Diagnosis and Management of Endocrine Disorders

Question 1

Metabolic disease resulting form the breakdown in the body’s ability to either produce and/ or either produce and / or utilize insulin, resulting in inappropriate hyperglycemia ruffly 14 million American have diabetes; ruffly 50% of all persons with diabetes are undiagnosed

Answer 1

Diabetes Mellitus (DM)

Question 2

Pathology:

1) Previously known as insulin-dependent or juvenile diabetes
b) Most common in adolescents but may occur in adulthood
c) Strongly associated with the presence of human leukocyte antigens (i.e. HLA-DRA3 or HLA-DRA4)
d) Islet cell antibodies found in approximately 90% of patients within 1st year of diagnosis
e) Ketone development usually occurs
f) Believed to be the result of an infectious or toxic environment insult to pancreatic B cells of genetically predisposed persons

Answer 2

Diabetes Mellitus (Type 1 DM)

Question 3

Pathology:
1) Previously known as non-IDDM or adult-
onset DM
2) The most common type of diabetes: > 90%
diabetes in the United States
3) Circulating insulin exist enough to prevent
ketoacidosis but is inadequate to meet the
patient’s insulin needs
4) Caused by either tissue insensitivity to
insulin or an insulin secretory defect
resulting in resistance and/or impaired
insulin production
5) Not linked to human leukocytes antigens
or islet cell antibodies
6) Associate with obesity and Syndrom X:
obesity, hypertension, normal lipid profile
(low HDLs and high triglycerides)
7) Metabolic syndrome:
a) Waist circumference: > 40 inches (101.6
cm) in men and > 35 inches (88.9 cm) in
women
b) BP > 130/ 85
c) Triglycerides > 150
d) FBG > 100
e) HDL: < 40 in men and < 50 in women

Answer 3

Diabetes Mellitus (Type 2 DM)

Question 4

Signs and symptoms of this: Type _____ DM

a) Polyuria
b) Polydipsia
c) Polyphagia
d) Nocturnal enuresis
e) Weight loss
f) Weakness/ fatigue
g) Other

Answer 4

Type 1 DM

Question 5

Signs and symptoms of this: Type ____ DM

a) Insidious ones fo hyperglycemia; the patient may be asymptomatic
b) Polyuria
c) Polydipsia
d) Recurrent vaginitis often the first symptom in women
e) Peripheral neuropathies
f) Blurred vision
g) Chronic skin infections including pruritus
h) Increased risk of rectal cancer

Answer 5

2

Question 6

Labs/ Diagnostics: DM type ___:
1) Random plasma glucose > 200 mg/dL with
polyuria, polydipsia, and weight loss
2) Serum fasting (at least 8 hrs) blood sugar >
126 mg/dL on two separate occasions
3) FBG may be elevated due to
corticosteroids, beta-blockers, thiazide
diuretics, statins
4) Ketonemia, ketonuria, or both
5) BUN/ creatinine elevated (dehydration)
6) Oral glucose tolerance test > 200 mg/dL
two hours postprandial- rarely used
7) Hbg A1c: Now use for routine diagnosis:
give an indication of glycemic control for
the past 2 to 3 months; normal = 5.5 to 7%
Impaired Glucose Tolerance: FBG > 100
and < 125

Answer 6

1

Question 7

Labs/ diagnostics: DM type ____

1) Same as for type 1 DM except for no ketones in blood/ urine

Answer 7

type 2 DM

Question 8

Management type 1 DM:
1) Treatment plans for all diabetes must be highly individualized
2) Analyze baseline studies
    a) Age of honest 
    b) 
    c) Cardiac risk factors
    d) Presence of ketones
    e) Diagnostic markers
    f) Cholesterol, triglycerides, ECG
    g) Renal studies, as needed
    h) Baseline physical exam noting 
       peripheral pulses, neurologic function. 
       eye and foot exams

Answer 8

2) b) Obesity

Question 9

Dietary teaching: Consult dietitian/ DM 1
a) Total carbohydrate intake _____% total
calorie intake
b) Fats 20 to 30% total calories
c) Fibers 25 g/ 1000 calories
d) Protien 10 to 20% total calories

Answer 9

a) 55 to 60

Question 10

Diabetes Mellitus (Type 1 DM):
If the patient presents with ketones, then insulin therapy is most likely warranted
a) The general rule of thumb is, to begin
with ____ u/ kg/day giving 2/3 of the
dose in the morning and remaining 1/3 in
the evening

Answer 10

a) 0.5 u/ kg/day

Question 11

DM type 1:
a) \_\_\_\_ \_\_\_\_ \_\_\_\_\_ \_\_\_\_\_\_
    1) Morning dose of insulin 2/3 NPH and 
       1/3 Regular 
   2) Evening dose 1/2 NPH 1/2 Regular

