T3 - DM/Thyroid - Endocrine/GI Flashcards
MODY and LADA
Mature Onset Diabetes of the Young
Late Autoimmune DM in Adults
AGBI
Alpha cells - glucose
Beta cells - insulin
In DM2, initially there is _______ levels of insulin, and then as the cells tire out, insulin levels _______
High
Drop
What is c-peptide? Are levels high or low in T1DM? T2DM?
The part that gets cleaved during enzymatic activation of insulin. If 0 insulin is produced (T1DM), then it makes sense that c-peptide levels would be LOW.
T2DM would be. Hight.
Ominous Octet of DM
Impaired insulin secretion from Beta cells
Increased glucagon secretion from alpha cells
NT dysfunction (satiety)
Decreased glucose uptake in muscles
Increased glucose reabsorption by kidneys
Increased lypolysis
Decreased incretin effects
Increased hepatic glucose production
According to ADA, who should get screened for DM?
Adults over 35 who have a BMI >25 and at least 1 risk (risks = 1st deg relative with DM, high risk race, Hx CVD, HTN, HDL <35 or TG >250, Hx PCOS, physical inactivity, preDM A1c >5.6)
Test q3 years or yearly
How often should pre-diabetics get checked for DM?
Yearly screening
A1C for pre-diabetes and diabetes
Pre = 5.7-6.4
DM= >=6.5
When should kids get screened for DM?
Kids 10yo or at the onset of puberty who are overweight/obese (85% or more) with 1 or more RF.
Fasting plasma glucose is ____ in pre-dm and _____ in DM. Goal for diabetics is ______
Goal A1c for diabetics is _______
OGTT after 2 hours of 75G glucose load for pre-DM is _______ and DM is _______.
Goal post prandial BG for diabetics is ______
100-125, >=126, 80-130
<7%
140-199, >=200
<180
When should pregnant patients get their OGTT?
24-28wks
PP women who had GDM should have an OGTT at ______
4-12 wks PP
Women who had GDM should be screened ______
For DM every 3 years for life.
Hemaglobinopathies and anemias - why do these matter in DM?
They can cause a falsely low A1C since the RBCs turn over more rapidly than every 3 months.
Insulin is initiated at _______ u/kg/day and titration. Most are at around _________ u/kg/day
0.2-0.6
0.4-1.0
“-tides” are ________ and “-flozin” are _______
GLP1
SGLT-2
An expected _____ bump in creatinine happens with the initiation of ACEi/ARB therapy. Anything more than this should be investigated.
10%
If the patient has proteinuria, what Rx should be considered?
Control glucose (<7%)
Control BP (<140/90)
ACEi/ARB
SGLT2
Diabetic neuropathy can “goof up” proprioception which can lead to more ______
Falls
NAFLD + NASH can lead to
Cirrhosis, hepatic ca, portal HTN, liver failure.
Level 1, 2 and 3 hyPOglycemia.
1 = 54-70
2 <54
3 severe event requiring treatment
If you’re a diabetic, you should expect to burn between ______ CHO per 30min of moderate exercise
1-20.
More episodes of hypoglycemia you have, the less your brain recognizes hypoglycemia.
Acidosis in diabetics -
RR?
Na?
K?
Increased
Falsely decreased
Falsely high
How do you calculate the anion gap? What is normal?
Take the number of cations (+Na) minus the sum of the number of anions (- CL and HCO3)
Normal is 8-12
Urine dipstick doesn’t read the MAIN ketone in DKA, only the other 2, so if ketones are low, or neg, it could still have ketones.
What is the SICK acronym for DM?
On sick days:
Sugar: Check your Sugar every 2-3 hours or as necessary
Insulin: Always take your Insulin
Carbs: Drink lots of fluids. If sugars are high drink sugar free beverages. If sugars are low, drink Carb containing beverages.
Ketones: check your urine ketones every 4 hours. Take rapid acting insulin if ketones are present.
For DM, the PCV pneumococcal vaccine is recommended for 19-65yo.
Too much thyroid hormone during development = _________ stature. Why?
Short. Because the bones mature and ossify sooner than normal.
What will you see in TSH and T4 in Hashimoto’s?
Increase TSH and decrease T4
If TSH is high and T3/T4 are normal/low, then what is the condition?
Hypothyroidism or sub clinical hypothyroidism.
If TSH is low and T3/T4 are normal/high, what is the conditions?
Hyperthyroidism or sub clinical hyperthyroid.
In Central hypopthyroidism, what differs from primary hypothyroidism?
Central = normal/low or slightly high TSH with low or low-normal t3/T4.
Single best test of thyroid function?
TSH
Titration TSH at a 6-8wk follow up.
