Kirila Endo Repro Flashcards
Parathyroid disorders
Ok
45 yo male no complaints. Normal but calcium of 11 (normal 8-11) and phosphorus 1.6 (2.2-4.8). PMH negative,
Is albumin protein bound
Ionized non protein bound and active.
Next step?
Blood work to include renal function and parathyroid hormone
If PTH high what is diagnosis
Hyperparathyroidism
Increase ca and decrease PO4
Ok
If ca is low, PO4 high
Ok
What is ca and PO4 move the same
Vitamin D issue
PTH low which is not a possible explanation
Malignant, multiple myeloma, VD intoxication, exercise induced, granulomatous disease
Vitamin d intoxication
Granulomatous-joint pain, lupus, RA
If PTH low
Malignancy, granulomatous disease, drugs, Mets, MM, lymphoma, vit d intoxication,
Do you work up further hypercal if pth is low
YES
Keep doing work up
Primary hyperparathyroidism
Solitary nodules, parathyroid CA, MEN
Which of following is associated with rapid development of hypercalcemia
Pulmonary edema, dehydration, psychiatric issues, kidney stones, pneumonia
Hyperosmoal state
Dehydration
Acute
Rapid development
Polyuria, dehydration, renal impairment (not long term)
Slow development hypercalcemia
Stones, bone problems (if in serum not in bone), psychiatric issues,
Patients now presents to you with a depressed moos, was diagnosed with kidney stone last year and developed stress fractures after trying to jog regularly. How approach manage
Begin bisphosphoate as an outpatient
At time of stone-IV hydration
Bed rest restricted activity-more osteoclast activity-so never rest with bone strength issues
Treat chronic hypercalcemis
Increase fluids, monitor, labs periodically, if comorbidities meds
What med use if this patient got HTN with hypercalcemia
Loop diuretics-take out calcium
Excrete ca
Thiazides-resorb calcium
What are risk of increasing ca excretion
Stones, fluid shifting and volume depletion (meds)
Discuss with patient so have informed consent
84 yo female resides in a nursing home and requires help with activities of daily living (ADL)
Normal renal and hepatic function
Ca 7.5 (8-11) and phosphorus 1,5 (2.2-4.8)
Albumin 3.5 (3.5-5)
Vitamin D hypovitaminosis
What lab order now
1,25 oh VD
Who get VD defiency
Old shut ins
25 oh vit s
Converted in kidney
25 oh
Stored to convert
Free ionized calcium is metabolically active
Yup
What is not influenced by rote in binding
Ionized calcium-it is free not bound and active
How correct for low albumin
Ca=measured ca(mg/dL)+ .8 (4-serum albumin(g/dL)
7.6+.8(4-3.5)=8 corrected
Treat low calcium
Build storage as long as can make usable vd
Aggressive
Mile 8-8.4
Moderate<8, >7.5
Severe
Acute change-tumor
93 yo female is residing in a nursing home and requires help with ADL Cr-1.1 Ca 10.5 (8-11), PO4 1.5 Albumin 3 What is corrected ca
11.3 mg//dL
Actually hypercalcemia
82 yo woman ca 9.1 phos 2.5 albumin is 3 (3.5-4) what is serum calcium
Normal
And so the phosphate level would be normal too. But what would th concentration of ca in urine be
Increased
Patients need help doing everything and doesn’t move unless someone moves her
Increased osteoclast activity
Bone resorption ca increase in blood
PTH suppressed by of neg feedback from high ca in ecf and calcuria begins))
Kidneys as long as are able with maintain homeostasis
56 male renal insuffiency secondary to diabetic nephropathy. HTN BMI 41. BUN 34 (8-25) cr 2.3 (.6-1.5), albumin 3,4 (3.5-50 calcium 8.1, phos 5.3 Gfr 30 (100)
Why ca so low but PTH is up
Stage III-IV kidney fail
Kidneys are damaged enough so ca is not resorted and vd is not active
PTH high
Renal failure cant convert VD to active
Why is phos high when vd is low
Chronic kidney disease negatively impacts phosphate wasting