Answer 11

a) Conventional Split Dose Mixtures

Question 12

DM type 1:
b) ______ ______
1) Reduced or omit the p.m. dose and add
a portion at bedtime

Answer 12

Intensive Therapy

Question 13

DM type 1:

1) _____ (Novolog)
2) Gargine (Lantas)- prolonged duration
3) Lispro (Humalog)- rapid onset

Answer 13

1) Aspart

Question 14

DM Type ____:

Same as for type 1 DM except for ___ ketones in blood/ urine

Answer 14

no

Question 15

DM type _____

a) Obtain baseline data as outlined for type 1 DM
b) Therapy should begin with weight control for obese patients
c) Dietary treatment with guidelines
d) exercise
e) Consider early use of oral anti-diabetics
f) Insulin therapy may be needed in future years of treatment

Answer 15

2

Question 16

Oral Antidiabetic choices ( 5 classes):
_______: Most widely prescribed; stimulate the pancreas to release more insulting
– 2nd generation: Glipizide (Glucotrol). Glyburide (DiaBeta, Micronase), Glimepiride (Amaryl)

Answer 16

Sulfonylureas

Question 17

_____: Good adjunct to sulfonylureas but can be used alone, especially for obese patients
– Metformin (Glucophage): Standard of care upon the diagnosis of Type 2 DM; lactic acidosis is a potential side effect

Answer 17

Biguanides

Question 18

____ ____ ____: Bind to disaccharidases more readily than sucrose so less glucose is absorbed by the gut
– Acarbose (Precose), Miglitol (Glyset)

Answer 18

Alpha-glucosidase inhibitors

Question 19

__________ “ Glitazones”; decrease gluconeogensesis

• • Rosiglitazone maleate (Avandia)
• • Pioglitazone hydrochloride (Actos)

Answer 19

Thiazolidinediones

Question 20

_______ ____ ____ _____: Rapidly absorbed for the intestine and mimics the effect of rapidly acting insulin.

• • Repaglinide (Prandin)
• -Nateglinide (Starlix)

Answer 20

Non- sulfonylurea Insulin Release Stimulators

Question 21

Management continued: Diabetes Mellitus type 2:
a) ______ (Byetta): Injectable that mimics the effects of incretins (signals pancreas to increase insulin secretion and the liver to spot producing glucagon): may cause significant nausea, vomiting, and diarrhea

Answer 21

Exenatide

Question 22

Management continued: Diabetes Mellitus type 2:

________ (Januvia): Dipeptidyl peptidase -4 (DPP4 inhibitor); DPP4 breakds down incretins

Answer 22

Sitagliptin

Question 23

Management continued: Diabetes Mellitus type 2:
________ (Symlin): Injectable for Type 1 and 2 DM; resemble human amylin slow absorption of glucose and inhibits the action of glucagons; promotes weight loss while decreasing blood glucose levels

Answer 23

Pramlintide

Question 24

______ ____: Nocturnal hypoglycemia develops stimulating a surge of counter-regulatory hormone (____ ____) which raise blood sugar. Note that the patient is hypoglycemic at 0300 but rebounds with elevated blood glucose at 0700

Answer 24

Somogyi Effects

Question 25

Treatment for Somogyi Effect include:

Answer 25

Reduce or omit the at bedtime does of insulin

Question 26

____ _____ Results when the tissue becomes desensitized to insulin nocturnal; Note that the blood glucose become progressively elevated throughout the night, resulting in elevated level at 0700

Answer 26

Dawn Phenomenon

Question 27

Treatment of the Dawn Phenomenon is:

Answer 27

Add or increase the at bedtime dose of insulin

Question 28

a) Stat of intracellular dehydration as a result of elevated blood glucose levels b) Often, an acute complication of type 1 DM c) Maybe the presenting sign of DM

Answer 28

Diabetic Ketoacidosis (DKA)

Question 29

Signs and symptoms of this are: a) polyuria, including nocturia b) polydipsia c) weakness/ fatigue, nausea, and vomiting d) Kussmaul's breathing e) Altered LOC f) fruity breath g) Hypotension and tachycardia h) Poor skin turgor

Answer 29

Diabetic Ketoacidosis (DKA)

Question 30

Lab/ diagnostics: Diabetic Ketoacidosis (DKA) a) protect airway: administer O2 b) Refer for: a) fluid resuscitation: _____ fluids (NS), then 1/2 NS, followed by D51/2 NS b) 0.10 U/kg regular insulin IV bolus followed by 0.1 kg/hr c) Supportive care

Answer 30

b) a) Isotonic fluids

Question 31

Patho: 1) State of greatly elevated serum glucose, hyperosmolality, and severe dehydration without ketone production 2) Usually occurs as a complication of type 2 DM 3) Patients cannot produce enough insulin to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion 4) Mortality rate around 30 to 50 %