Young adults will start at _______% predicted dose calculated by ______
Middle age start at ______ % predicted dose _______
Elderly or Cardiopulmonary disease start at _________
79-90% (1.5-2.2mcg/kg ideal body weight)
65-75% (1.5-2.0mcg/kg ideal body weight)
12.5-25mcg/d and add 25mcg every 6 weeks.
Restoring a euthyroid state in some one with hypothyroidism especially elderly and those with cardiopulmonary disease can cause ________
Tachycardia
Increased O2 consumption/demand
Exacerbation of underlying cause
What should we consider in every patient newly diagnosed with hypothyroidism?
Adrenal insufficiency
How should you take synthroid?
On an empty stomach first thing in the morning (only water- no food OR COFFEE!) and wait at least 30 minutes prior to any food or other medications.
Your patient has been put on the starting dose of synthroid for hypothyroidism. They are back for their 6 week follow up and their TSH level is <0.5. What should you do?
What if their level was >4?
<0.5, then decrease dose by 12.5-25mcg
If > 4, then increase dose by 12.5-25mcg.
What is the therapeutic TSH range while on medication?
0.5-2
TSH will be >___ but < ____ in subclinical hypothyroidism. Should you treat?
5 less than 10
Treat if symptomatic. Monitor for worsening.
What is Pemberton’s sign?
If a patient has a goiter or enlarged thyroid gland, if they raise their hands up to their ears and leave for 1-2 minutes, their face will flush due to compression of the veins and can’t empty from the face.
Are “cold” or “hot” thyroid nodules more concerning?
Cold. More likely to be cancerous (1/20)
Hot are generally benign.
______% of post partum thyroiditis regain normal function
80%
H.Pylori triune treatment:
PPI, Amoxicillin and clarithromycin for 10 days.
IBS (as opposed to just regular constipation or diarrhea) must have:
BLOATING.
Difference between UC and CD
UC - superficial layer only, 3x more common than chron’s, colon only,
CD - all layers of the intestine and all areas including oral mucosa, strictures and fistulas, erythema nodosium.
Both- fatigue, tenesmus, anemia, bowel urgency.
What is a good test for patients who come in with nausea.
PO challenge. Can they keep fluid and meds down?
Associated symptoms with n/v
Eating disorders, pain, headache, dizziness, tinnitus, diarrhea, fever, anxiety, AMS, pregnancy, new medication (SE), recent bad food intake.
Some DDX for N/v
Acute abdomen, morning sickness, eating disorder, pregnancy, constipation, infection, pain, med SE, migraine, metabolic cause (DKA/HHS), Meniere’s MI, cholecystitis.
Buttaro pg 744 - antiemetic meds
Upper abd pain UPPERSTOMACH acronym
Urinary - stone, infx
Pancreas - pancreatitis, mass
Pulmonary. - PNA/PE
Ectopic - pregnancy
Really early appendicitis
Stomach - GI, perf, ulcer
Twisting - volvulous, ischemic bowel
Obstruction - bowel, FB
MI - ACS, myocarditis/pericarditis, aneurysm
Aorta - AAA, dissection
Cholecystitis/cholangitis
Hepatic - hepatitis.
What 3 things should be done first if you have an abd pain complaint?
ABCs, sick or not sick, ECG.
What type of pain main increase with cough?
Parietal pain (irritation of the peritoneum)
What type of pain is dull, cramping, poorly localized?
Visceral
How does referred pain typically present?
Aching
Www.merkmanual.com
classic triad for appendicitis
RLQ pain, anorexia and nausea
4 PE tests for appendicitis
Psoas sign
Obturator sign
McBurney’s point
Rovsing’s sign (palpate LLQ and pain is felt in RLQ)
What percentage of patients have increased WBC in appendicitis?
75-90%
Most common cause of GI obstruction?
Adhesions post surgery, hernias and tumors.
T/F: Ileus is the same as obstruction
False. Ileus can lead to an obstruction
RF for pancreatitis
ETOH, gallstones, HLD
In 50% of pancreatitis patients, pain radiates to the _______
Back
__________% of pancreatitis patients have associated N/v
90
A 3 fold increase in lipase can indicate pancreatitis, but not what KIND.
Murphy’s sign is used to assess for cholecystitis. How do you test?
Inspiratory arrest with palpation of RUQ under ribs.
Peritonitis is usually secondary to another cause. Patients appear _____ and don’t want to ______
Very sick
Move
GER can be normal physiology. GERD is ______ with troublesome symptoms
> 2weeks
Some DDX for GERD
MI, esophagitis, peptic ulcer, post nasal drip, H.Pylori.
