Metabolism & Endocrine

Question 1

What is Conn’s syndrome? Is the K elevated?

Answer 1

Conn’s Syndrome

• Primary hyperaldosteronism
• Hypernatremia
• Hypokalemia
• Hypertension

Question 2

List 8 causes of hypophosphatemia

Answer 2

1. Malnourished
2. EtOH abuse
3. Hyperventilation
4. Sepsis
5. NMS
6. Insulin
7. Diuretics
8. Burns
9. Hyperparathyroidism

Question 3

List FOUR tests that can help diagnose adrenal insufficiency

Answer 3

To Diagnose

1. AM Cortisol
2. AM ACTH
   * Differentiates 1* from 2* (1* = high ACTH)
3. ACTH Stimulation Test
   * Baseline cortisol
   * Give 250mcg of ACTH, measure again at 30/60m
   * If cortisol <20, gland doesn’t work (Primary AI)
   * Normal patient should double cortisol
4. 24h Urine for 17-OH Steroids

If in doubt re: diagnosis, give dexamethasone because hydrocortisone has mineralocorticoid activity.

Question 4

List SIX causes of a high osmolar gap

Answer 4

1. EtOH
2. Methanol
3. Isopropyl Alcohol
4. Ethylene Glycol
5. DKA
6. Mannitol/Sorbitol
7. Hyperlipidemia
8. CKD

Question 5

Outline your management of hypercalcemia in the ED

Answer 5

1. Fluids, fluids, fluids
2. Diuretics are contentious: if you give any, make it Lasix
3. Bisphosphonates
4. Calcitonin 4 IU/kg
5. Hydrocortisone (if granulomatous dz, not cancer)
6. Remove offending agent/treat underlying condition

Question 6

What is the formula for the anion gap? What is the correction for albumin?

Answer 6

Anion Gap

• Na⁺ - (HCO3^- + Cl^-)

For every 10 g/L drop in albumin remove 2.5 from expected AG

Question 7

How would you approach severely symptomatic hyponatremia and how quickly would you correct the serum sodium?

Answer 7

Severe Hyponatremia

• Hypertonic (3%) saline 100ml over 10 mins
• Will inrease Na⁺ 2-3 mmol/L
• 3% saline = 513mEq/L OR about 0.5 mEq/mL
• Repeat q10min until seizures stop

Sodium Correction

• Target: 120 mEq/L or until not seizing
• Acute: 1 mEq/L/h
• Chronic: 0.5 mEq/L/h, max 12mEq/day
• Administer D5W and DDAVP if corrected too rapidly

Question 8

How can the measured sodium in patients with hyperglycemia be corrected?

Answer 8

↑ Glucose 10 mmol/L causes ↓ Na⁺ 3 mmol/L

Question 9

Differentiate activated hyperthyroidism from unactivated (apathetic) hyperthyroidism

Answer 9

Activated Hyperthyroidism

• 4th decade
• Duration of symptoms: 8 months
• Weight loss: 10 lbs
• Thyroid weight 70 g
• Eye findings: Frequent
• CHF: Common
• Afib: 1/3 of patients
• Depression: Uncommon

Apathetic Hyperthyroidism

• 7th decade (ELDERLY)
• Duration of symptoms: 26 months
• Weight loss: 40 lbs
• Thyroid weight: 45 g
• Eye findings: Rare
• CHF: Common
• AFib: ¾ of patients
• Depression: Common

Question 10

Differentiate primary and secondary adrenal insufficiency. List FIVE causes of each.

Answer 10

Primary AI = the gland has failed

• Acute
  1. Addison’s disease (MCC in the West)
  2. TB (MCC worldwide)
  3. Waterhouse-Friederich (Neisseria)
  4. Trauma
  5. Anticoagulation
• Chronic
  1. Addison’s
  2. TB
  3. HIV
  4. Adrenal mets
  5. Adrenalectomy
  6. Etomidate

Secondary AI = the pituitary has failed

• Acute
  1. Sheehan syndrome
  2. Pituitary apoplexy
  3. TBI
  4. Sepsis
• Chronic
  1. Pituitary tumor
  2. Surgery
  3. Steroids
  4. Empty Sella
  5. Brain rads

Question 11

List SIX causes of increased ADH

Answer 11

​SIADH and Normal

1. Increased osmolarity (Na⁺)
2. Decreased BP
3. SAH
4. Pain
5. Medications (SSRI)
6. Low pressure, low volume
7. Caffeine

Question 12

The anion gap takes into consideration chloride and bicarb. What are FIVE classic unmeasured anions?

