Endocrine Issues and Disorders

Question 1

Type 1 diabetes

Answer 1

acute onset
human leukocyte antigens strongly associated
destruction of pancreatic islet cells by isle tell antibodies (autoimmune process)
ketones in blood and urine

Question 2

s/sx of type 1 DM

Answer 2

polyuria, polydipsia and polyphagia 
nocturnal enuresis 
weight loss, with increased hunger
fatigue and weakness, paraesthesia
LOC changes ranging from irritability to coma (most present with this for the first time)
loss of SQ fat and muscling waiting suggestive of insidious onset 
dysfx of peripheral sensory nerves 
evidence of dehydration

Question 3

s/sx of type 1 DM in advance disease

Answer 3

ophthalmic exam may reveal micro aneurysms or cotton wool spots
evidence of peripheral visceral insufficiency
diminshed DTRs

Question 4

Labs of Type 1 DM

Answer 4

• looks dehydrated
  serum fasting blood sugar >/= 126 on 2 separate occasions
  random blood sugar >/=200 and polydipsia, polyuria, and weight loo indicate the need to confirm the dx by fasting studies
  glycosuria and ketonuria
  plasma ketones
  BUN and creatinine may be increased (dehydrated)
  increased hgb A1c
  impaired glucose tolerance: fasting >/=100 and =125

Question 5

Dietary teaching of Type 1 DM

Answer 5

total carb intake: 50-60% of total caloric intake

fats: 25-30% of total calories
fiber: 25g/1000 calories
protein: 10-20% of total calories

Question 6

Patients presenting with ketones in type 1 DM must start ______.

Answer 6

insulin

**begin with 0.5 u/kg/day, giving 2/3 of dose in morning and the remaining 1/3 in the evening

Question 7

Somogyi Effect

Answer 7

**think tsunami, go up and down

when nocturnal hypoglycemia stimulates a surge of counter regulatory hormones that raise blood sugar–pt is hypoglycemic at 3 am and rebounds with an elevated blood sugar at 7 am (so hyperglycemic)

treat by reducing or eliminating the HS dose of insulin

Question 8

Dawn phemomenon

Answer 8

tissue become desensitized to insulin nocturnally. Blood sugar gets progressively higher through the night and is elevated at 7 am. This desensitization is felt to be d/t the presence of growth hormone that spikes at night

treat by adding or increasing the dose of HS insulin

Question 9

Type 2 diabetes mellitus

Answer 9

previously referred to as non0insulin dependent DM or adult onset
not linked to human leukocyte antigen system
no islet cell antibodies identified
presence of obesity or family history increases risk

Question 10

S/sx of type 2 DM

Answer 10

insidious onset of hyperglycemia may be asymptomatic
generalized pruritus
recurrent vaginits is often the first symptom in women
peripheral neuropathies and recurrent blurred vision are more common than in DM1
chronic skin infections
acanthosis nigricans
polydipsia, polyphagia, polyuria may be present but less common symptoms DM2
in early disease, physical findings are unremarkable

Question 11

Labs for type 2 DM

Answer 11

same as for type 1 DM except no ketones in blood and urine

Question 12

What circumstances should you consider screening for DM2

Answer 12

obesity and has 2 of the risk factors:
family hx of type 2 DM
race/ethnicity of african american, native american, hispanic or asian/pacific islanders
signs associated with insulin resistance
screening if done should begin at age 10 or onset of puberty (whatever occurs first) and repeat every 2 years

Question 13

Signs of insulin resistance:

Answer 13

acanthosis nigricans
hypertension
dyslipidemia
polycystic ovarian disease

Question 14

Oral antidiabetics for type 2 DM

Answer 14

metformin (FDA approved in children)
850 mg twice a day or 500 mg 3x/day
reduces gluconeogenesis
do not give to hepatic or renal failure or to those prone to hypoxia
significant GI upset
little or no hypoglycemia
discontinue 48 hours prior to a procedure