Answer 31

Hyperosmolar Hyperglycemic Non-ketosis (HHNK)

Question 32

Signs and symptoms: Hyperosmolar Hyperglycemic Non-ketosis (HHNK) 1) Polyuria 2) Weakness 3) Altered LOC 4) __________ 5) Tachycardia 6) Poor skin turgor 7) Other signs of dehydration

Answer 32

4) Hypotension

Question 33

Lab/ diagnostics: Hyperosmolar Hyperglycemia Non- Ketosis (HHNK) 1) Greatly elevated serum glucose ( > 600 mg/dL; commonly > 1000 mg/dL) 2) Hyperosmolality (> _____ mOsm/L) 3) Elevated BUN and Cr 4) Elevated Hgb A1c 5) Relatively normal pH 6) Normal anion gap

Answer 33

2) 310 mOsm/L

Question 34

Management: HHNK 1) Protect airway; administer O2 2) Refer for: a) Normal saline IV massive fluid replacement (overall fluid deficit maybe 6 to 10 liters), then 1/2 NS, followed by D5 1/2 NS b) ____ Units regular insulin IV followed by 10 to 15 Units subcutaneous (immediately) c) Additional insulin depends on the the severity of condition and response- may not be necessary d) Supportive care

Answer 34

2) b) 15 units

Question 35

a) Hypothalamus - --> ----> ----> b) Thyroid releasing hormone - --> ---> ----> c) ______ _____ - --> ---> ----> d) Thyroid Stimulating Hormone - --> ---> ----> e) Thyroid Gland

Answer 35

Anterior pituitary

Question 36

Causes/Etiology: A) _________: 1) More common in women (8:1 ratio) • 2) Onset most commonly between 20 and 40 years of age 3) Grave's disease is the most common presentation 4) Other causes of hyperthyroidism include toxic adenoma, subacute thyroiditis, TSH secreting tumor of the pituitary, high dose, amiodarone

Answer 36

Hyperthyroidism •

Question 37

Signs and symptoms: Hyperthyroidism 1) Nervousness 2) Anxiety 3) Increased sweating 4) _______ 5) Emotional lability 6) Fine tremors 7) Hyperreflexia of DTRs 8) Increased appetite 9) ___ ____ 10) Smooth, warm, moist velvety skin • 11) Fine/thin hair• 12) Exophthalmos• 13) Lid lag• 14) Tachycardia 15) Heat intolerance 16) Others• 17) Increases incidence of atrial fibrillation

Answer 37

4) Fatigue | 9) Weight loss

Question 38

Hypothyroidism Signs/Symptoms: 1) Primary disease of the thyroid gland • 2) Pituitary deficiency of TSH • 3) Hypothalamic deficiency of TRH • 4) _____ ______ 5) Hashimoto'sthyroiditis • 6) Idiopathic causes 7) Damage to the gland

Answer 38

4) Iodine deficiency

Question 39

Hypothyroidism: 1) Extreme weakness • 2) Muscle fatigue • 3) Arthralgias 4) Cramps 5) Cold intolerance • 6) Constipation 7) ____ ____ 8) Dry skin 9) Hair loss 10) Brittle nails 11) Puffy eyes 12) Edema of the hands and face • 13) _______ 14) Slowed DTRs • 15) _______ bowel sounds

Answer 39

7) Weight gain 13) Bradycardia • 15) Hypoactive bowel sounds

Question 40

Laboratory/ Diagnosis: Management: Hyperthyroidism 1) TSH assay is the most sensitive test and is low in most cases 2) Serum T3, T4, thyroid resin uptake, and free thyroxine index increased Sometimes T4 is normal, but T3 elevated (_____ ng/dL) 3) Serum ANA usually elevated without evidence of lupus or other collagen diseases 4) Thyroid radioactive iodine uptake and scan usually performed to establish etiology of hyperthyroidism - A high iodine uptake is consistent with Grave's disease - A low uptake is consistent with subacute thyroiditis 5) MRI of the orbits is tile preferred choice for visualizing Grave's ophthalmopathy

Answer 40

2) 80-230 ng/ dL

Question 41

Management: Hyperthyroidism 1) Specialist referral as needed, especially with patients who have co-morbidities • 2) ________ (Inderal) for symptomatic relief: Begin dosing with 10 mg p.o., may go to 80 mg four times daily • 3) Thiourea drugs for patients with mild cases, small goiters or fear of isotopes -Methimazole (Tapazole) 30-60 mg every day in 3 divided doses - Propylthiouracil 1300-600 mg daily in 4 divided doses 4) Radioactive iodine ____ used to destroy goiters 5) Thyroid surgery (must be euthyroid prop) 6) Lugol's solution 2-3 gtts p.o, everyday X 10 days to reduce the vascularity of the gland 7) Patients with subacute thyroiditis are best treated symptomatically with Propranolol