Answer 12

1. Albumin
2. Lactate
3. Ketones
4. Sulfate
5. Phosphate
6. Organic acids

Question 13

What is the pathophysiology of rhabdomyolysis?

Answer 13

• Depletion of ATP (exercise, drug, trauma) causing…
• ATP-dependent ion channel failure causing…
• Huge increase in intracellular calcium causing…
• Increased muscle contractility
• Protease activity
• Mitochondrial dysfunction causing O₂ free radicals
• Apoptosis

Question 14

List the 6 progressive ECG changes of hyperkalemia

Answer 14

1. Peaked T waves
2. Loss of P waves
3. Widening of QRS
4. Sine wave
5. Vfib
6. Asystole

Question 15

List 6 causes of hyperkalemia

Answer 15

1. Hemolysis
2. Renal failure
3. Drugs (Spironolactone, ACEi, NSAIDs)
4. Tumour lysis syndrome
5. Rhabdomyolysis
6. Digoxin toxicity
7. Amiloride
8. Iatrogenic

Question 16

Give FOUR causes for falsely low anion gap

Answer 16

High levels of unmeasured cations:

1. Lithium
2. Hypergammaglobulinemia (MM)
3. Hypertriglyceridemia
4. Bromide toxicity
5. Hypoalbuminemia

Question 17

List SIX triggers for DKA

Answer 17

The 8 “I’s”

1. Initial
2. Insulin non-compliance
3. Infarct (MI/CVA)
4. Infection
5. Incision (surgery)
6. Insemination (pregnancy)
7. Intoxication
8. Iatrogenic (medication changes)

Question 18

List SIX symptoms consistent with thyrotoxicosis

List SIX signs consistent with thyrotoxicosis

Answer 18

Symptoms

SOB, exercise intolerance, palpitations, weight loss, appearance change, hair loss, anxiety, temperature intolerance, restless, oligomenorrhea

Signs

Afib, proptosis, tachycardia, CHF, fever, neck swelling, bruit, tremor, hyperreflexia

Question 19

In regards to the serum glucose, how is diabetes diagnosed?

Answer 19

• Random plasma glucose >11.1 mmol/L
• Fasting plasma glucose >7 mmol/L

Question 20

List 6 drugs that have been associated with rhabdomyolysis

Answer 20

1. Barbiturates
2. Benzodiazepines
3. Colchicine
4. Corticosteroids
5. Isoniazid
6. Lithium
7. MAOIs
8. Narcotics
9. Neuroleptics
10. Phenothiazines
11. Salicylates
12. Serotonergics
13. Statins
14. Theophylline
15. TCAs

Question 21

List EIGHT causes of respiratory alkalosis

Answer 21

Central

1. Head Injury
2. Stroke
3. Anxiety
4. Pain
5. ASA
6. Pregnancy
7. High-altitude
8. Anemia

Pulmonary

1. Hypoxia
2. PE
3. Pneumonia
4. Asthma
5. Pulmonary edema
6. Mechanical ventilation

Question 22

Explain the phenomenon of paradoxical worsening of ketosis as AKA/DKA is treated.

Answer 22

• AKA/DKA is mostly β-hydroxybutyrate
• As its treated, it is converted to acetoacetate
• Urine dipstick tests acetoacetate, not β-hydroxybutyrate
• Dip looks more positive as treatment starts

Question 23

List TEN causes of hypercalcemia

Answer 23

Malignancy

• Lung
• Multiple Myeloma
• Bone mets

Endocrine

• Hyperparathyroidism
• Hyperthyroidism
• Vitamin D excess

Granulomatous

• Sarcoidosis
• TB
• Crohn’s

Drugs

• Thiazides
• Iatrogenic calcium

Miscellaneous

• Paget’s
• Dehydration
• Rhabdomyolysis

Question 24

What is the management of hyponatremia in the asymptomatic or mild-mod symptomatic patient?

