Endocrine Disorders Flashcards
What is DM Type 1?
- autoimmune destruction of beta cells
- inability to produce insulin
- ↓ beta-cell mass → ↓ insulin secretion → ↑ blood glucose levels
DM Type 1 - Physical Exam Findings
- usually normal
- *red flags (signs of DKA): Kussmaul respirations, dehydration, hypotension, AMS
Complications of DM Types 1 & 2
- infections: cause of considerable morbidity and mortality, most common signs are skin and urinary tract
- ophthalmologic: diabetic retinopathy, microvascular diseases, senile cataracts
- nephropathy
- neuropathy: peripheral sensory neuropathy is most common type
- macrovascular: all diabetes experience faster atherosclerosis; small arteries of brain, lower extremities, and kidneys; increases risk of ischemic heart disease, PVD; leading cause of death of diabetics
Diagnostics for DM Types 1 & 2
- *blood glucose studies: fasting BG > 126 x2 occasions (generally diagnostic)
DM Type 1 - Presentation
- *polyuria, polydipsia, polyphagia (typically associated with glucose > 200)
- acute onset
- weight loss
- blurry vision, muscle cramps
- ketotic episode
DM Type 1 - components of management
- self-monitoring, frequency of checks
- insulin therapy
- management of hypoglycemia and hyperglycemia
- diet
- activity: exercise regularly, may get hypoglycemic if rigorously exercising > 30 minutes
- glycemic control during illness/surgery
Glycemic Control During Surgery/Illness
- illness and surgery produce state of insulin resistance
- *NPO and those who aren’t eating need to have sugars checked and insulin given if needed
- *BG checks more frequently
DM - dietary teaching
- carb counting or modified plate method
- glycemic index
- low glycemic index: lower glucose spikes after eating
- artificial sweeteners don’t raise BG
DM Type 1 - Insulin
- goal is to provide insulin in most physiologic way possible by giving basal (glargine or detemir) and pre-prandial
- basal should be 40-50% of total insulin given/day
- basal insulin should be given regardless of NPO status
- short-acting: lispro, aspart
Estimated total daily amount of insulin needed
- Patient weight in kg x 0.5
* there are a lot of different prescribing methods
Pre-breakfast hyperglycemia: Somogyi effect and Dawn phenomenon
Somogyi effect - nocturnal hypoglycemia , ↓ 0300 BG, ↑ pre-breakfast BG, ↓ HS (evening) dose
Dawn Phenomenon - sugar gets progressively higher throughout night, ↑ 0300 BG, ↑ pre-breakfast BG, ↑ HS (evening) dose
What is DM type 2?
- dysfunction causing hyperglycemia
- defective/decreased insulin secretion
- insulin resistance
- excessive/inappropriate glucagon secretion
- followed by loss of beta cells
DM Type 2 - Presentation
- asymptomatic
- insidious onset
- peripheral neuropathies
DM Type 2 - Physical Exam findings
- normal exam
- obesity?
- more likely to see complications here
- skin: acanthosis nigricans, candida infections
- feet: dry, atrophy, claw toes, ulcers
DM Type 2 - Management
- glycemic control (same as DM 1)
- BP < 130/80 (ACE or ARB is first-line)
- lifestyle optimization: essential, multidisciplinary approach, do not delay pharm therapy but should happen at same time
- weight control
- diet (same as DM 1)
- oral antidiabetics
- insulin therapy (if PO unsuccessful)
DM Type 2 - Pharm management
- Biguanides (FIRST LINE): Metformin
- AE: lactic acidosis (MSK pain = tip-off, GI (diarrhea)
- CKD is no longer contraindication
DKA - Presentation
- insidious increase in polyuria/polydipsia
- malaise, weakness, fatigue
- n/v
- abdominal pain
- decreased appetitie, anorexia
- rapid weight loss
- AMS (mild disorientation, confusion, frank coma)
DKA - exam findings
- ill appearing
- dry mucous membranes
- *labored respirations (Kussmauls)
- decreased skin turgor
- acetone (ketotic) breath odor
- VS change: tachycardia, hypotensive, hypothermia
- *altered LOC/AMS
- *abdominal tenderness
DKA - diagnosics
- ABG: pH < 7.3, pCO2 decreased
- CMP/BMP: bicarb < 15, hyperglycemia > 250
- serum osmality (elevated)
- serum ketones +
- UA (glucosuria + ketonuria)
DKA - Management
- admit to ICU
- NPO
- serial labs
- correct fluid loss: *isotonic IVF (0.9% saline), 1-3L in first hour, change fluids to D5 0.45% when glucose < 250
- correct hyperglycemia with insulin: bolus 0.1 unit/kg/hr, continuous 0.1 unit/kg/hr, optimal BG decline 100 mg/dL/h
- correct electrolytes (especially K+): when acidosis corrects, K will go back into cells causing a drop
- correction of acid-base balance: only if patient is decompensating from acidosis
- tx of any concurrent infections
Hyperosmolar Hyperglycemic State (HHS) - what is it?
