MDT S/S, Treatment Flashcards
Essentials of diagnosis for what issue?
(1) Polyuria / Polydipsia
(2) Weight loss
(3) Plasma glucose of 126 mg/dL or higher after an overnight fast, documented on more than one occasion.
(4) Ketonemia / ketonuria - inadequate insulin leads to inadequate glucose within muscle cells which promotes fat metabolism (the source of ketones).
Diabetes
signs and symptoms of what issue
May include polyuria, polydipsia, fatigue, polyphagia, unexplained weight loss, poor wound healing, blurred vision, and a higher prevalence of certain infections, especially candidal vaginitis and balanitis, recurrent/severe urinary tract infections, recurrent skin infections, and malignant otitis externa.
Classic diabetes
Insulin is indicated for type 1 diabetes as well as for type 2 diabetes with what issues?
hyperglycemia not adequately controlled with diet alone or combined with other medications
Short Term Therapy Type 1 1) Treatment of type 1 DM requires a multidisciplinary approach by the healthcare team (Physician, Nurse, and Dietitian). 2) Patients diagnosed with new-onset of type 1 DM require \_\_\_\_\_\_\_\_ therapy. 3) Immediate short term goal is to what?
2) lifelong insulin
3) control hyperglycemia, maintain serum electrolytes and hydration to avoid DKA episodes.
Essentials of diagnosis for what issue?
(a) Insulin resistance due to inadequate activity of insulin receptors.
(b) Most patients are over 40 years of age and obese through is becoming more common in adolescence.
(c) Polyuria and polydipsia. Ketonurea and weight loss generally are uncommon at time of diagnosis. Candidal vaginitis in women may be an initial manifestation. Many patients have few or no symptoms.
(d) Plasma glucose of 126 mg/dL or higher after an overnight fast on more than one occasion.
(e) Random glucose of 200mg/dL or higher.
(f) Hemoglobin A1C of 6.5% or higher.
(g) Hypertension, dyslipidemia, and atherosclerosis are often associated.
Type 2 Diabetes
Treatment type 2 diabetes
Stage 1
diet modification and weight reduction.
a) Diet (Recording food eaten)
b) Exercise (Incorporating regular exercise)
Treatment type 2 diabetes
-stage 2
includes various oral antidiabetic medications.
a) Biguanides (Metformin/Glucophage) ***First line medication
b) Sulfonylurea’s
c) Meglitinide analogs
d) Dipeptidyl Peptidase derivative
e) Thiazolidinediones
f) α-Glucosidase Inhibitors
g) Glucagon-Like Peptide Receptors Agonist
h) Sodium-glucose cotransporter-2 (SGLT2 Inhibitor)
Treatment: type 2 diabetes
Stage 3
insulin requirement
-due to inability to achieve adequate glucose control with oral medications
Signs and symptoms of what issue?
Patients with this may have a wide array of symptoms and signs.
(2) The clinical manifestations are divided into two broad categories: neuroglycopenic and sympathomimetic.
(a) Neuroglycopenic
–1) As glucose is the main energy source for CNS function, most episodes of symptomatic hypoglycemia include neurologic dysfunction.
–2) With a decline in serum sugar, the brain quickly exhausts its reserve supply of carbohydrate fuel, resulting in CNS dysfunction.
–3) This manifests most commonly by alterations in consciousness, lethargy, confusion, combativeness, agitation, and unresponsiveness.
–4) Other neuroglycopenic manifestations include seizures and focal neurologic deficit
(b) Sympathomimetic
–1) A rapid fall in blood glucose levels or the hypothalamic sensing of
neuroglycopenia causes the release of the counter-regulatory hormones, primarily the catecholamines epinephrine and norepinephrine.
—-a) Typical symptoms include anxiety, nervousness, irritability, nausea, vomiting, palpitations, and tremor
hypoglycemia
Treatment for Hypoglycemia if able to tolerate PO
drink juices, sucrose water, or glucose solutions; eat candy or other foods; or chew on glucose tablets when symptoms occur.
Immediate treatment of hypoglycemia involves provision of _____
Glucose
Treatment for hypoglycemia
Adults unable to eat or drink can be given what?
