disease

96
Q 
normals:
TSH
Total T4
Free T4
T3
A

TSH: 0.4 - 5.0
Tot T4: 4.5 - 11.5
Free T4: 0.8 - 2.8
T3: 75 - 200

97
Q

Most common presentation of hyperthyroidism?

A

Grave’s Disease

98
Q

5 potential causes of hyperthyroidism

A 
Grave's Disease
subacute thyroiditis
toxic adenoma
TSH secreting pituitary tumor
high dose amiodarone
99
Q

What cardiac med has the potential AE of hyperthyroidism?

A

amiodarone (at high doses)

100
Q

6 causes of hypothyroidism

A 
Hashimoto's thyroiditis
pituitary TSH deficiency
hypothalamic TRH deficiency
iodine deficiency
gland damage
idiopathic
101
Q

hyperthyroidism: mgmt

A
  • 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
Q

Thyroid disease indication + use for propranolol (Inderal)?

A

symptomatic relief for hyperthyroidism, also, subacute thyroiditis best treated symptomatically with it

begin @ 10mg up to 80mg QID;

103
Q

Thyroid disease indication + use for lugol’s solution?

A

in hyperthyroidism to reduce gland vascularity, 2 - 3 gtt PO QD x10 days

104
Q

Thyroid disease indication + use + 2 examples of thiourea drugs?

A

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
Q

thyroid storm: mgmt

A

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
Q

myxedema coma: what is it + mgmt x6

A

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
Q

What is the dosage of levothyroxine in a myxedema coma?

A

IV !!!!!!!
levothyroxine 400 mcg IV once
THEN
100 mcg QD

108
Q

Why do you see hypertension in Cushing’s Syndrome?

A

steroids induce vasoconstriction

109
Q

What 2 adrenal-related labs can be seen in Addison’s Disease?

A

↓↓ plasma cortisol: less than 5 mcg/dL @ 0800

cosyntropin test

110
Q

Addison’s Disease x4

A

autoimmune destruction of adrenals
bilateral adrenal hemorrhage (ex: w anticoag tx)
pituitary failure = ↓ ACTH
metastatic cancer

111
Q

Cushing’s vs Addison’s: glucose, Na, K

A

CUSHY:
hypergly, hyperNa, hypoK

ADDY:
hypogly, hypoNa, hyperK

112
Q

Addison’s Disease: inpatient mgmt

A

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
Q

What is often the underlying cause for Addison’s Disease?

A

infection - sepsis

114
Q

What is usually ineffective in the treatment of Addison’s Disease requiring hospitalization?

A

vasopressors

115
Q

The symptoms of SIADH are largely related to what imbalance?

A

hyponatremia

116
Q

SIADH: mgmt for 3 different levels of acuity

A

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
Q

urine specific gravity normal

A

1.010 - 1.030

118
Q

What is a vasopressin (Desmopressin) challenge test and when is it used?

A

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
Q

diabetes insipidus mgmt x 2 serum levels + acute + maintenance

A

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
Q

pheochromocytoma: diagnostic process x4

A

TSH: if normal…

then check

  • plasma-free metanephrines
  • assay of urine catecholamines

then CT of adrenal glands: confirms & localizes tumor

121
Q

What is important to r/o if you suspect pheochromocytoma? How do you rule it out x3?

A

hyperthyroidism! r/o with
TSH level

observation of labile hypertension and postural hypotension

122
Q

in suspected pheochromocytoma, 24 hour urine test expected findings **

A

2.2+ ug metanephrine / mg creat
AND
5.5+ ug VMA / mg creat

MICROGRAMS OF METANEPHRINE AND VMA

0 BOARDS (14 decks)

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