AGACNP ANCC BOARDS- ENDOCRINE Questions and Answers

AGACNP ANCC BOARDS- ENDOCRINE Questions and Answers Metabolic Syndrome- 5 components? 1. waist circumference 40 in (101.6cm) in men 35 in (88.9cm) in women 2. BP 130/85 3. Triglycerides 150 4. Fasting blood glucose 100 5. HDL 40 in men 50 in women Yes to 3/5 component is equal to metabolic syndrome, it means the risk of diabetes is high as well as sudden cardioembolic death Dawn Phenomenon tissues become desensitized to insulin nocturnally and glucose progressively increases overnight "the dawn is rising" Dawn Phenomenon Treatment Increase bedtime insulin dosage Most common arrhythmia encountered in hyperthyroidism AFIB Somogyi Effect nocturnal hypogylecmia stimulating a surge of counter regulatory hormones which increase blood glucose, pt hypoglycemic at 0300 and hyperglycemis at 0700 Somogyi Effect Treatment reduce or omit bedtime isnsulin dose Metformin (Biguanide) Mech: ↓ gluconeogenesis, ↑ glycolysis, peripheral glucose uptake Use: type 2 DM (first line Tox: lactic acidosis (X renal insufficiency) NO weight gain Sulfonylureas glipizide, glyburide, glimepiride MOA- stiumulate the pancreas to secrete more insulin Thiazolidinediones Pioglitazone Rosiglitazone MOA- decrease gluconeogenesis ADR- CHF exacerbation by causing fluid retention DKA Intracellular dehydration 2/2 elevated BG. Diagnostics: BG250, ketonemia/uria, acidosis, hyperkalemia, low HCO3, Low CO2, leukocytosis, hyperosmolality Tx: airway, isotonic fluids, then 1/2 NS, then D51/2NS after BG250. Insulin gtt (0.1U/Kg/hr) HHNKS Hyperosmolar hyperglycemic nonketonic syndrome is a syndrome in which hyperglycemia and hyperosmolarity predominate, with possible alterations of the sensorium. TX- rehydrate and insuling gtt Hyperthyroidism Causes Graves disease (diffuse toxic goiter) is most common. Subacute or painless thyroiditis. Toxic nodular goiter. TSH secreting tumor of the pituitary. High dose amiodarone Hyperthyroidism Diagnostics TSH is decreased (most sensitive test) T3 is elevated ANA is also elevated high idione uptake scan is consistent with Graves disease low idione uptake scan is consistent with subacute thryoiditis Hypothyroidism causes Hashmimotos thyroiditis (#1 cause) primary dz of thyroid gland pituitary deficiency of TSH goiter removed Hyperthyroidism Tx (drugs) Methimazole and PTU Thyroid Crisis Tx PTU Propanolol IV Hydrocortison *avoid ASA on discharge What side effect of levothyroxine is most likely to lead to non-compliance when first initiated? alopecia You are treating a patient for hypothyroidism. Which lab value is monitored for treatment/synthroid effectiveness? TSH Hypothyroidism Sx extreme weakness muscle fatigue cold intolerance dry skin hair loss bradycardia slowed DTRs weight gain cramps Hypohyroidism Tx Levothyroxine 50-100mcg daily TSH increased, T4 down consistent with hypothyroidism Myxedema Coma TX -airway, IV Synthroid, slow rewarming, symptomatic care Cushings ACTH hyper secretion by pituitary, adrenal tumors, chronic glucocorticoids. Sx: obesity, buffalo hump, acne, poor wound healing, hypertension, weakness, frequent infections(steroids decrease inflammatory response). Dx: Hyperglycemia, hypernatremia, hypokalemia, elevated cortisol in AM, dexamethasone suppression test to differentiate. Tx: Determine cause. D/C meds, pituitary adenoma resection, surgical resection of tumors. Addisons Disease Deficiency in coristol, androgens, and aldosterone Triad of labs in Cushings hyperglycemia hypernatremia hypokalemia (due to aldosterone and RASS causing sodium retention and K+ and H+ loss in the nephron at the DCT) Pituitary tumor removal approach: transphenodial resection through the nose Addisons S/S hyperpigmentation in buccal mucosa and skin creases diffuse tanning/freckles orthostatis and hypotension scant axillary/pubic hair Addisons Labs hypoglycemia hyponatremia hyperkalemia elevated ESR plasma cortisol 5mcg/dl @ 8am For the past few months, 29 year old Janine has been gaining weight while experiencing amenorrhea and increasingly severe acne. She has gained more than 20 pounds, and you note that she is carrying her weight around the midline, w/BL purplish striae across both flanks. You suspect Cushing's syndrome. Which of the following findings would not contribute to a Dx? 1-Urine free cortisol = 360 μg/day 2-Glycosuria 3-WBC 19 4- After a high dose of dexamethasone, there is a 90% reduction in urinary free cortisol D- in cushings the pituitary does not respond to dexamethasone *note A- normal urine coristol is 50 Which of the following is not a criteria of Metabolic Syndrome? 