-glucagon 0.5 or 1 mg SC/IM or -50% dextrose 50 to 100 mL IV bolus with or without a continuous infusion of 5 to 10% dextrose solution sufficient to resolve symptoms
DISPOSITION HYPOGLYCEMIA
Either continued or recurrent mental status alteration, recurrent hypoglycemia, or a downward trend in serial glucose values during observation despite adequate replacement therapy demands….
admission to the hospital MEDEVAC
What is the disposition of this patient HYPOGLYCEMIA
A responsible adult who will monitor the patient’s mental status frequently, coupled with a motivated patient who will perform serum glucose determinations frequently and who can maintain oral feeding.
outpatient observation
What are the clinical signs of hypoglycemia
confusion, irritability, fatigue, anxiety, sweating, irregular heart rhythm, perioral paresthesia
Essentials of diagnosis for what issue?
(1) Hyperglycemia > 250 mg/dL
(2) Acidosis with blood pH < 7.3
(3) Serum bicarbonate < 15 mEq/L
(4) Serum positive for ketones
Diabetic Ketoacidosis
Clinical Findings for what issue?
(1) May begin with a day or more of polyuria, polydipsia, marked fatigue, nausea and vomiting and, finally, mental stupor that can progress to coma.
(2) Dehydration, possible stupor.
(3) Rapid deep breathing and a “fruity” breath odor of acetone.
(4) Hypotension with tachycardia indicates profound fluid and electrolyte depletion.
(5) Mild hypothermia usually present; elevated or even a normal temperature may suggest infection.
(6) Abdominal pain and tenderness in the absence of abdominal disease; conversely, cholecystitis or pancreatitis may occur with minimal symptoms and signs.
Diabetic KETO
What is the mainstay of tx for DKA
Initially Insulin plus fluid and electrolyte replacement
-Consult Medical Officer prior to Insulin Administration
Insulin TX for DKA
- Begin with loading dose of ____ unit/kg as IV bolus, followed by ____ unit/kg/h, continuously infused or given hourly as an IM injection
- Recheck _______ before repeat insulin injection(s).
- ________ insulin into the fluid line so the rate of fluid replacement can be changed without altering the insulin delivery rate
- If plasma glucose level fails to fall at least ___% in the first hour, give repeat loading dose
- 0.15 unit/kg IV followed by 0.1 unit/kg/h IM
- blood glucose
- “Piggy-back”
- 10%
Disposition of DKA
MEDIVAC
Essentials of diagnosis for what issue?
(1) Weakness, cold intolerance, constipation, depression, menorrhagia, hoarseness, dry skin, bradycardia
(2) Delayed return of deep tendon reflexes
(3) Serum free tetraiodothyronine aka thyroxine (T4) low
(4) Thyroid-stimulating hormone (TSH) elevated in primary hypothyroidism
Hypothyroidism
Treatment for hypothyroidism
-levothyroxine is started at 25 – 75 mcg/day administered
orally
-Thyroid function tests should be repeated every 4 to 6 weeks for medication titration until TSH is at goal.
What issue?
Long term untreated hypothyroidism can leads to this condition characterized by hypothermia, hypotension, hypoventilation, hypoxia, hypercapnia, hyponatremia, convulsions and abnormal CNS sign
Myxedema coma
What issue?
- signs
(a) Thin, brittle nails
(b) Thinning of hair
(c) Pallor
(d) Poor turgor of mucosa
(e) Delayed return of deep tendon reflexes - symptoms
(a) Fatigue, lethargy, weakness
(b) Arthralgias, myalgias, muscle cramps
(c) Cold intolerance
(d) Difficulty concentrating
(e) Constipation
(f) Dry skin
(g) Headache
(h) Weight gain
(i) Menorrhagia
Early Hypothyroidism
What issue?
- signs
(a) Goiter
(b) Puffiness of face and eyelids
(c) Thinning of outer eyebrows
(d) Tongue thickening
(e) Hard pitting edema
(f) Pleural, peritoneal, pericardial, and joint effusions - symptoms
(a) Slow speech
(b) Peripheral edema
(c) Pallor
(d) Hoarseness
(e) Decreased senses of taste, smell, and hearing
(f) Dyspnea
(g) Absent sweating
(h) Amenorrhea or menorrhagia
(i) Galactorrhea
LAte Hypothyroidism
Essentials of diagnosis for what issue?