Answer 24

Hypovolemic hyponatremia

• NS 0.9% to correct deficit

Euvolemic hyponatremia

• Free-water restriction

Hypervolemic hyponatremia

• Free-water restriction and diuresis +/- dialysis

Question 25

List SIX causes of metabolic alkalosis

Answer 25

**CLEVER PD** * **C**ontraction * **L**icorice * **E**ndocrine (Conn's, Cushing's) * **V**omiting * **E**xcess alkali (Antacids) * **R**efeeding/**R**enal * **P**ost-hypercapnia * **D**iuretics

Question 26

When would you treat hyponatremia acutely?

Answer 26

**Both of:** 1. Sodium \<120 mEq/L 2. Altered, focal neuro deficits, or seizing **Treatment** * 3% saline 100 cc IV over 15 minutes (raises Na 2-3 mEq)

Question 27

List 5 precipitants of myxedema coma Who is the typical patient that will present with myxedema coma? What will their vitals be like?

Answer 27

**Precipitants** * Infection * Infarction * Incision (Surgery) * GI bleed * Hypoglycemia * Hypothermia * Medications **Typical Patients** * Older women * Thyroidectomy **Vitals** * Hypothermic * Bradycardic * Hypotensive * Altered

Question 28

What are the ECG changes in hypocalcemia?

Answer 28

* Short PR * Long QT * ST depression * TWI * U wave Arrhythmia is uncommon.

Question 29

Describe the clinical presentation of hypocalcemia

Answer 29

**Neuromuscular** * Paresthesias * Muscle weakness * Muscle spasm * Tetany * Chvostek's and Trousseau's signs * Hyperreflexia * Seizures **Cardiovascular** * Bradycardia * Hypotension * Cardiac arrest * Digitalis insensitivity * QT prolongation **Pulmonary** * Bronchospasm * Laryngospasm **Psychiatric** * Anxiety * Depression * Irritability * Confusion * Psychosis * Dementia

Question 30

How do you calculate how much hypertonic saline to administer to a patient who has severe symptoms but is not actively seizing?

Answer 30

**Step 1: Calculate sodium deficit** * Na_Deficit = TBW \* (Na_Desired - Na_Measured) * Assume TBW = 60% of weight * Assume Na_Desired = 120 mEq/L **Step 2: Calculate volume of 3% saline needed** * 3% saline = 513 mEq/L * Volume (cc) = (Na_Deficit/ 513) \* 1000 **Step 3: Calculate desired rate of infusion** * Rate = Volume (cc) / [(Na_Desired - Na_Measured)\*2] * Assumes max safe rate = 0.5 mEq/hr **Example** A 70kg man presents twitching with a sodium of 112. Assuming this is chronic, how much and how fast will you correct him? Step 1: * Na_Deficit = TBW \* (Na_Desired - Na_Measured) * Na_Deficit = (0.6\*70) \* (120 - 112) * Na_Deficit = 42 \* 8 * Na_Deficit = 336 mEq Step 2: * Volume (cc) = (Na_Deficit/ 513) \* 1000 * Volume (cc) = (336/ 513) \* 1000 * Volume (cc) = 655 cc Step 3: * Rate = Volume (cc) / [(Na_Desired - Na_Measured)\*2] * Rate = 655 / [(120 - 112)\*2] * Rate = 655 / 16 * Rate = 41 cc/hr for 16 hours

Question 31

List EIGHT causes of high anion gap metabolic acidosis

Answer 31

**MUDPILES CAT** 1. **M**ethanol/**M**etformin 2. **U**remia 3. **D**KA 4. **P**ropylene glycol/**P**araldehyde 5. **I**ron, INH 6. **L**actate 7. **E**thylene Glycol 8. **S**alicylates 9. **C**O, **C**yanide 10. **A**lcoholic Ketoacidosis 11. **T**oluene

Question 32

How is acid sensed in the body? How is H+ maintained?