Question 15

Hyperthyroidism

Answer 15

increased T3
increased T4
decreased TSH

Question 16

Grave’s disease

Answer 16

most common in children associated with diffuse enlargement of thyroid, hyperactivity of the gland, and presence of antibodies against different fractions of the thyroid gland

Question 17

Causes/incidence of hyperthyroidism

Answer 17

more common in females
onset between 12-14 years of age

other causes: toxic adenoma, thyroiditis, TSH secreting pit tumor, high dose amiodarone)

Question 18

Signs and symptoms of hyperthyroidism

Answer 18

everything sped up

nervousness, restlessness
heat intolerance, increased sweating, warm moist skin
muscle cramps
frequent basilar migraine 
weight changes (usually a loss0
palpitations, chest pain
menstrual irregulatories 
fine hair 

a.fib
tachycardia
thyroid goiter (often without bruit)
grave's opthalmopathy may be present
hyperactive DTR

Question 19

Labs for hyperthyroidism

Answer 19

TSH decreased
T4 increased
T3 increased
ANA usually elevated without evidence of lupus

Question 20

Management of hyperthyroidism

Answer 20

Refer to endocrine
Meds: propranolol and thiourea drugs (PTU and tapazole)

other treatments: radioactive iodine, thyroid seizure, 2-3 gets of lugol’s solution

Question 21

Hypothroidism

Answer 21

T3 decreased
T4 decreased
TSH increased

d/t disease in thyroid gland or deficiency of pituitary thyroid stimulating hormone or hypothalamic thyrotropin releasing hormone

most often due to autoimmune thyroiditis

Question 22

Congenital cause of hypothyroidism

Answer 22

may affect fetus in first trimester
absence or underdevelopment of thyroid gland
inherent dysfunction in transport/assimilation of iodine
hypothalamic of pit disorder
occurs in 1:4000 live births

Question 23

Juvenile cause of hypothyroidism

Answer 23

hashimoto's thyroiditis 
pituitary deficiency of TSH
hypothalamic deficiency of TRH
iodide deficiency 
damage to the gland

Question 24

Signs and symptoms of hypothyroidism in neonates/infants

Answer 24

no obvious symptoms in the first month of life
lethargy, poor feeding, prolonged bilirubin elevation
growth deceleration
large fontanels
bradycardia
hypotonia

Question 25

Signs and symptoms of hypothyroidism in older children

Answer 25

weakness, muscle fatigue
arthralgias, cramps
cold intolerance 
constipation 
weight gain 
mental/physical sluggishness, poor motor coordination
delayed bone age, poor growth
dry skin, thinning hair, brittle nails
puffy eyes and thick tongue
edema of the hands and face, ascites
slowed DTRs
diminished heart sounds

Question 26

Lab tests for hypothyroidism

Answer 26

newborn screening is mandatory

Elevated TSH
Dec T4
Dec Free Tr
increased serum cholesterol and liver enzymes
hyponatremia, hypoglycemia 
anemia

Question 27

Management of hypothyroidism

Answer 27

refer to endocrine

treat with synthroid (not generic)

Question 28

Short stature

Answer 28

height falling> 2 SD below mean or a marked devotion from perviously established growth curve
failure to grow more than 4 cm per year

Question 29

Normal variants for short stature

Answer 29

familial genetic variant: normal linear growth velocity and a short target height

constitutional delay: bone age consistent with height age–slow growth rate for first 2-3 year of life, then a low-normal growth velocity

family history of short stature and delayed puberty are often present

Question 30

Conditions with disproportionate short stature

Answer 30

dwarfism

rickets

Question 31

Conditions with proportionate short stature

Answer 31

IUGR
maternal/fetal infection
chromosomal abnormalities 
FTT
variety of endocrine disease: hypopituitarism, GH deficiency, diabetes, hypothyroidism

Question 32

Labs for short stature

Answer 32

CBC, LFT, electrolyte, ESR, bone age, UA, thyroid function test, celiac disease, stool for ova and parasites, growth hormone level, sweat test if recurrent bronchitis (rule out CF)