endocrine

Question 1

conditions that precede a thryoid storm

Answer 1

hyperthryoidism or thryoidtoxicosis

Question 2

MCC of throid storm

Answer 2

Graves disease

autoimmune hyperthryoidism

Question 3

MCC of hyperthryoidism

Answer 3

grave’s

Question 4

MCC OF HYPOTHYROIDISM

Answer 4

Autoimmune (Hashimoto’s disease) most common cause

Other causes include nonautoimmune thyroid failure, postablative/postsurgical, radiation tx, medications, toxins

Question 5

presentation of hypothy

Answer 5

i. Fatigue
ii. Weakness
iii. cold intolerance
iv. constipation
v. weight gain,
vi. depression,
vii. impaired mental funx
viii. dry skin,
ix. coarse hair
x. hair loss,
xi. brittle nails,
xii. muscle weakness,
xiii. edema,
xiv. hoarseness
xv. dysphagia,
xvi. menstrual irregularity

Question 6

e. Physical Exam hypothyroidism

Answer 6

i. Bradycardia
ii. Palpable goiter
iii. Macroglossia
iv. Delayed tendon reflexes

Question 7

myexdema precipitation

Answer 7

a. Infection
b. MI
c. CVA
d. Trauma
e. Opioid use

Question 8

1. Decreased mental status
2. Hypothermia
3. Bradycardia
4. Hypotension
5. Hypoventilation
6. Facial & periorbital edema, swollen lips, macroglossia, ptosis
7. Skin is cold and very dry, nonpitting edema can be found throughout
8. Precipitating illness

signs of

Answer 8

myexdema coma

Question 9

dx of myexdema coma

Answer 9

1. Serum TSH, Free T4, (Free T3)
   a. TSH can be as high as 600 (nml range 0.4-4.5)
   b. T4/T3 levels may be undetectable
2. CMP (hypoglycemia, hyponatremia common)
3. CBC w/differential
4. EKG
5. CXR

check for adrenal insufficiency too

Question 10

Checking for adrenal insufficiency before thyroid tx because…

Answer 10

Checking for adrenal insufficiency before thyroid tx b/c giving TH to low cortisol levels —> hypermetabolic state

Question 11

management of a myxedema coma includes

Answer 11

hyroid hormone (T4 alone vs T4 & T3):

a. Thyroxine 200-400mcg IV, followed by 50-100mcg qd;
b. Can add T3 5-20mcg IV, followed by 2.5-10mcg q8 hrs

supportive: a. electrolyte abnormalities
b. hypothermia
c. hypotension
d. ventilatory support

hydrocortisone if can’t exclude adrenal insufficiency

MONITOR

Question 12

Complications of hyperthyroid

Answer 12

Afib–> from too much thyroid

CHF leads to

Question 13

3 treatments for a thyroid storm

Answer 13

1. Beta-blocker to control symptoms:
   a. Propanolol 0.5-1mg IV over 10 minutes, then 1-2mg over 10 minutes every few hrs
2. Thionamides to block thyroid hormone synthesis:
   a. Propylthiouracil (PTU) 200mg q4 hrs (po, NG tube, rectal)
   b. Methimazole 20mg q4-6 hrs (po, NG tube, rectal)
3. Iodine to block release of T4/T3:
   a. Lugol’s solution, 10 drops po TID. Given at least 1 hour after thionamide administration to prevent iodine being used as substrate for new hormone synthesis

Question 14

low cortisol & low aldosterone

tired, fatigues

weight loss, anorexia
N/V
Hypovolemic, Hypotensive (on their way to shock)

Answer 14

addison’s

and hyperpigmentation

Question 15

most common cause of adrenal crisis

Answer 15

Severe, acute adrenocortical insufficiency

MC and most severe in pts w/ primary AI
i. loss of cortisol AND aldosterone function

Question 16

precipitating factors for adrenal crisis

Answer 16

i. Dehydration
ii. Infection
iii. Trauma
iv. Surgery
v. Acute and abrupt withdrawal of steroids for AI or with long term use for another autoimmune disease
vi. Inadequate stress dosing with AI

Question 17

presentation with adrenal crisis

Answer 17

i. Profound weakness or fatigue, LOC, AMS
ii. Nausea, vomiting, dizziness
iii. Abdominal/flank pain
iv. Diaphoretic, febrile, tachycardic, tachypneic
v. Hypotensive and volume depleted- the big problems
vi. Can rapidly progress to shock, seizures and coma

Question 18

adrenal crisis ddx

Answer 18

i. Cholelithiasis
ii. Gastroenteritis
iii. Hypercalcemia
iv. Hyperkalemia
v. Hypoglycemia
vi. Hyponatremia
vii. Hypothyroidism/Myxedema coma
viii. Metabolic acidosis
ix. Hypopituitarism

Question 19

how do you confirm a adrenal crisis

Answer 19

Serum electrolytes! (Hyponatremia and hyperkalemia, possible hypoglycemia and hypercalcemia- rare)

Serum cortisol, ACTH, renin (to confirm dx)
CBC w/diff , cultures (underlying infection)
TSH and FT4

Question 20

Tx (initiated immediately! No waiting for results)

Answer 20

ii. Aggressive IV fluid replacement
1. 5% dextrose in normal saline solution (D5NS)
2. 1-3 liters within first 12-24 hrs based on volume status & urine output

Hydrocortisone 100mg IV bolus, or dexamethasone 4mg IV bolus

Mineralcorticoid replacement not necessary acutely because of saline infusion and steroid treatment

Frequent hemodynamic & electrolyte monitoring is crucial**

Question 21

other than grave’s disease what cause hyperthyroid

Answer 21

i. Other causes: toxic nodular goiter, thyroiditis, excess iodine intake, TSH producing adenoma

Question 22

When would you switch fluids to 5% dextrose for a pt in DKA

Answer 22

b. When glucose reaches 200mg/dL, add 5% dextrose to saline

Question 23

when can you start SC insulin instead of IV

Answer 23

1. Serum glucose <200mg/dL
2. Serum anion gap <12meq/L
3. Serum bicarbonate > 18meq/L
4. Venous pH > 7.30

Question 24

HHS is different from type 1 because

Answer 24

• most commonly seen in >65yo with type 2 DM; insulin deficiency is present but NOT absolute, evolves more insidiously

a nonketotic state : the residual insulin secretion is sufficient to minimize ketosis but does not control hyperglycemia

Question 25

why is HHS more dangerous

Answer 25

more severe neurological manifestations

Question 26

reasons for HHS

Answer 26

inadequate insulin tx/noncompliance (21-40%)

acute illness/infection (32-60%)