(1) Sweating, weight loss, heat intolerance, menstrual irregularity, tachycardia, tremor,
stare (exophthalmos due to extraocular muscle edema)
(2) In Graves’ disease
–a) Goiter (often with bruit)
–b) Ophthalmopathy
–c) Thyroid stimulating immunoglobulins (activate TSH receptor in thyroid gland)
Hyperthyroidism
What issue? Signs: (a) Fever (b) Tachycardia (c) Diaphoresis/sweating (d) Tremors (e) Disorientation/psychosis (f) Goiter (g) Exophthalmos (h) Hyperreflexia (i) Pretibial myxedema Symptoms: (a) Weight loss despite increased appetite (b) Dysphagia or dyspnea 2° to goiter (c) Rash/pruritus/hyperhidrosis (d) Palpation/chest pain (e) Diarrhea (f) Myalgias and weakness (g) Nervousness/anxiety (h) Menstrual irregularities (i) Heat intolerance (j) Insomnia and fatigue
Hyperthyriodism
What issue?
(a) This disorder, rarely seen today, is an extreme form of thyrotoxicosis that may be triggered by stressful illness, thyroid surgery, or Radioactive iodine (RAI) administration.
(b) Manifested by marked delirium, severe tachycardia, vomiting, diarrhea, dehydration and, in many cases, very high fever.
(c) The mortality rate is high.
Thyroid storm
Treatment for hyperthyroidism
- Radioactive Iodine
- Propranolol (β blocker)
- —-Generally used for symptomatic relief of tachycardia, tremors, diaphoresis, and anxiety until the hyperthyroidism is resolved.
What is the treatment of choice for active duty service members since thyroid suppressing medications (methimazole and propylthiouracil) generally preclude ongoing military service (not deployable).
Radioactive Iodine
Disposition of hyperthyroidism
MEDIVAC
Long term treatment HYPERTHYRIODISM:
(a) ________ is the most widely recommended permanent treatment of hyperthyroidism.
(b) Another permanent cure for hyperthyroidism is to _____________________.
- —–1) Both long term treatment options results in the patient developing hypothyroidism and lifelong need for ____________ is expected.
a) Radioactive iodine
b) surgically remove all or part of the thyroid gland
c) thyroid hormone replacement (levothyroxine)
Pt has these issues after Radioactive iodine (RAI) administration what would you suspect?
- marked delirium,
- severe tachycardia,
- vomiting,
- diarrhea,
- dehydration
- very high fever
Thyroid storm
THYROID NODULE
These issues are higher risk of what?
1) History of head-neck radiation in childhood
2) Family history of thyroid cancer
3) Personal history of another malignancy
malignancy
Most of the time the only signs and symptoms of thyroid nodule is…
the nodule…..
What is suggested by these S/s
1) Hoarseness or vocal cord paralysis
2) Nodules in men or young women
3) Nodule that is solitary, firm, large, or adherent to trachea or strap muscles
4) Vocal cord paralysis
5) Enlarged lymph node(s)
6) Distant metastatic lesions
Malignancy
Treatment thyroid nodule
(a) Refer to endocrinology (thyroid biopsies typically performed by an endocrinologist or interventional radiologist)
(b) Ultrasound guided fine-needle aspiration (FNA) biopsy of suspicious nodules (thyroiditis may coexist with malignancy)
Disposition if thyriod nodule is suspected to be malignant
MEDEVAC
Disposition if thyriod nodule is suspected to be benign.
referral to Endocrinology
PT with nodule has these S/s what would you suspect?
1) Sweating
2) Weight loss
3) Anxiety
4) Loose stools
5) Heat intolerance
6) Tachycardia
7) Tremor
hyperthyroidism
caused by Toxic multinodular goiter and hyperfunctioning nodules
Metabolic Syndrome is defined as a constellation of _____ or more of the following:
(a) Abdominal obesity
(b) Triglycerides 150mg/dl or higher
(c) HDL <40mg/dl for men or 50mg/dl for women
(d) Fasting glucose of 110mg/dl or higher
(e) Hypertension
3
Risk Factor Modification for metabolic syndrome
(1) Counseling appropriate weight management and physical activity is paramount. Obesity is the most important modifiable risk factor.
(2) Diet modification if needed for improved weight (calories), glucose (simple sugars), or blood pressure control (salt intake).
(3) Nutrition referral advised for tailored dietary counseling.
(4) Metformin may be considered if impaired fasting glucose is present.