Answer 41

2) Propranolol | 4) 131-I

Question 42

Treatment of Thyroid Crisis: 1) ________ 150-250 mg every 6 hours OR 2) Methimazole (Tapazole) 15-25 mg every 6 hours WITH the following in one hour: a) Lugol's solution 10 gtts t.i.d. OR - b) Sodium iodide 1 gm slow IV along with c) _______ 0.5 - 2 gm IV every 4 hours or 20 - 120 mg p.o. every 6 hours with d) Hydrocortisone 50 mg every 6 hours with rapid reduction as situation improves 3) Avoid ASA

Answer 42

1) Propylthiouracil | 2) c) Propranolol

Question 43

``` Hypothyroidism Labs: • 1) TSH: Elevated 2) T4: ______________ • 3) Resin T3 uptake: Decreased (T3 is not a reliable test) 4) Hyponatremia 5) Hypoglycemia ```

Answer 43

2) Low or low normal

Question 44

Management of Hypothyroidism: 1) _________ (Synthroid): 50-100 mcg every day, increasing dosage by 25 mcg every 1-2 weeks until symptoms stabilize; > 60 years of age, decrease the dosage

Answer 44

1) Levothyroxine

Question 45

In-Patient Management of Myxedema Coma: • 1) Protect airway: Mechanical ventilation as needed 2) Fluid replacement, as needed • ___________ (Synthroid) 400 meg IV x 1, then 100 mcg every day • 3) Supporthypotension 4) Slow rewarming with blankets (not hyperthermia blankets): Avoid circulatory collapse 5) Symptomatic care

Answer 45

Levothyroxine

Question 46

Cushing'sSyndrome Cause/ etiology: 1) ____ hypersecretion by the pituitary • 2) Adrenal tumors 3) Chronic administration of glucocorticoids

Answer 46

1) ACTH

Question 47

Signs/ symptoms of _____ _____: 1) Central obesity • 2) Moon Face with buffalo hump 3) Acne 4) Poor wound healing 5) Purple striae 6) Hirsutism 7) Hypertension 8) Weakness 9) Amenorrhea 10) Impotence 11) Headache 12) Polyuria and thirst 13) Labile mood 14) Frequent infections

Answer 47

Cushing's Syndrome

Question 48

Cause/ etiology of Addison's Disease: 1) Deficient _____, androgens, and aldosterone 2) Autoimmune destruction of the adrenal gland 3) ______cancer 4) Bilateral adrenal hemorrhage (e.g., with anticoagulant therapy) • 5) Pituitary failure resulting in decreased ACTH

Answer 48

1) cortisol | 3) Metastatic

Question 49

``` Laboratory/ Diagnosis: Cushing's Syndrome 1) Hyperglycemia • 2) Hypernatremia • 3) ________• 4) Glycosuria • 5) Leukocytosis 6) Elevated plasma cortisol in the a.m. 7) Dexamethasone suppression test to differentiate cause 8) Serum _____ ```

Answer 49

3) Hypokalemia | 8) ACTH

Question 50

``` Signs and symptoms of Addison's Disease: 1) ________ in buccal mucosa and skin creases (especially knuckles, nail beds, nipples, palmar creases, and posterior neck) 2) Diffuse tanning and freckles • 3) Orthostasis and hypotension • 4) Scant axillary and pubic hair • 5) Rapid worsening of chronic signs and symptoms (acute) • 6) ____ (acute) 7) Changes in the level of consciousness (acute) ```

Answer 50

1) Hyperpigmentation | 6) Fever

Question 51

Laboratory/ diagnosis of Addison's Disease: 1) ____________ 2) Hyponatremia • 3) Hyperkalemia • 4) Elevated ____ 5) Lymphocytosis 6) Plasma cortisol

Answer 51

1) Hypoglycemia • 4) ESR 6) 5

Question 52

Management of Cushing's Syndrome: 1) Depends on the cause: a) Discontinue medications inducing symptoms b) ___________ resection of a pituitary adenoma c) Surgical removal of adrenal tumors - d)Resection of ACTH secreting tumors • 2) Manageelectrolytebalance

Answer 52

1) b) Transsphenoidal

Question 53

Outpatient Management: Addison's Disease • 1) Specialist referral 2) Glucocorticoid and mineralocorticoid replacement a) - b) - Fludrocortisone acetate (Florinef)

Answer 53

a) Hydrocortisone

Question 54

Inpatient Management: Addison's Disease• 1) _______ (Solu-Cortef): 100-300 mg IV -initially with NS; replace volume with D5NS at 500 cc /hr X 4 hours and then taper per condition 2) Vasopressors usually ineffective • 3) Treat the underlying cause: Often is an infection

Answer 54

1) Hydrocortisone