33 yo female presents with bl foot pain. Breast feeding her 4 month baby girl g3p1. Shin splints, mid back pain, thin and wearing wrk out clothes, bit fatigues which present for 8 months. But wore last four months , chapped lips, murmur , scoliosis , calcaneous pain plantar fasciitis ,
X ray long bone demineralized,
Get PTH VD
Not just old women can be anorexics , dietary restrictions, STEROID TREATMENT IN MEN
Usually older female but don’t discount
Osteophytes on calcaneal
MRI after scoliosis x ray
Wear shin bones see if anything metabolis or traumatic cased it
Of spin-wedge fracture,
What do
DEXA get
Wrist heels legs fingers-peripheral screening
For her do central test-lower spine and hip its more accurate DO IT HERE
Do low back and hip DEXA
How treat this woman
Social, physical, stretching, counseling
Ca carbonate (recommended
If on meds for stomach acidity give calcium citrate
78 yo right hilar mass on cxr. Squamous cell carcinoma of lung, albumin 2.5 ca 16, would you expect pth high low or normal
His ekg shoes shortened qt segment-initial treatment
Low
Already in hospital, ca high ——iv hydration to allow kidney to get rid of it with increase perfusion. No thiazide maybe loop diuretics
May add bisphosphnate wont act as quickly
Acute situation
Hypercalcemia ekg
Short qt
Long qt low ca
Want to check 25 oh first
To see storage first want to know if its intact
Need to see stores
Not 1,25 oh VD - would probably check both
If peripheral DEXA bad from screening send to central screening
Thyroid
Ok
Ft3 and 4
Free unbound
Increase tsh decrease pt4
Primary hypothyroidism
Decrease tsh and increase ft4
Primary hyperthyroidism
25 yo female increased frequency ensues, cant sit still, hungry, no weight gain, throat is bigger and tight . What lab
First. Complete your history , ROS and PE
Then TSH FT4 and FT3
You notice she cant sit still what is number one differential
Secondary constipation due to GI obstruction -NO
Manic phase, viral thyroiditis, pituitary adenoma
Symptoms of hyperthyroid include what
Warm. Moist skin, increased HR, goiter, muscle weakness.
Which finding may not get better even with proper treatment
Exophthalmos
Ophthalmic hyperthyroidism
Lid lag, exophthalmos
Bruits hyperthyroid
Over thyroid enlargement
Other symptoms
HR up, rhythm quality, tremor, warm moist, gynecomastia, sweat, diarrhea, polyuria, weight loss, fatigue weak, oligomenorrhea, dry skin, heat intolerance, sweating, palpitations
Opposite with hypothyroidism
For Graves’ disease, which antibody test
TSI antibody
Diagnose graces
TSH-but not needed
Thyroid scan shoe uptake -but not needed TSI not needed
All need is clinical!!!!!!!!!!!!!!!!!!!!!
Graces hot nodule
Difffuse
Only )) wild eterine if the actual uptake is increased as expected in graves scan
Iodine
Iodine scan want
Treat graves
Bb will decrease symptomas as quickly as possible
PTU can be used in preg not methimazole
Alter dose every month
Thyrotoxicosis
Extreme hyperthyroidism
Graves
Exophthalmos
Clubbing
Pretibial myxedema
47 year old male lump in throat noticeable when turn head or shaving ….fullness on right side . What test critical to workup
TSH..it is your go to
Also get ft4
TSH
Why tsh
Know if nodule is hyperfunctioning
If tsh low then what
Thyroid scan with iodine
Radioactive iodine ablation-graves
Low TSH
Thyroid scan
Nodule may be hot producing thyroid hormone
Something suppressing tsh
Normal TSH
FNA
Have to see what nodule is doing. Nodule may be cold
If scan unilaterally hot what is it
Graves-everything turn up
Hypothyroidism-nothing light up
Toxic multinodular goiter
What if just one spot light up
Toxic nodule
Post op evaluation
Look for signs of ca disorder
Also recurrent laryngeal nerve int here. So listen for hoarseness.