(5) Blood pressure medications depending on comorbidities
Metabolic Syndrome is defined as 3 ore more of what?
(a) Abdominal obesity
(b) Triglycerides 150mg/dl or higher
(c) HDL <40mg/dl for men or 50mg/dl for women
(d) Fasting glucose of 110mg/dl or higher
(e) Hypertension
Essentials of diagnosis for what issue?
(a) Weakness, abdominal pain, fever, confusion, vomiting
(b) Low blood pressure, dehydration
(c) Skin pigmentation may be increased
(d) Insufficient aldosterone will result in elevated serum potassium and low sodium.
(e) Insufficient cortisol may result in hypoglycemia
(f) Dehydration and hypotension may result in poor kidney perfusion (may see elevated blood urea nitrogen and creatinine)
Acute Adrenal Crisis- Adrenocortical Insufficiency
What issue?
- Symptoms:
1) Headaches
2) Lassitude (lethargy)
3) Nausea/Vomiting
4) Abdominal pain and diarrhea
5) Confusion or coma
6) Cyanosis
7) Dehydration
8) Sparse Axillary hair - Signs:
1) Skin hyperpigmentation
2) Fever
3) Hyperkalemia
4) Hyponatremia
5) Hypotension
6) Eosinophilia
Acute Adrenal Crisis -Adrenal insufficiency
Treatment Acute Adrenal insufficiency
1) immediately treat with hydrocortisone 100-300 mg IV and saline.
2) Then continue hydrocortisone 50-100mg IV Q6H for first day, Q8H the second day, and taper as clinically appropriate.
Disposition acute adrenal insufficiency
MEDEVAC as soon as possible
Essentials of diagnosis for what issue?
(a) Weakness, fatigability, anorexia, weight loss; nausea/vomiting, diarrhea; abdominal pain, muscle and joint pains; amenorrhea.
(b) Sparse axillary hair; increased skin pigmentation, especially of creases, pressure areas, and nipples.
(c) Hypotension, small heart.
(d) Potassium high, sodium low, blood urea nitrogen high
(e) Plasma cortisol levels are low or fail to rise after administration of corticotropic. Elevated ACTH level.
Chronic Adrenal Insufficiency
What issue?
- Symptoms:
1) Weakness and fatigability
2) Weight loss
3) Myalgias
4) Arthralgia’s
5) Anorexia
6) Nausea/Vomiting
7) Anxiety
8) Mental irritability - Signs:
1) Hyperpigmentation skin changes
2) Hypopigmented skin (Vitiligo 10%)
3) Hypoglycemia
4) Hypotensive blood pressure
5) Nail beds (longitudinal pigmented bands)
6) Small heart
7) Scant axillary and pubic hair
Chronic Adrenal Insufficiency
Treatment Chronic Adrenal Insufficiency
Hydrocortisone is the drug of choice. Most Addison patients are well
maintained on 15 – 30 mg of hydrocortisone orally daily in two divided doses.
Disposition Chronic Adrenal Insufficiency
MEDEVAC
What issue has this Presentation
(1) Fatigue
(2) Decreased strength
(3) Poor libido
(4) Hot flushes
(5) Erectile dysfunction
(6) Gynecomastia
(7) Infertility
(8) Small testes
Hypogonadism
Common endocrine disorder of unknown pathophysiology affecting up to 10% of women of reproductive age.
- Characterized by
(a) Anovulation
(b) Polycystic ovaries
(c) Hyperandrogenism
Polycystic Ovarian Syndrome
Clinical findings of what issue?
(1) Menstrual disorders (anovulation / menorrhagia)
(2) Infertility
(3) Hirsutism
(4) Obesity
(5) Acne
(6) Insulin resistance, DM2, metabolic syndrome
(7) Dyslipidemia
(8) Perinatal complications if able to become pregnant
Polycystic Ovarian Syndrome
Treatment
1) ___________________ which reduce hyperinsulinism and improve chances of ovulation.
2) In _______ patients with polycystic ovarian syndrome, weight reduction and exercise are often effective in reversing the metabolic effects and in inducing ovulation.
3) Consider _______ is the above are not effective
1) Weight management and routine physical exercise
2) obese
3) Metformin
PCOS should be diagnosed / treated with advice from who
OBGYN, family practice, internal
medicine, or internal medicine.