Answer 32

**pH Sensing** * Central = Medulla * Peripheral = Carotid body **H+ Homeostasis** * H/K⁺ renal antiporter * Carbonic anhydrase * Buffering capacity

Question 33

What is a delta gap? How do you calculate it?

Answer 33

Used to assess if more than just HAGMA * Delta Gap: Change in AG / Change in Bicarb * Remember alphabetical **A**(G) before **B**(icarb) The ratio gives one of four results: * \<0.4 due to a pure NAGMA * 0.4 – 0.8 due to a mixed NAGMA + HAGMA * 0.8 – 2.0 due to a pure HAGMA * \>2.0 due to a mixed HAGMA + metabolic alkalosis **Here's a worked example:** * Hgb 142 WBC 17 Plt 355 * Na 136 K 5.3 Cl 115 HCO3 7 Urea 28.6 Cr 522 Glc 5.5 * Ca 2.49 PO4 1.52 Mg 1.02 Albumin 36 * EtOH \< 1 Acetaminophen \< 13 Salicylates \< 0.1 * VBG: pH 6.94 pCO2 30 HCO3 6 BE -26 * Lactate 2.4 * B-hydroxybutyrate 1.55 **Calculate the delta ratio** * Delta ratio = [AG-12] / [24-HCO3] * Delta Ratio = (14-12) / (24-7) * Delta Ratio = 0.117

Question 34

# Define the following: * Wolff-Chaikoff Effect * Jod-Basedow Effect

Answer 34

**Wolff-Chaik_OFF_ Effect** * Excess iodide inhibits trapping + thyroglobulin iodination * Excess iodide blocks thyroid hormone release **Jod-Basedow Effect** * Excess iodide induces more thyroid hormone creation * Can cause hyperthyroidism in patients with multinodular goiter and Graves’ disease

Question 35

List 5 glucoregulatory hormones and describe their mechanism of action

Answer 35

1. **Insulin (ANABOLIC)** * Augments hepatic glucose uptake and storage * Inhibits gluconeogenesis and glycogenolysis 2. **Glucagon (CATABOLIC)** * Released by α-cells of pancreatic islets * Triggers for release: hypoglycemia; stress, trauma, infection, starvation, exercise * Increases hepatic adenyl cyclase activity = increased gluconeogenesis and glycogenolysis 3. **Epinephrine (CATABOLIC)** * Increase hepatic glycogenolysis + gluconeogenesis 4. **Cortisol (CATABOLIC)** 5. ​**GH (CATABOLIC)****​** * Neither cortisol nor GH are rapid glucose changers

Question 36

How do you treat suspected adrenal crisis?

Answer 36

**For Patient with KNOWN AI:** * Hydrocortisone is preferred because it has intrinsic mineralocorticoid activity **For Patient with UNCONFIRMED AI:** * Dexamethasone is preferred because it does not have mineralocorticoid activity and does not interfere with the ACTH stimulation test

Question 37

List EIGHT triggers of thyroid storm

Answer 37

1. Infection 2. Brain bleeds 3. Head injury 4. Iatrogenic (over-medicated) 5. Amiodarone 6. Burns 7. Thyroid surgery 8. Pregnancy 9. CHF 10. PE 11. Hyperemesis

Question 38

How would you treat hypocalcemia in the ED?

Answer 38

**If peripheral IV:** * 2 amps Calcium gluconate * 1 amp CaGluconate = 93 mg Ca **If central IV/Arrest:** * 1 amp Calcium chloride * 1 amp CaCl = 272 mg Ca **Note:** * Replace magnesium if refractory * Stop if bradycardic/AVB * Effects last 2 hours (think hyperK)

Question 39

How do you manage thyroid storm?