FNA
Sensitive and specific
Limited by poor technique or a hypocellular sample may not be adequate
Unless the nodule is causing problems, watchful waiting is usually all that i needed
WHICH OF THE FOLLOWING HEPLS support a benign nodule diagnosis
Tenderness-
Very young or old, firm fixed, male more likely to be non benign , history of neck irradiation, LAD
27 yo female agitated, 15 lb weight loss. Worried impact ability to get pregnant. Unable to it still. Hard time holding coffee mug since started shaking with 406 weeks ago
Hyperthyroidism
TSH up now what
Check t4
Why is tsh high and hyperthyroid
There is continuous production and unopposed rebased of tsh trying to stimulate thyroid
TSH adenoma
Increased and unopposed tsh production
Feedback loop no alter tsh
Hashimoto burn out
Start hyper then hypo
Viral thyroiditis
Hypothyroidism. Scan with not much hotness
Puffy face, puffy eyes skin thickening
Hypothyroidism
Bradycardia,
Just tsh it may mislead you so get what
Free t4
Myxedematous
Slow ..like thyrotoxicosis extreme of hypothyroid. Get puffy
Hypothyroid
Illl 4 month ago viral uri lost 15 lb and diarrhea at time .
Hasimoto…was in hyper and now in hype
Low functioning thyroid
Hasimoto burn out
Viral thyroiditis
Painless thyroiditis
Subacute thyroiditis
External irradiation to neck
Prior rai therapy for graves
Acute illnesss
Euthyroid
Condition is normal. Euthyroid sick
Iodine defiency
Africa
Clincial aspects of diabetes mellitus
Ok
Can adults be diagnosed with type 1
Yup
Finger stick/subcutaneous
Capillary glucose monitoring
Venous sample
Out of vein
Basal/bolus insulin need both
Basal-steady state rate long acting insulin to achieve more steady state
Bolus-can be adjusted at mealtime and things
NEED BOTHHHHHHHHHHs
Sliding scale
Based on patient blood sugar (capillary or venous sample) can proactively dose or retroactive get high gluose and dos insulin
Retroactive
Don’t want to treat old news..means didn’t cover them leading up it it, but in acute care hospital setting this is important to adjust basal and bolus rates
Hba1c
Average of 3-4 months glucose rbc binding to glucose (120 days)
Glycosylaed hemoglobin
What effects HBa1c
Anemia, rbc abnormality,
Presentation of CM
Mental status change, abdominal pain, dehydration
Mental status change
Insulin should be on the differential (high or low)
Abdominal pain
Diabetic ketoacidosis with ketone breath-type 1 more prone
DKA (more likely in type 1) and NKHS (more likely in type 2)
Nothing absolute
DKA
Nail polish remover smell/fruity breath, ketones, acidosis, hyperglycemia , coma
Unresponsive 18 y/o male DM1 since 6 and intermittent control
Grave digger from MN-8 am, not good compliance
Insulin NPH premix , doesn’t follow set eating schedule or end schedule
Mucus membrane dry, skin tumor poor
Tachypnea, high temp but not 100.4, cant tell ab pain bc unresponsive, kussmal
Thorough skin and MSK survery-look for trauma and infection Chest x ray Urine sample for drug Alcohol level UA for infection
Brain last thing to go
Insulin independent glucose utilization
What cause DKA
Infection-pneumonia, uti, gastroenteritis, sepsis
Inadequate insulin
Ate more carbs didn’t plan and dose appropriate
New diagnose not sure how to do it
Infarction DKA
Coronary, cerebral, mesenteric, peripheral
Surgery
Drugs (cocain)
-more predisposed to DKA bc put stress on body
Symptoms DKA
Anorexia, n/v, polyuria, thirst
Signs DKA
Kussmal0rapid deep breaths
Acetone breath
