test 3 Flashcards
win
cushings syndrome causes
excess steroids, pituitary
adenoma
cushings syndrome S/S
central obesity, weight gain, round
face, buffalo hump, thin and brittle skin,
easy bruising, acne, hirsutism,
osteopenia/porosis, HTN, low K, HLD,
glucose intolerance, irritable, emotional
lability, depression, prone to infections
cushings diagnostics
24 hour urinary free cortisol,
cortisol level, dexamethasone overnight
test, if + MRI pituitary, CRH test, if ACTH
low CT of adrenals
cushings treatment
dc tumor
addisons disease causes
autoimmune, drug induced,
infections, congenital, tumor/cancer
addisons disease S/S
S/S: fatigue, weight loss, anorexia, myalgia, joint pain, fever, anemia, postural hypotension, low BP, GI symptoms, craves salt, low Na, high K, itchy and dry skin
addisons disease dx
short cosyntropin test, CBC, BMP, TSH
addisons disease treatment
hyrdrocortisone 100-200 mg over 24 hours IV or IM, monitor
resolution by s/
DM normal A1C
<5.6
Prediabetic A1C
5.7-6.4
Diabetic A1C
> 6.5
when to screen for DM
> 45 years old every 3 years and earlier if BMI is over >25
DM therapy goal
• Goal of therapy is to reduce hyperglycemia and prevent long term
microvascular and macrovascular complications
DM complications
retinopathy, nephropathy, neuropathy
DM medical therapy
Comprehensive medical therapy includes glycemic control , eye exam,
foot exam, BP monitoring, vaccines, lipids and renal function
monitoring, education
Type 1 DM cause
Caused by pancreatic islet B cell
destruction > either
autoimmune or idiopathic
Type 1 DM fasting glucose score vs random glucose score to dx and urine
Fasting glucose > 126 mg/dl on
more than 1 occasion
Random glucose > 200 mg/dl
with polyuria, polydipsia, and
weight loss
• + ketones
Type 2 Diabetes
Circulating endogenous insulin is
inadequate to prevent
hyperglycemia (insulin resistance)
type 2 DM
age
symptoms
fasting glucose score
a1c score
normal co morbidity
> 40 and obese • Polyuria and polydipsia • Fasting glucose > 126 mg/dl on more than 1 occasion • HbA1C > 6.5% • HTN, HLD, and atherosclerosis are usually present
type 1 DM S/S
• S/S: polyuria and polydipsia as a result of osmotic diuresis, blurred
vision, weight loss, postural hypotension, parasthesias
type 1 DM treatment
Treatment: insulin
• Short acting: lispro, regular
• Long acting: NPH, detemir
• Combos: 75/25, 70/30, 50/50
Insulin dosing
units/kg/day
Calculate total daily dose (0.5-0.7 units/kg/day)
• Divide total insulin into basal and bolus dosing
• Basal = long acting insulin
• Bolus = short acting insulin, divide out before meals
type 2 dm S/S
S/S: polyuria and polydipsia, unexplained candida vulvovaginitis in
women, central obesity
dm 2 treatment
Treatment is three-fold
- Glycemic control
- Co-morbidities
- Screen for complications
medications dm 2
Medications: oral agents such as biguanides (metformin),
sulfonylureas (glipizide), thiazolidinedione (pioglitazone), insulin
under certain conditions
type 2 dm management
goal FBS and random sugar and when to start oral agent
- Start with diet and exercise for weight loss for FBS <200 or random <250
- Begin oral agent if FBS 250-300 or random 250-350
type 2 dm oral agents
Metformin first line or
2. Glitazone second line for obese patients, sulfonylurea for lean patients
3. 3 months re-eval if not improved, start dual therapy > metformin with sulfonyurea or