Answer 39

**PCP's** * **P**ropranolol (60 mg PO) * Blocks conversion/symptoms * **C**orticosteroids (Hydrocortisone 200 mg IV) * Blocks conversion/autoimmune * **P**TU (1000 mg PO) * Blocks synthesis * **S**SKI (5 drops, 1 hour after PTU) * Blocks release

Question 40

List the 5 most common causes of hypokalemia

Answer 40

**Renal losses** * Diuretics **Non-renal losses** * Vomiting * Diarrhea **Decreased intake** * Malnourished * Alcoholism **Intracellular shift** * Hyperventilation * Insulin * Sympathomimetics **Endocrine** * Conn's * Cushing * Bartter's syndrome

Question 41

Provide FIVE causes of a “double gap” (Anion + Osmolar)

Answer 41

1. Methanol 2. Ethylene glycol 3. DKA 4. AKA 5. Sepsis 6. Chronic Renal failure

Question 42

How does amiodarone cause thyroid issues?

Answer 42

* Has iodine in it * Structurally similar to T4 * Can cause thyrotoxicosis * Directly toxic to the gland

Question 43

List EIGHT causes of rhabdomyolysis

Answer 43

1. Prolonged immobilization 2. Excessive exercise 3. Muscle ischemia 4. Temperature extremes * Heatstroke, NMS, MH * Hypothermia 5. Electrical current 6. Electrolyte abnormalities * HypoK/Na/Phos 7. Illicit Drugs * Opiates/Sympathomimetics 8. Post-CPR 9. Medications * Succinylcholine * Statins, Fibrates, Antipsychotics 10. Infections 11. Metabolic myopathies 12. Connective tissue disorders 13. Rheumatologic disorders * Polymyositis, dermatomyositis, Sjogren’s * SLE 14. Hypothyroidism 15. Biologic toxins * Snakebite, African honey bee

Question 44

What are the clinical effects of hypermagnesemia?

Answer 44

**\>1.6 mmol/L** * Muscle weakness, hyporeflexia * Nausea and vomiting * Hypotension secondary to vasodilation **\>4.0 mmol/L** * Coma * Hypoventilation * Neuromuscular Paralysis * Cardiac arrhythmias, bradycardia and death

Question 45

Outline your treatment of DKA, with specific doses and goals

Answer 45

**1. Resuscitation** * NS 10 cc/kg, repeated until not in shock **2. Fluid Resuscitation** * NS 250 cc/hr * Add KCl once K \< 5 mmol/L AND patient has UOP * Change to D5½NS once BG drops to 15 mmol/L **3. Insulin** * Insulin R 0.1 units/kg/hr IV * No bolus * Stop when AG normal **Goals of DKA Treatment:** 1. Correct metabolic acidosis 2. Correct electrolyte abnormalities 3. Identify and Tx underlying trigger

Question 46

What are your FIVE priorities in managing a thyroid storm?

Answer 46

1. Block conversion of T4-T3 (Steroids, Propanol, PTU) 2. Block release of thyroid hormone (iodide) 3. Block the adrenergic effects (beta-blockers) 4. Block production of thyroid hormone (PTU/Methimazole) 5. Supportive care 6. Find inciting event

Question 47

List 6 causes of diabetes insipidus

Answer 47

**Central** 1. Trauma 2. Malignancy 3. Pituitary surgery 4. SAH **Nephrogenic** 1. Renal disease 2. Medications (lithium) 3. Genetic disorders **Pathophysiology** ADH causes free water reabsorption. If lacking or ineffective, you void very dilute urine.

Question 48

List complications associated with IV NaHCO3 therapy

Answer 48

1. Paradoxical CNS acidosis 2. Impaired oxygen delivery 3. Hypokalemia 4. Hypocalcemia 5. “Overshoot” alkalosis 6. Hypernatremia 7. Volume overload 8. Hyperosmolality

Question 49

Name the scoring system for diagnosis of thyroid storm What are the six elements of this scoring system?

Answer 49

**Burch-Wartofsky Score** "**T**hyroid **P**roblems **M**ake **F**atties **G**o **C**razy" 1. **T**achy 2. **P**recipitating event 3. **M**ental status 4. **F**ever 5. **G**I/hepatic 6. **C**HF \>45 points definitive 25-44 maybe \<25 prob not

Question 50

Explain the Somogyi phenomenon

Answer 50

High blood sugar in AM misinterpreted as not enough insulin at PM when actually they are hypoglycemic in PM and the hyperglycemia in the AM is from counterregulatory hormones.