Dry mucous membranes and poor skin tumor
Lab DKA
Hyperglycemia
Kenos is
Metabolic acidosis
- calculate anion fap-increased in DKA
- K effected bu it shift k out of cells
High anion gap
Methanol, uremia, diabetic ketoacidosis, paraldehyde , isopropyl alcohol, iron INH (isoniazid), lactic acidosis, ethylene glycol, salicylate
Kid gramma purse get isoniazid
Baby high anion cap acidosis
Correction na
Serum not abnormal and may look high bc acidosis, DKA actually
Correct K
Serum may be normal or high, actually total body defect
Hyhyperamylasemia
Can be salivary
Diabetic and glucose metabolism disorders bc have pancreatitis that is origin
Leukocytosis DKA
Stress
Treat DKA if in Er and not turned around year
ICU bc can crash quickly bc greater nurse to patient ratio, safer and can put on monitor and do more aggressive treatment
-acid base status, renal function, K and other electrolytes *
If had turned around fast maybe med SURG floor
Frequent monitor what
Urine consistently , status, vitals, glucose, blood gas, K
1-2-3 rule fluid replacement
2-3 L normal saline 1-3 hours .9%
Then 1/2 strength saline at 150 ml/hr
When glucose reaches 250, switch to D51/2NS at 100-200 ml/hr
Fluid deficit is often 3-5 L
Fluid deficit in DKA
3-5 L (8-10 L in other)
Initial insulin
10-20 units IV or IM
Then 5-10 units/hr continuous IC
Increase if no response in 1-2 hours-orders can be written with guidelines to titrate
eval for underlying causes
Cultures, ekg, cxr, drug screen, seek additional history from family or patient as mental status approves
Blood work initial
BSG at least hourly
Electrolytes q 2-4 hours with or without ABG
K replacement
Monitor electrolytes every 2 hours
Once below 5.5 consider adding K
When supplementing K
Renal function, ekg, verify urinary output
Foley
3 types three lumen, 2 lumen, 1 lumen
Indwelling-imply balloon so can stay in
3rd lumen irrigation, med, chemo can send med or fluid through that
Straight cath-single lumen to get urinary sample do not want to put this in if anticipate leaving Catheter in place. If know will stay in use indwelling style
DKA treatment goal
Increase rate of glucose utilization in insulin dependent tissues
-150-250
Reverse ketonemia and acidosis
Correct depletion of water and electrolytes
Start intermittent or long term insulin
When can eat(seen by status improves, no n/v, no ab pain)
Anion gap normali
Allow overlap timing of IV with SQ insulin-usually by 30-60 minutes ——dont wanna stop IV and nothing to back it up, start oral or SQ and resume wait hour for effect
Non ketones hyperosmolar state NKHS
Woo
Who gets it
Old , frail, refusing food medicine, history T2DM on insulin and oral agents
NKHS what precipitates
Relative insulin defiency, inadequate flui intake, osmotic diuresis induced by hyperglycemia
Refusing food and meds, decreased fluid intake
If sugar up dry u out bc osmotic diuresis
Precipitating factor
Sepsis, MI, glucocorticoids, phenytoin, thiazide diuretics, impaired access to water
Symptoms
Polyuria, thirst, altered mental state
Absent generalized body complaints, no kussmal, no acidosis , no ab pain
Serum acetone level NKHS
Mild lactic acidosis, moderate ketonuria from starvation, corrected serum Na usually increased
Can have a bit of ketones and acidosis-but wont be extreme
Corrected Na increased
ICU
Yes!! Frequent monitoring of gen status, vitals, glucose,
Acid base
Renal function
K
At least first 12-24 hours then go from there!!!!!