1-BP 140/90 2-Waist 40 inches 3-TG 150 4-HDL 40 1- 140/90 (it is 130/85) Addisons Disease/ Cosynotropin Positive Test (ACTH) A rise in cortisol level to greater than 18 ug/dl within 60 minutes demonstrates a normal result. A rise in cortisol to less than 18 ug/dl demonstrates an abnormal response. If the adrenal glands do not adequately stimulate to cosyntropin (ACTH), the patient has suppressed adrenal glands. An elevated baseline ACTH level suggests primary adrenal failure. 24 yo M presents with DKA. Now confused and irritable. ABG Ph 7.29/33/22. Received isotonic fulids x 1 hour, BP 110/70, HR 90. Blood glucose 550. What is the best IV fluid indicated 1/2 NS -the approach is isotonic fluids (NS) 1L in the first hour, then 500mL/hr, if BG is 500 an hour water deficit exceeds sodium loss, so switch to 1/2 NS, when BG drops 250 switch to D5 1/2NS to prevent hypoglycemia HHNKS fluids to use NS for massive fluid volume deficit, then ½ NS to hydrate the cell, then D5 ½ NS if on insulin gtt Which of the following are not included in the initial management of DKA? A-Isotonic fluids B-insulin infusion C-sodium bicarb D supportive care C- SODIUM BICARB Sodium bicarb is only indicated for DKA if pH 7.1 On physical exam you note hyperpigmentation in patients skin creases and buccal mucosa, along with diffuse tanning and freckles all over the body plus scant pubic and axillary hair. Labs NA 132, K 5.2 BG 128 and increase in ESR. What addiitonal lab or diagnostic test would help you pinpoint the diagnosis? 1-dexamethasone suppresion test 2-parthyroid hormone test 3-cosynotropin stim test 3- cosynoptropin stim test (test for Addisons dz) Dexamethasone Suppression Test o Dexamethasone suppression test (DST) § Performance of an overnight 1 mg dexamethasone suppression test will demonstrate a lack of the normal suppression by exogenous corticosteroid (dexamethasone) of adrenal cortisol production. In normal pt, the dexamethasone suppresses the early morning surge is plasma cortisol § Give dexamethasone 1mg at 11pm and check serum cortisol at 8am § Cortisol levels 1.8 mcg/dl is suggestive of CS SIADH -increase ADH & inappropriate water retention -release of ADH occurs independant of osmolality or volume dependant stimulation Etiology: tumors producing ADH (small lung cell ca), skull fractures, head trauma Sx: related to hyponatremia- mild headache, seizures, coma, decrease DTRs Labs- hyponatremia yet euvolemic Serum osmolality 280 (low) Urine Osmolality 100 (increased) urine sodium 20 (intra-renal loss) hypotonic euvolemic hyponatremia SIADH Treatment If serum Na 110 or neuro symptoms present- replace with isotonic or hypertonic saline and furosemide at 1-2mEq/hr (calculated) If serum sodium 120 restrict total fluids to 1L/hr diabetes indipidus (DI) decrease ADH and volume depletion excessive urination and extreme thirst Central- r/t pituitary of hypothalmus damage resulting in ADH insufficiency Nephrogenic: defect in the renal tubules resulting in renal insensitivity to ADH (genetic, pyelonephritis, sick cell anemia, K+ depletion, meds like lithium) Sx- thirst, craves water (fluid intake 5-20L/day), poluria, tachycardia, hypotension, dizziness, weight loss Labs- hypernatremia serum osmolality 290 urine osmolality 100 urine specific gravity 1.005 (normal 1.010-1.030) Central Diabetes Insipidus Diagnostic Approach- Desmopressin Test Desmopressin challenge test 0.05-0.1 ml nasally or 1g SQ or IV with measurement of urine volume; test is positive in central DI (urine osmolality increases after the challenge) and negative in nephrogenic DI No apparent cause, order MRI to see if theres a tumor DI treatment NA 150: give D5W IV and replace 1/2 volume deficit in 12-24 hrs When Na 150 switch to 1/2NS or .9NS DDAVP in acute situations maintenance dose of DDAVP is 10ug q12-24 hrs intra-nasally Urine Na 128, serum osmo 250, urine osmo 115. What is the suspected cause? SIADH Pheochromocytoma a benign tumor of the adrenal medulla that causes the gland to produce excess epinephrine & norepi -hypertension -labile BP -diaphoresis Pheochromocytoma Diagnostics -order TSH first** intial test, it will be normal -plasma free metanephrines (fastest test) -assay of urine catecholamines, metanephrines, and VMA -CT scan of adrenals to confirm and localize tumor