glitazone
4. Add a 3rd medication if still not improved.
5. Insulin therapy for A1C > 10%, FBG >300 or random >350
DKA
cause
S/S
Exam
Insulin deficient and glucagon excess increase blood sugar
• S/S: n/v, polyuria, polydipsia, abd pain, SOB
• Exam: tachy, hypotension, dehydrated, tachypnea, Kussmaul Respirations,
abd tenderness, lethargy to coma
DKA lab findings
lab findings
treatment
Lab findings: elevated glucose, hyponatremia, hypokalemic, AKI, + ketones,
increased anion gap, increased osmolality
• Treatment: ACUTE emergency, likely admit to ICU, check labs,
• IVF at 2-3 L NS over first 1-3 hours, then ½ NS at 250-500 ml/hour until FBS is 250
then switch to D5 ½ NS at 150-250 ml/hr
• Insulin bolus of 0.1 unit/kg then Insulin drip 0.1 units/kg per hour and increase each
hour until glucose begins to drop, hold insulin drip if K is not WNL.
• Treat electrolyte abnormalities
Hyperglycemic hyperosmolar state
definition
• Insulin deficiency increases hepatic glucose production and impair
glucose utilization
Hyperglycemic hyperosmalar state
• Labs: hyperglycemia (>600), normal Na, AKI, likely no ketones, slightly
increased anion gap
• S/S: polyuria, weight loss, diminished oral intake, underlying cause
such as infection
Hyperglycemic hyperosmolar state treatment
Treatment: 1-3 liters of NS over first 2-3 hours, watch Na, change to
½ NS if Na > 150, similar to DKA start insulin drip at 0.1 units/kg per
hour after a bolus of 0.1 units/kg
DM special considerations
ICU PT Med surge Pt TPN Glucocorticoids Preggers old heads
ICU patient – switch regimen to insulin drip to maintain glucose 140-
180
• Med/surg patient – keep outpatient regimen and adjust accordingly
• TPN – insulin added to TPN
• Glucocorticoids – increase insulin, oral agent likely not helpful
• Pregnancy – requires planning and strict regimens
• Older adults – 50% of usual starting dose
Diabetic Complications
Microvascular
• Retinopathy
• Macular edema
• Autonomic neuropathy
Macrovascular
• CAD
• PAD
• CVA
dm complications
other
Other • GI issues • Sexual dysfunction • Infections • Glaucoma • Hearing loss • Periodontal disease
Hypoglycemia
usual cause
SS
Tx
Usually caused by medications
• S/S: cognitive and behavioral changes, diaphoresis, pallor,
palpitations, tremor, anxiety, hunger, paresthesia
• Treatment: identify cause, oral glucose, IV glucose, glucagon IM
Syndrome of inappropriate secretion of
antidiuretic hormone
definition
causes
S/S
TX
Inappropriate secretion of AVP
• Causes: Cancer, head trauma, infections, CVA, neuro disorders,
medications, pneumothorax, asthma
• S/S: headache, confusion, anorexia, n/v, coma, convulsions
• Treatment: identify cause, treat underlying cause, fluid restriction,
diuretic to increase urine production (rids body of excess salt and
water), treat hyponatremia gradually (1% an hour)
thyroid disorders
hyper
Hyperthyroidism
• Low TSH
• Normal to high T4
thyroid disorders
hypo
Hypothyroidism
• Elevated TSH
• Low free T4
Hypothyroidism
causes
• Causes: autoimmune, iatrogenic, medications, congenital, iodine
deficiency, postpartum
hypothyroidism S/S
• S/S: fatigue, dry skin, cold, hair loss, poor memory, constipation,
weight gain with poor appetite, dyspnea, hoarse voice, hearing loss
hypothyroidism
exam
dx
management
Exam: myxedema, bradycardia, delayed tendon relaxation, carpal
tunnel syndrome
• Diagnostics: Check TSH, free T4, thyroid ultrasound
• Management: levothyroxine 1.6 mcg/kg 30 mins before breakfast