Question 51

List 3 types of **hypernatremia** and examples of each. How do you calculate free water deficits?

Answer 51

**Hypovolemia** * Check urine sodium * Low = Not drinking, critically ill, extrarenal loss * High = Diuretic **Euvolemic** * Urine Na High = Dehydrated * Urine Na Low/normal = Diabetes Insipidus **Hypervolemic - Don't need to measure the Urine** * Salt poisoning * Primary Hyperaldosteronism (Conn's) * Formula misfed babies **Water Deficit = [weight (kg) x 0.6] x [(Na level – 140) / 140]**

Question 52

List 6 causes of SIADH

Answer 52

1. Cancers: Small cell lung cancer 2. Infections: TB, Pneumonia 3. SAH 4. Head trauma 5. Pain 6. Nausea 7. Meningitis 8. Meds (SSRI, Haldol, Opioid, Antineoplastics)

Question 53

List FOUR causes of hypothyroidism

Answer 53

1. Hashimoto's 2. Neonatal 3. Drugs (Lithium, Amiodarone) 4. Central cause 5. Sheehan 6. Iodine deficiency

Question 54

List 8 causes of hypocalcemia

Answer 54

1. Hypoalbuminemia 2. Hyperphosphatemia 3. Hypomagnesemia 4. Hypoparathyroidism 5. Vit D deficiency 6. Respiratory alkalosis 7. Rhabdomyolysis 8. Tumour lysis syndrome 9. Massive transfusion 10. Hydrofluoric acid 11. Renal failure

Question 55

List SIX ECG features of hypokalemia

Answer 55

1. Prolonged QT 2. T wave flattening/inversion 3. ST depression 4. U wave 5. AV Block 6. Ectopy (PVCs) 7. Arrhythmias (Afib, Vfib, asystole)

Question 56

List 6 causes of hypomagnesemia

Answer 56

1. Alcoholics/malnourished/cirrhosis 2. Pancreatitis 3. GI losses – Laxatives, diarrhea, Crohn’s, UC 4. DKA – large diuresis from glucosuria 5. Renal losses * Diuretics * Aminoglycosides 6. Nephrotoxic chemotherapy 7. PPI use 8. Digoxin 9. HF toxicity 10. Bartter’s Syndrome

Question 57

How does the urinary sodium concentration help in the diagnosis of euvolemic hyponatremia?

Answer 57

**Euvolemic hyponatremia** U_Na⁺ \> 20mEq/L * Endocrinopathy (AI) * SIADH causing drugs * SIADH \>100 U_Na⁺ \< 10mEq/L * Polydipsia

Question 58

List 6 causes of hypokalemia

Answer 58

1. Loop diuretics (HCTZ/Furosemide) 2. NS administration 3. Diet 4. RTA 1/2 5. GI losses 6. Sweating 7. Malnutrition

Question 59

Compare and contrast HHS and DKA

Answer 59

**HHS** * Glucose is comically high \>33 * Not very acidotic pH \>7.3 * They're many liters down (higher BUN) * They don't have ketones in their urine **DKA** * Hyperglycemia but usually \< 33 * Acidotic * Dehydrated less (still high BUN) * Ketones

Question 60

Which TWO drugs should you AVOID in thyroid storm?

Answer 60

1. ASA 2. NSAIDs * These displace thyroid hormone from thyroglobulin 3. Amiodarone 4. Contrast dye * These have a high iodine load

Question 61

Outline your management of a glyburide overdose. How long should they be observed?

Answer 61

1. Charcoal, if safe/indicated 2. POCT Glucose q1h until stable * D50 IV push, if hypoglycemic 3. Dextrose infusion 4. Octreotide 50-100 mcg IV q12h * Only if hypoglycemic 5. Observe for 24 hours

Question 62

What are TWO features in a patient with Addison’s disease (primary AI) but NOT secondary AI?

Answer 62

1. **Hyperpigmentation** * Primary AI results in high ACTH * MSH is released with ACTH * ACTH also binds the MSH receptor 2. **Hypotension****​​** * ​​Aldosterone more affected in primary

Question 63

What are the types of RTA?