- hyperglycemia
- hyperosmolarity
- dehydration
- WITHOUT KETOACIDOSIS
Hyperosmolar Hyperglycemic State (HHS) - presentation
- known hx of DM2
- slightly insidious
- thirst, polydipsia, polyuria, weight loss, weakness
- focal/global neuro deficits (drowsiness, lethargy, delirium, coma, seizures, etc.)
Hyperosmolar Hyperglycemic State (HHS) - exam findings
- hydration status
- LOC
- source(s) of infection?
- VS: tachycardia, hypotension (late), tachypnea, temperature
Hyperosmolar Hyperglycemic State (HHS) - diagnostics
- glucose > 600
- serum osmolality > 310
- no acidosis
- CMP/BMP - normal anion gap, bicarb > 15
Hyperosmolar Hyperglycemic State (HHS) - management
- admit to ICU
- *vigorous rehydration: isotonic IVF (0.9% or 0.45% saline) = first line
- maintain electrolyte hemostasis
- correct hyperglycemia: don’t give initially, insulin drip
Hypoglycemia - presentation
- neurogenic: sweating, shaky, tachycarida, anxiety
- neuroglycopenic: weakness, tired, dizzy, confusion, blurry vision
- *Whipple triad: hx of hypoglycemic episodes, low plasma glucose, relief of symptoms after ingesting fast-acting carbs
Hypoglycemia - exam findings
- non-specific
- VS: hypothermia, tachypnea, HTN
- LOC
- diaphoresis
- know timing of onset in relation to meal ingestion
Hypoglycemia - management
- PO glucose tabs at onset of symptoms (mainstay)
Metabolic Syndrome - presentation
- HTN
- hyperglycemia
- hypertriglyceridemia
- abdominal obesity
- chest pains/SOB?
- acanthosis nigricans
- xanthomas/xanthelasmas
Metabolic Syndrome - diagnostics
At least 3/5 of following:
- fasting glucose > 100
- BP > 130/80
- TG > 150
- HDL < 40 (men), < 50 (women)
- waist circumference > 102 cm/40 inches (men), 88 cm/25 inches (women)
Metabolic Syndrome - management
- lifestyle modifications + weight loss
- HLD: statins
- BP: antihypertensives as appropriate
- hyperglycemia: metformin
Polycystic Ovarian Syndrome (PCOS) - major features
- menstrual dysfunction
- anovulation
- signs of hyperadrogenism
Polycystic Ovarian Syndrome (PCOS) - presentation/exam findings
- menstrual disorders
- hirsutism
- infertility
- obesity +/- metabolic syndrome
- diabetes
- s/s hyperaldosteronism (excess body hair in male pattern)
- virilizing signs (deep voice, increased muscle mass)
- acanthosis nigricans
Polycystic Ovarian Syndrome (PCOS) - diagnostics
- dx of exclusion
- baseline screenings: thyroid function, serum prolactin, free androgen
- hormones levels
- US - transvaginal
- CT/MRI - if tumor is suspected
Polycystic Ovarian Syndrome (PCOS) - management
- non-pharm = first line: diet, exercise, weight loss
- pharm (reserved for metabolic derangements such as anovulation, hirsutism, etc.) = PO contraceptives is first line
Hypothyroidism - presentation/ exam findings
- EVERYTHING IS SLOWER
- weakness and muscle fatigue
- cold intolerance
- constipation
- weight gain
- hair loss and brittle nails
- edema, puffy eyes
- goiter
- alopecia
- RED FLAGS: AMS, hypothermia, bradycardia, hypercarbia, hyponatremia
High serum vs. lower serum osmolality
High = greater concentration of particles (hemoconcentrated) Low = lower concentration of particles (hemodiluted)
Normal Serum and Urine osmolality
Serum = 285-295 Urine = 100-900
Hypothyroidism - diagnostics
- *TSH (elevated)
- *Free T4 (low or normal)
- BMP/CMP: hyponatremia, hypoglycemia
Hypothyroidism - management
Levothyroxine (Synthroid)
- initial: 25-75 mcg PO daily
- increase by 25 mcg q1-2weeks
- goal TSH 0.4-2.0 mU/L
Myexedema Coma/Crisis - what is it?