autoimmune hypothyroidism
AKA definition
AKA Hashimoto’s or autoimmune hypothyroidism > marked
lymphocytic infiltration of the thyroid causing atrophy and fibrosis
hashimotos decline in functions
symptoms
dx
Gradual decrease in function
• Minor symptoms (see prior slide)
S/S: fatigue, dry skin, cold, hair loss, poor memory, constipation,
weight gain with poor appetite, dyspnea, hoarse voice, hearing loss
• Diagnostics: TSH, if elevated check unbound T4, TPO antibodies,
Thyroid US , FNA biopsy to confirm
Myxedema coma
what is it
s/s
tx
special considerations
Severe hypothyroidism
• S/S: decreased LOC, seizures, hypothermia
• Treatment: IV bolus levothyroxine 500 ug
Special considerations:
• Pregnancy > frequent monitoring
• Elderly > likely need lower dose
hyperthyroidism
causes
Causes: Grave’s Disease, goiter, adenoma, CA, thyroiditis, medications, gestational
hyperthyroidism s/s
S/S: hyperactive, irritable, palpitations, fatigue, weakness, weight loss with increased appetite,
diarrhea, polyuria, loss of libido, oligomenorrhea
hyperthyroidism
exam
dx
tx
Exam: tachy, tremors, goiter, warm, moist skin, muscle weakness, gynecomastia, lid retraction or lag
• Diagnostics: TSH, unbound T4, unbound T3, US
• Management: thionamides
Complications of hyperthyroidism
• Complications: Optic nerve compression, use NO SPECS scoring N (0) = no signs or symptoms O (1) = only signs no symptoms S (2) = soft tissue involvement P (3)= proptosis E (4)= extraocular involvement C (5) = Corneal involvement S (6) = sight loss
graves disease treatment
Start antithyroid drug and check levels every 4-6 weeks
• PTU 100-200 mg every 6-8 hours and reduce dose as symptoms and labs
improve
• Propranolol controls adrenergic symptoms
• Radioiodine to destroy thyroid cells
• Subtotal or total thyroidectomy for relapse after medications or if goiter is too big
thyroid storm
definition
s/s
management
Life threatening
Severe hyperthyroidism
• S/S: Fever, delirium, seizures, coma, vomiting, diarrhea, jaundice,
cardiac failure, arrhythmia, hyperthermia
• Management: ICU, supportive care, large doses of PTU given via NGT
or rectally, propranolol
opthalmopathy
Mild to moderate no treatment needed
• Management: Stop smoking, control thyroid hormone, artificial tears
for discomfort, eye ointment, dark glasses with side frames, sleep
upright for edema or diuretics, patches while sleeping to protect
cornea, optic nerve involvement needs emergency surgery, IV
methylprednisolone preferred for moderate, orbital decom
thyroitis
causes
s/s
tx
Causes: infection, radiation, drug induced, autoimmune
• S/S: throat pain, tender goiter, fever, dysphagia, erythema,
lymphadenopathy
• Treatment: high dose ASA or NSAIDs to control pain, steroids if not
resolving and tapered over 6-8 weeks, low dose levothyroxine
• Can be acute, subacute or chronic
goiter
Goiter • Asymptomatic • Can be diffuse nontoxic or multinodular nontoxic • On exam thyroid will feel abnormal • Treat labs
hyperpara thyroid disorder PTH calcium and phosphate cause monitor tx
Hyperparathyroid • Increased PTH • Hypercalcemic, hypophosphatemia, • Caused by tumors, adenomas, genetics • Monitor Ca, urinary calcium, cr. Clearance, serum creatinine, bone density • Treatment – remove abnormal tissue
hypoparathroid
PTH
calcium phosphatemia
cause
tx
Absent PTH • Hypocalcemia, hyperphosphatemia • Caused by genetics, surgical removal of gland • Treatment – vitamin D, oral Calcium intake, treat concurrent issues such as CKD, low
