Endocrine and metabolic disorders Flashcards
What is the dawn phenomenon?
Decreased sensitivity to insulin between 5 am and 8 am
What is the Somogyi effect?
nocturnal hypoglycemia -> surge of counter-regulatory hormones -> increased blood glucose by 7 am
What is myxedema crisis? What is the diagnostic workup?
What are the s/s?
What often precedes it?
How is it managed?
Extreme hypothyroidism (decr. free T4, incr. TSH)
s/s:
- hypothermia
- hypoventilation
- hypotension
- AMS (including coma)
- hyponatremia
- hypoglycemia
Often preceded by:
- infection
- major cardiopulmonary illness
- major neurologic illness
Management:
- Load T4 IV
- Maybe T3 if unstable
- Adrenal replacement therapy
- Levothyroxine
purple book 7-4
What is thyroid storm? What is the diagnostic workup?
What are the s/s?
How is it managed?
Extreme hyperthyroidism (incr. free T4 and T3, decr. TSH)
s/s:
- delirium
- fever
- tachycardia
- systolic HTN with wide pulse pressure
- GI symptoms
Management:
- B blocker
- PTU or methimazole
purple book 7-4
Thyrotoxicosis is another term for hyperthyroidism.
What is the diagnostic workup for hyperthyroidism?
What are the s/s of hyperthyroidism?
What is the management for hyperthyroidism?
Incr. FT4, FT3; decr. TSH
s/s:
- restlessness
- sweating
- tremor
- moist, warm skin
- fine hair
- tachycardia, afib
- weight loss
- increased frequency of stools
- menstrual irregularities
- hyperreflexia
- osteoporosis
- stare & lid lag
Management:
- B blocker
- methimazole, PTU
- maybe surgery, depending on cause
purple book 7-4
What is the definition of sick euthyroid syndrome?
Should you replace thyroxine in this case?
- Thyroid function test abnormalities in patients with severe nonthyroidal illness
- Replacement thyroxine not helpful nor recommended for critically ill patients with decreased T3/T4 unless other s/s of hypothyroidism
purple book 7-5
Review the adrenal axis
What are the clinical manifestations of adrenal insufficiency?
- weakness, fatigue
- anorexia
- orthostatic hypotension
- N/V
- hyponatremia
- primary: hyperpigmentation, hyperkalemia
purple book 7-9
What is the diagnostic workup for suspected adrenal insufficiency?
- Early a.m. serum cortisol < 3 mcg/dL virtually diagnostic
- > 18 rules it out
- Cosyntropin stimulation test
purple book 7-9
What is the management of adrenal insufficiency?
Acute:
- volume resuscitation with NS
- IV hydrocortisone
Chronic:
- Hydrocortisone or prednisone
- Fludrocortisone (not in secondary)
- Dexamethasone prefilled syringe given to pt for emergency situations
purple book 7-9
What are some causes of primary adrenal insufficiency?
- autoimmune
- infection
- vascular (hemorrhage, thrombosis, HIT, etc)
- metastatic
- deposition diseases (hemochromatosis, sarcoidosis, etc)
- drugs (ketoconazole, rifampin, etc)
purple book 7-9
What is the difference between Cushing syndrome and Cushing disease?
Cushing syndrome: cortisol excess
Cushing disease: cortisol excess due to pituitary ACTH hypersecretion
What are some causes of hypercortisolism?
- Most common is iatrogenic Cushing syndrome caused by exogenous glucocorticoids
- Pituitary adenoma (Cushing disease)
- Adrenal tumor (Cushing syndrome)
- Ectopic ACTH (SCLC, etc.)
purple book 7-7
What are the clinical manifestations of hypercortisolism?
- Most specific: spontaneous bruising, proximal myopathy, striae, hypokalemia
- Less specific: central obesity with extremity wasting, dorsocervical fat pads, rounded facies
- Nonspecific: glucose intolerance or DM, obesity, oligo- or amenorrhea, osteoporosis
purple book 7-7
How is Cushing syndrome treated?
Surgical resection of pituitary adenoma, adrenal tumor, or ectopic ACTH-secreting tumor with lifelong glucocorticoid replacement therapy
purple book 7-8
What are some causes of primary hyperaldosteronism?
- adrenal hyperplasia
- adenoma
- carcinoma
purple book 7-8
What are the clinical manifestations of hyperaldosteronism?
- Mild to moderate HTN
- HA
- muscle weakness
- polyuria
- polydipsia
- hypokalemia
purple book 7-8
What diagnostic studies are used to confirm hyperaldosteronism?
- Check aldosterone and plasma aldosterone:renin ratio (>20 = primary hyperaldosteronism)
- Confirm with sodium suppression test (sodium load fails to suppress aldosterone)
purple book 7-8
What is the treatment for hyperaldosteronism?
- Hyperplasia -> spironolactone
- Adenoma -> adrenalectomy vs medical rx with spironolactone
- Carcinoma -> adrenalectomy
purple book 7-9
What are the common precipitants of DKA (6 I’s)?
- Insulin deficiency
- Iatrogenic (glucocorticoids)
- Infection
- Inflammation
- Ischemia/Infarction
- Intoxication
purple book 7-14
What are the clinical manifestations of DKA?
- polyuria, polydipsia, dehydration, increased HR, hypotension, dry mucous membranes, decreased skin turgor
- N/V, abdominal pain, ileus
- Kussmaul respirations (deep) to compensate for metabolic acidosis, with acetone breath
- AMS (somnolence, stupor, coma)
purple book 7-14
What diagnostic studies are used to confirm DKA?
- Anion gap metabolic acidosis
- Ketosis (urine and serum ketones)
- Increased serum glucose
How is DKA managed?
- Rule out possible precipitants (infections, MI, etc.)
- Aggressive hydration (NS)
- Insulin
- Electrolyte supplementation
purple book 7-15
What is the definition of hyperosmolar hyperglycemic state (aka nonketotic hyperosmola coma)?
- Extreme hyperglycemia without ketoacidosis + hyperosmolarity + AMS in DMII (usually elderly)
- purple book 7-15*