Fluid
2-3 L NA for 1-3 hours (opposed to 1)
Fluid deficit is 8-10 L
-reverse over next 24-48 hours using 1/2 strength saline (.45)
When glucose reaches 250 switch to D51/2NS at 100-200 ml/r
Insulin
Regular over IC
5-10 units IV bolus
3-7. Units continuous
Transition to eating as with DKA when awake and number turning around
Monitor K
Similarities
Insulin-absolute or relative Glucagon excess Volume depletion Mental status Both ICU until where they are and how quickly changin
Differences
Fluid deficit much greater NKHS
Some drugs can contribute to NKHS**
NV ab pain ketoacidosis not in NKHS
Diagnosis of T2DM what end organ damage already have
Lots already Look for neuropathy, retinopathy, nephropathy, heart disease
May not be aware that they already have thes
Get baseline ekg , ask about activity tolerance,
56 yo T2DM hba1c 9, refuses insulin secondary to job demands, heavy manual labor for 30 years, chest pain sent him to the Er
MI
-dramatic increase in cardiovascular mortality in people with T2DM
Better control less risk but still risk-vascular damage with disease process
When present with DM
Check for CVD
HBA1c less than 6
Lower risk of CVD mortality and all events
Hba1c
Average 3 month
Is lower better
Less than 7 considered satisfactory
But too low can get glucose spread-difference between highest and lowest in 24 hours period, if spread larger then shown greater risk of vascular damage
May not be lower always better
If lower better and under tight control
Risk of falling , if old could die
Autonomic neuropathy vs peripheral
Peripheral-pain hands feet numb
Autonomic -central see gastric emptying
Gastric pacemaker
Has wave forms and can help with gastric emptying
Diabetes a grit emptying
Delayed emptying->if gave insulin but didn’t get the food in to back dosing up so drop down then have stomach empty when weren’t covered by insulin so peak in glucose
Prob with insulin and autonomic
More frequent needle stick and monitoring
All bets are off with dosing
Some patients N/V bc stomach cant hold stuff get malnutrition
*insulin unpredictable high low sugar when normally be able to guess how to dose!!!! Issue
If decreased insulin requirements
Decreased clearing of insulin-imply (used to need 10 unit and 5 now)
Kidney is failing -erratic control vs wow his diabetes is better! No! Things are BAD
85 yo man has DM 2 20 years. Quarterly office follow up. Good dosing, noticed his sugars seemed much more easily controlled with less meds.
Worsening renal function
Gastropathy
Very erratic and absorption so hard to control
Peripheral neuropathy
On healing ulcers
Autonomic
Tummy prob
Declining kidney functions yp1 or 2
Either!
Screening for proteinuria
Spot urine sample
-protein standard urine dipstick not sensitive if proteinuria <300 mg/24 hr
Most common type is albumin
Standard urine dipstick
No detect if lesss than 300
Get UA
Can get results if protein (albumin) is high enough to trigger over 300
Protein smaller microabumni
Need special request to get
A type dipstick
More sensitive
30-300 mg
Random urine sample
Don’t need to fast or collect, just pee in cup and do
Microalbumin /Cr
More accurate than. Measuring microalbumin alone-ratio corrects for variations due to urine concentration
Microalbumin Emma
30-300
Absolute number of protein spilled
24 horus
Need to get serum cr at the same time to determine cr clearance
Difficult to do!!
Usually do when at point to see nephrologist
37 T2DM non healing foot ulcer
A1C 13.3
700-800 now able to comply had other circumstances in life work
Adjust meds came back in
DM is an immune compromised state glucose>150 interferes with neutrophil function
Debilitated from lac of circulation to tissue
Peripheral neuropathy-show changes and adjustments
Multiple comorbidities-immune compromised
Monofilament testing
Nylon fiber 10 guage touch patients foot have look away and
Feet and legs go before upper extremities test it on their hand first
Once a year, but do foot inspection quarterly
Foot care
Plastic mirror
Never be barefoot
Moisturize, but not between or under toes
Prescription shoes-Medicare pay for one pair a year
Podiatry
Best treatment
TLC-lifestyle changes!!
Walk up stairs not escalator
Quarterly
A1C, glucose logs(SGM), foot inspection
Annual
Dilated eye exam
Urine protein screening (microalbumin/Cr ration)
Monofilament testing