Answer 63

**Type I – Distal RTA** * Failure of H+ excretion (H⁺/K⁺ antiporter) * Acidemia and hypokalemia * Get urinary stones, nephrocalcinosis, and bone demineralization **Type II – Proximal RTA** * Failure to reabsorb bicarb * Metabolic acidosis * Fanconi syndrome​ **Type IV – Hypoaldosteronism** * Impaired ammonium (NH₄) excretion * Metabolic acidosis * Hyponatremia, hyperkalemia (opposite of Conn's) Type III is historical and was a combination of I and II. Only seen in children and never again.

Question 64

What are the typical diagnostic criteria for DKA?

Answer 64

**Diagnosis** 1. pH \<7.3 or Bicarb \<18 2. Ketones (elevated AG) 3. Glucose \>11.1

Question 65

List 6 causes of Non-AG metabolic acidosis

Answer 65

**HARDUP** * **H**yperchloraemia * **A**cetazolamide, Addison’s disease * **R**enal tubular acidosis * **D**iarrhea, ileostomies, fistulae * **U**reteroenterostomies * **P**ancreatoenterostomies

Question 66

How is serum calcium altered by the albumin level?

Answer 66

Every 10 decrease in albumin is a decrease of 0.2 calcium

Question 67

What is your management of severe hypermagnesemia?

Answer 67

* Stop infusion of Mg (if running) * 2 amps Calcium gluconate * Dilution with IV NS * Lasix * Dialysis

Question 68

List EIGHT causes of thyrotoxicosis

Answer 68

1. Grave's 2. Excess Iodine 3. Autoimmune thyroiditis 4. Hashimoto's 5. Multinodular goiter 6. Toxic adenoma 7. Follicular cell carcinoma 8. Pituitary tumour 9. Teratomas/Hydatidiform moles 10. Amiodarone

Question 69

Walkthrough the Renin-Angiotensin-Aldosterone System and how the body responds to a decreased intravascular volume

Answer 69

* Juxtaglom cells sense less blood flow and release renin * Renin causes the release of angiotensin 1 from the liver * Angiotensin I converted to Angiotensin II in the lungs * causes smooth muscle contraction * causes adrenals to secrete aldosterone * causes the pituitary to secrete ADH * Aldosterone causes Na⁺ retention and K⁺ excretion

Question 70

A 70 kg patient is seizing with a Na of 110. What is your treatment? How much do you think it will correct?

Answer 70

3% saline 100 cc over 10 min IV q10min until not seizing Each 84 cc will raise the Na by 1 mEq/K * Multiply body **water** by 2 to get cc of 3% saline to raise 1 * 70 kg \* 0.6 = 42 * 42 \* 2 = 84 cc 3% saline

Question 71

What are FIVE treatment goals with myxedema?

Answer 71

1. Replace fluids 2. Replace electrolytes 3. Check a glucose 4. T4 300mcg IV 5. Warm them 6. Hydrocortisone 100mg IV 7. Antibiotics because they're likely septic

Question 72

What is normal serum pH, pCO2 and HCO3?

Answer 72

* pH = 7.35-7.45 * pCO₂ = 35-45 mmHg * HCO₃ = 22-29 mmol/L

Question 73

What is a normal compensatory response for the following? * Metabolic acidosis * Metabolic alkalosis * Respiratory acidosis * Respiratory alkalosis

Answer 73

**Metabolic Acidosis** * **1** loss in bicarb = **1** drop in CO₂ **Metabolic Alkalosis** * **1** increase in bicarb = **0.5** increase in CO₂ **Respiratory Acidosis** * **10** increase in pCO₂ = **1** increase in HCO₃ **Respiratory Alkalosis** * **10** loss in pCO₂ = **2** loss in HCO₃

Question 74

What are the clinical features of hypercalcemia?