severe hypothyroidism
Myexedema Coma/Crisis - red flags of hypothyroidism
- AMS (stupor, delirium, seizures, coma)
- severely slowed processes: extreme hypothermia, hyponatremia, repsiratory depression, hypotention, bradyarrhythmias
Myexedema Coma/Crisis - presentation
- hypotension/shock
- hypothermia
- bradycardia
- bradypnea
- macroglossia
- edema
Myexedema Coma/Crisis - management
- admit to ICU
- ABCs - may need intubated
- *refer to endocrine!
- *IV thyroid replacement: Levothyroxine
- initial dose 400 mcg IV x1
- subsequent doses 50-100 mcg IV daily
Hyperthyroidism - presentation
- EVERYTHING IS FASTER
- nervousness/restless
- anxiety
- perspiration
- heat intolerance
- palpitations, tachycardia, atrial arrhythmias
- weight loss
- frequent BMs
- fine hair
- systolic HTN
- menstrual irregularities
- exophthalmos (Graves)
- lid lag (Graves)
Hyperthyroidism - diagnostics
Thyroid Function Studies
- low TSH, high free T4
Thyroid radioactive iodine uptake + scan
- high uptake indicates Graves
Hyperthyroidism - management
Referral PRN
Pharm
- propranolol (Inderal) initiate 10 mg PO
- Thioruea drugs (mild cases, small goiters) such as Methimazole and PTU
Radioactive Iodine
Must be euthyroid before surgery
Long-term monitoring
- TSH 6 weeks, 12 weeks, 6 months, annually
Thyroid Storm - red flags for hyperthyroidism
- fever
- tachycardia
- HTN
- neuro/GI abnormalities
Thyroid Storm - presentation/exam findings
- fever and sweating
- poor feeding/weight loss
- respiratory distress
- fatigue
- n/v/d + abdominal pain
- anxiety
- altered behavior
- seizures
- HTN
- arrhythmias (a fib/flutter, VT)
- agitation, confusion
Thyroid Storm - management
- admit to ICU
- refer to endocrine
- IVF resuscitation (D5 containing IVF)
- aggressive temperature management
- beta-blockade
- correct hyperthyroid state: PTU or methimazoel
- avoid ASA
- decrease environmental stimuli
Cushing’s Syndrome - presentation/ exam findings
- weight gain
- stretch marks
- easy bruising
- hirsutism
- weakness
- impotence
- polyuria + thirst
- labile mood
- infections
- buffalo hump
- mood face
- acne
- central obesity
- thin extremities
Cushing’s Syndrome - diagnostics
- TRIAD: HYPOkalemia, HYPERglycemia, leukocytosis
- elevated plasma cortisol in AM
- MRI to r/o pituitary tumor
Cushing’s Syndrome - management
- refer to endocrine
- high-protein diet
- surgery to resect tumor
- gradual withdrawal of corticosteroids (if that is cause)
- long-term follow up: osteoporosis, susceptibility to infection, DM, HTN, risk for adrenal crisis
Addison’s Disease - presentation/exam findings
- insidious or acute
- weakness, fatigue
- weight loss
- n/v
- arthralgias
- hyperpigmentation (buccal mucosa, knuckles, nail beds, posterior neck, nipples)
- freckles
- orthostatic hypotension
- scant axillary/pubic hair
Addison’s Disease - diagnostics
- TRIAD: HYPOglycemia, HYPOnatremia, HYPERkalemia
- low plasma cortisol in AM
Addison’s Disease - management
- refer to endocrine
- replacement therapy: hydrocortisone 15-25mg PO daily in 2 divided dosese
Acute Adrenal Insufficiency (Addisonian Crisis) - red flag symptoms
- profound fatigue
- dehydration
- severe abdominal pain
- n/v
- hypotension + shock
- hypoglycemia
- renal failure/shutdown
Acute Adrenal Insufficiency (Addisonian Crisis) - management
- admit to ICU
- mechanical ventilation and vasopressor support
- replace glucocorticoids: hydrocortisone 100-300 mg IV initially
Diabetes Insipidus - what is it?
