Clinical Endocrine Cases

Question 1

What is bolus insulin?

Answer 1

“Basal” level insulin. It is the long-acting insulin used to make a steady state of glucose. It can be adjusted at mealtime and based on FSG (“sliding scale”).

Question 2

3 guidelines for diagnosis of T2DM

Answer 2

FPG >/ 126 mg/dl

2-hr. plasma glucose >/ 200 mg/dl during a 75 g OGTT

HbA1C >/ 6.5%

Question 3

5 etiologies of DKA

Answer 3

Poor insulin control

Infection: pneumonia, UTI, GE, sepsis

Infarction

Surgery

Drugs - cocaine

Question 4

What type of acidosis occurs in DKA?

Answer 4

High anion gap metabolic acidosis (MUDPILES)

Question 5

What is the 1-2-3 rule for fluid replacement in DKA? (3)

How much is the deficit usually?

Answer 5

1. 2-3 L of NS (0.9%) over first 1-3 hrs. (5-10 ml/kg/hr).
2. Then, half strength saline (0.45%) at 150 ml/hr.
3. When glucose reaches 250 mg/dl, switch to 5% dextrose and 0.45% saline at 100-200 ml/hr.

Usually 3-5 L

Question 6

How is regular insulin administered in DKA? (3)

Answer 6

1. 10-20 units IV or IM.
2. Then, 5-10 units/hr. continuous IV.
3. Increase if no response in 1-2 hrs. - orders can be written w/ guidelines to titrate.

Question 7

At what point should you consider K+ replacement in DKA?

When supplementing, what 3 things must be kept in mind?

Answer 7

K+ < 5.5 mEq/L

Renal function
Baseline EKG for monitoring
Verifying urine output and measure hourly - likely will need urinary catheter initially

Question 8

DKA treatment goals (3)

Answer 8

Increase rate of glucose utilization in insulin-dependent tissues: 150-250 mEq/dL

Reverse ketonemia and acidosis

Correct water depletion and electrolytes

Question 9

When should you begin intermediate or long-acting insulin in DKA? (2)

What must occur between time of administration of IV and SQ insulin?

Answer 9

1. When patient is able to eat shown by the following:
   - mental status improved
   - no N/V
   - no abdominal pain
2. Anion gap normalized

Allow overlap timing of IV w/ SQ insulin: usually by 30-60 min.

Question 10

What symptoms of DKA are often absent in NKHS?

What are 2 components specific to NKHS?

Answer 10

N/V, abdominal pain and Kussmaul respirations.

Fluid deficit is bigger in NKHS.
Some drugs may contribute to NKHS.

Question 11

Fluid replacement in NKHS (2)

What is the fluid deficit usually?

Answer 11

2-3 L NS over first 1-3 hrs.
When glucose reaches 250 mg/dl, switch to 5% dextrose and 0.45% saline at 100-200 ml/hr.

Usually 8-10 L

Question 12

What type of insulin is used in NKHS?

Answer 12

Regular insulin - IV or IM. Transition when eating, same as DKA.

Question 13

Lower A1C is usually good, but tighter control might lead to…

Answer 13

Lows that cause syncope and increased risk of falls.

Question 14

Earliest measurable sign of proteinuria and diabetic effect of nephropathy is…

Answer 14

Microalbuminuria: 30-300 mg

Question 15

Quarterly evaluation of DM includes: (3)

Annual evaluation (3)

Answer 15

Quarterly

• HbA1C
• review of self-glucose monitoring (look at log if possible)
• foot inspection

Annual

• dilated eye exam
• urine protein screen
• monofilament testing

Question 16

Cause of tertiary thyroid disorders

Answer 16

HPA dysfunction

Question 17

What is Euthyroid Sick?

What might cause it?

What should you be cautioned about?

Answer 17

Critically ill patient whose lab results don’t fit a primary, secondary or tertiary pattern.

May be due to protein shifts, protective effect of decreased metabolism or maladaptive process.

Caution interpreting thyroid testing and treatment in this situation.

Question 18

When should you do an FNA of a thyroid nodule?

Answer 18

If only the cause symptoms - otherwise watchful waiting is a good plan.

Question 19

If Ca++ and PO4- levels move the same direction, what should you think is the culprit?

Answer 19

Vit. D-related

Question 20

Hypercalcemia of malignancy is evidenced by…

What is the first treatment measure?

Answer 20

Mental status changes and/or EKG changes.

Aggressive volume expansion w/ isotonic saline is first measure.