Answer 74

**Bones, Stones, Groans, Psychic Moans** * Stones (Renal calculi) * Bones (Osteolysis) * Moans (Abdominal pain, N/V, constipation) * Groans (PUD, pancreatitis) * Psychiatric overtones (Psychosis, depression)

Question 75

Give a reason for a falsely elevated AG

Answer 75

Low levels of unmeasured cations: 1. Hypomagnesemia 2. Hypocalcemia 3. Hypokalemia

Question 76

List three types of hyponatremia and an approach to each

Answer 76

**Hypovolemic** * Urine Na Low = GI loss, Third spacing, Pancreatitis, Burns * Urine Na Normal/High = Diuretics **Euvolemic** * Urine Na Normal/High \>40 = SIADH, AI, Hypothyroidism * Urine Na Low = Polydipsia, Beer potomania **Hypervolemic** * Cirrhosis * CHF * Renal failure

Question 77

List 4 metabolic/endocrine abnormalities expected with primary adrenal insufficiency

Answer 77

The adrenal gland makes: * Salt (Aldosterone) * Sugar (Cortisol) * Sex (DHEA) **Primary AI** * Hyponatremia * Hyperkalemia * Hypoglycemia * Acidosis * Hypercalcemia

Question 78

How is osmolality calculated?

Answer 78

Osmolality = 2(Na) + Sugar + BUN + 1.25(EtOH) 2 salts and a sticky BUN + 1.25(EtOH)

Question 79

List the MOA of each of these drugs: * A. Biguanides * B. Sulfonylureas * C. Thiazolidinediones * D. Meglitinides * E. Dipeptidyl peptidase 4 inhibitors * F. SGLT-2 Inhibitors

Answer 79

**A. Biguanides (Metformin)** * Decreases hepatic glycogenolysis **B. Sulfonylureas (Glyburide)** * Causes insulin release **C. Thiazolinediones (Rosiglitazone)** * Increase sensitivity to insulin **D. Meglitinides (Repaglinide)** * Post-prandial insulin release **E. Dipeptidyl peptidase 4 (DPP4) inhibitors (Januvia)** * Decrease insulin degradation **F. SGLT-2 Inhibitors (Dapagliflozin - Invokana)** * Decreased glucose reuptake in kidney

Question 80

List steps in the management of rhabdomyolysis

Answer 80

**Volume Resuscitation** * NS 2L IV then give bicarb * Target urine output is 3cc/kg/hr **Urine Alkalization** * Only if CK \>5,000 * Bicarb infusion * Target urine pH \> 6.5 and serum pH 7.4-7.45 * Not evidence-based * Discontinue if hypocalcemia, pH\>7.5, or bicarb \>30 **Mannitol** * 1 g/kg over 30 min then 5 g/h IV (120 g/day) * Controversial * Monitor osmol gap – stop if \>55mOsm/kg **Renal Replacement Therapy** * Indicated for: * Persistent acidosis * Volume overload * Hyperkalemia (not responding) * Oliguria/Anuria despite fluids

Question 81

List 6 causes of hypermagnesemia

Answer 81

1. Iatrogenic 2. Laxatives (Magnesium oxide) 3. Antacids 4. Dialysate 5. Bowel obstruction 6. Anticholinergics 7. Narcotics 8. Lithium 9. Hypothyroidism 10. TLS 11. Adrenal insufficiency

Question 82

List SIX causes of respiratory acidosis

Answer 82

**Causes of inability to breath off CO₂** 1. COPD 2. Pneumonia 3. Asthma **Decreased LOC** * TBI * Brain bleed * Opioids **Neuromuscular weakness** * Myasthenia * C-spine injury (C3/4/5) * Guillain Barre

Question 83

What are the four goals of treatment in myxedema coma?

Answer 83

1. Correct electrolytes 2. Supportive care for the patient 3. Correct underlying condition 4. Correct thyroid A lot are adrenal suppressed as well

Question 84

Provide a formula to estimate how much hypertonic saline is needed to raise the serum sodium by 1 mEq/L.

Answer 84

* 3% saline has 513 mmol/L of sodium * ~0.5 mmol/mL or 1 mmol/2 mL * TBW = 60% of body weight * So, if you multiply TBW by 2, that's the amount in mL **Example** * A 120 kg man has 120 \* 0.6 = 72 L of water * 72 \* 2 = **144 cc 3% saline** would raise Na by 1 mmol/L