If someone has Barrett’s esophagus, how often should they get their EGD?
1-2years WITH biopsy.
Peptic ulcers - _____% caused by chronic NSAID use. Pain ________ and relieved by __________
25
Wakens patient’s at night.
Relieved by eating or vomiting.
PPI should not be used for more than a few months. Assess for chronic PPI OTC use.
Constipation is a ______ not a _______
Symptoms
Disease.
What is the Rome IV criteria for constipation?
Must have 2 or more of the following:
2 or less stools/week
Hard or lumpy stool
Straining
Feeling of obstruction or incomplete evacuation
Manual assistance >25% of the time
NOT meet criteria for IBS-C.
Difference between NAFLD and NASH
NonAlcoholic Fatty Liver Disease - Non-inflammatory no S/s. No Treatment. Lifestyle modification.
NASH - NonAlcoholic Steatohepatitis- inflammatory. No s/s but rarely fatigue, malaise or vague RUQ discomfort
With NASH or NAFLD, you will see an increase in what labs?
AST and ALT 2-5x normal ratio and elevated ALK phos.
What is the Fib-4 test for NASH risk?
Age (35-65)
AST
ALT
Platelet count
How do patients present with cirrhosis?
CV
Derm
Neuro
GI
Hem
Repro
CV - esophageal varices, capital Medusa, ankle edema
Derm - spider nevi, clearly icterus, jaundice
Neuro - coma, liver flap (course hand tremor)
GI - femoral hepaticus, jaundice, hemorrhoids, splenomegaly, hematemesis, peptic ulcers, melena
Hem - anemia, bleeding tendency
Repro - testicular atrophy, Gynecomastia,
5 categories of diarrhea
Infection
Inflammatory
Secretory
Malabsorption/osmotic
Increased motility
Carcinoid tumor or VIPomas would be an example of. _______ diarrhea.
Secretory
IBS-D would be an example of _____ diarrhea
Increased motility
UC and CD would be examples of _____ diarrhea
Inflammatory
Celiac disease, lactose intolerance, post-op short bowel or pancreatic insufficiency (CF) would be examples of ____ diarrhea.
Malabsorption.
What is a BRAT diet?
Banana, rice, apples, toast
If someone has a malabsorption condition, what should you check/replenish ?
Fat sol vitamins (DEAK), poor absorption of carbs (underweight), Iron, minerals like B12 and proteins.
What is celiac disease often miss diagnosed as?
IBS
What is dermatitis herpetiformis?
Skin condition associated with celiac disease.
How do you screen for Celiac Disease?
tTG-IgA and total IgA
Clinical considerations for Celiac disease?
GFD for life, registered dietician referral, test and treat for nutrient deficiencies (iron, folic acid, VitD, vit B12), screen for osteoporosis (70% develop osteopenia), and repeat tTGA 6mo post GFD
IBD has a peak onset of ________ and another peak at _______
20/30
50s
Imaging results using the terms “string sign”, “rectal sparing”, “thumb printing” “ skip lesions” or “cobblestone mucosa” suggests _________
Chron’s Disease
Dietary management of Chron’s disease?
Increased fiber
Low fat
Trial dairy restriction
Rheum and dietician referral
Vitamin/mineral supplements
Bloody diarrhea, arthritis, skin lesions, tenesmus and tachycardia/orthostatic hypotention could be signs of _____
UC
Low grade fever, watery diarrhea, perianal fissures, fistulas are signs of ____
Chron’s disease
Lubiprostone. (Amitiza) is a ______ and FDA approved for treatment of ______ in ______ only, not ______
Chloride channel activator
IBS-C
Women
Men
1st line tx for IBS-D
2nd line
Loperamide
Bile acid sequestrants and antispasmodics PRN and prophy.
What are carcinoid syndrome and VIPoma?
Carcinoid syndrome - serotonin secreting cancerous tumors
VIPoma - neuroendocrine tumor that secrete vasoactive intestinal polypeptide (VIP)
These both cause secretory type diarrhea
RF for colon CA
Age >50
Smoking
IBD
Family Hx
Obesity
Diet high in red meat and fats.
Colon cancer screening
Grade A for 50-75
Grade B for age 45-49 and Grade C for age 75
One main cause of GI bleeds?
Diverticulosis
Constellation of LLQ tenderness, w/w/out peritoneal s/s, fever and leukocytosis could suggest?
Sigmoid diverticulitis
Avoid these 4 things in diverticular disease:
Laxatives, enemas, opioids and NSAIDS.
90% of NON-STI or IBD related anal fissures are posterior midline. A lateral midline anal fissure often indicates ____, ____ or _____
UC, CD STI.