- insufficient ADH
- passage of large volume (> 3L/24h) of DILUTE urine (< 300 mOsm/kg)
Diabetes Insipidus - central vs. nephrogenic
Central - decreased secretion of ADH
Nephrogenic - inability of kidneys to concentrate urine d/t ADH resistance
Diabetes Insipidus - presentation/exam findings
- thirst/craving for water (intake 5-20 L/day)
- polyuria (2-20 L/day)
- weight loss
- LOC changes
- dizziness
- febrile
- tachycardic
- hypotension
- poor skin turgor and other signs of dehydration
Diabetes Insipidus - diagnostics
- hypernatremia
- serum osmolality > 290 mOsm/kg (hemoconcentrated)
- urine osmolality < 100 mOsm/kg (hemodiluted)
- suspecting central DI? - DDAVP challenge
Diabetes Insipidus - management
- PO/IV fluid replacement
- calculate TBW deficit = 0.6 x patient weight (kg) x (patient’s Na/140-1)
- *Central? - DDAVP
- nephrogenic? - thiazide diuretic
SIADH - presentation/exam findings
- HA
- seizures/coma
- weight gain/edema
- n/v
- cold intolerance
- neurologic changes (AMS/LOC changes when Na < 125)
SIADH - diagnostics
- hyponatremic (BUT euvolemia)
- *serum osmolality < 280 mOsm/kg (hemodiluted)
- *urine osmolality > 100 (mOsm/kg (hemoconcentrated)
SIADH - management
- *treat underlying cause
- possibly refer to renal
- manage hyponatremia
Pheochromocytoma - what is it?
- tumor of adrenal medulla
- excess catacholamine release (epi/norepi)
Pheochromocytoma - presentation/exam findings
- severe HA
- polydipsia, polyphagia
- anxiety/panic-attack like symptoms
- palpitations
- profuse sweating
- tremors
- hyperglycemia
- tachycardia
- HTN
Pheochromocytoma - diagnotics
- TSH normal
- increased plasma free metanephrines
- 24 hour urine for metanephrines
- MRI abdomen/pelvis (tumor)
Pheochromocytoma - management
- admit to ICU
- fluid resuscitation
- surgery - tumor resection
- BP control (alpha-adrenergic blockers only pre-op)
- follow up: BP, urine/serum metanephrines 2 weeks post-up, annually for 10 years
Acromegaly & Gigantism - what is it?
- same disorder but gigantism happens when epiphyseal plates are still open and acromegaly happens when epiphyseal plates are closed (adulthood)
Acromegaly - presentation/exam findings
- insidious
- soft tissue swelling
- enlargement of extremities
- hyperhidrosis
- increased shoe/ring size
- coarsening of facial features
- macroglossia
- arthritis
Gigantism - presentation/exam findings
- dramatic
- longitudinal acceleration of linear growth
- HA, visual changes
Acromegaly & Gigantism - diagnostics
- fasting random serum IGF-I
- serum GH
- serum prolactin
- MRI: pituitary tumor (90% of cases)
Acromegaly & Gigantism - complications
- metabolic/endocrine: DM, high triglycerides, goiter
- respiratory: increased lung capacity, smaller airway, dyspnea, OSA
- CV: HTN, cardiomyopathy
- neuromuscular: weakness, spinal stenosis, carpal tunnel syndrome
- cancer
Acromegaly & Gigantism - mangement
- surgery (tumor resection)
- follow-up imaging 12 weeks post-op
