ahd group a rounds february 14, 2013 endocrine emergencies thyroid, adrenal, diabetic dr. gary...
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AHD Group A RoundsFebruary 14, 2013
Endocrine EmergenciesThyroid, Adrenal, Diabetic
Dr. Gary Greenberg MD FRCP EM
Objectives
• Review the common causes, clinical signs, symptoms, pathophysiology and management of the following metabolic emergencies related to thyroid disease states, adrenal insufficiency and diabetes:
• Thyrotoxicosis, thyroid storm, myxedema coma, adrenal crisis, non ketotic hyperglycemic hyperosmolar state and diabetic ketoacidosis, hypoglycemia, New onset diabetes, diabetic complications.
Case Example
• 32 yo female presents with new onset of fatigue, palpitations, tremor, anxiety, insomnia, exertional dyspnea, 20 lb wt loss.
• PHX: Appendicitis. Meds: none Allergies: none• Examination: thin, anxious, BP 140/60, P 120
regular, EOM normal, no proptosis but has non tender thyroid enlargement, no nodules.
• Chest/CVS/Abdomen all normal. Fine tremor outstretched hand, reflexes brisk.
These are other symptoms of hyperthyroidism except
• A) Heat intolerance.
• B) Fever
• C) Diarrhea
• D) Reduced appetite
Which is the most common cause of hyperthyroidism at age < 50 ?
• A) Hashimotos Thyroiditis
• B) Graves Disease
• C) Multinodular Goiter
Graves Disease- Common findings except
• A) Pretibial myxedema ( mucopolysaccharide deposition ).
• B) Ocular Abnormalities ( lid lag, proptosis, diplopia).
• C) Thyroid Bruit
Tenderness of the thyroid gland is indicative of
• A) Graves Disease
• B) Hashimotos Thyroiditis
• C) Subacute Thyroditis
The following can induce hyperthyroidism except
• A) Seaweed ingestion B) IV Contrast agents• C) Potato chips• D) Amiodarone• E) Lithium
The following tests should be done in suspected thyrotoxicosis except
• A) TSH, Free T4, T3 levels.
• B) Thyroid ultrasound
• C) Thyroid nuclear scan
A thyroid scan in Graves Disease will show
• A) Decreased uptake of radioactive iodine
• B) Patchy uptake with hot nodules
• C) Diffuse uptake
Initial treatment of thyrotoxicosis may include the following except
• A) Dexamethasone
• B) Propanolol
• C) Antithyroid drugs ( Propylthiouracil/ Methimazole )
• D) Radioactive Iodine ablation
Thyroid Storm requires all of the following findings except
• A) Fever
• B) Tachycardia
• C) Altered Mental Status
• D) Diarrhea
The overresponsiveness of the sympathetic nervous system is due to
• A) excessive circulating catecholamines
• B) Excessively elevated serum T3,T4 levels
• C) Unknown
Treatment of Thyroid Storm includes all except
• A) Treatment of fever• B) Supportive measures• C) Increase levels of thyroid stimulating hormone• D) Inhibit Thyroid hormone synthesis and release• E) Inhibit peripheral conversion of T4 to T3• F) Reduce thyroid hormone effects on adrenergic
state
CASE
• 62 year old patient with long standing Grave’s Disease, had onset of fever, cough for 2 days. Presents with agitation, nausea, vomiting, Temp. 38.2, HR 125/min, pedal edema.
• Does this patient have Thyroid Storm or just Pneumonia?
Common causes of Primary Hypothyroidism are the following except
• A) Antithyroid drugs
• B) Autoimmune Disorders
• C) Previous radioactive Iodine treatment of Graves Disease
Classic Presentation of Hypothyroidism includes all except
• A) Cold intolerance• B) Weight gain• C) Dry puffy skin around the eyes.• D) Galactorrhea• E) Slow movements
These lab tests are helpful in Hypothyroidism except
• A) T 3 level
• B) T4 level
• C) Elevated cholesterol
• D) TSH
These are found in Myxedema Coma except
• A) Temperature is often < 32 degrees C.
• B) Patients often shiver.
• C) Dysfunction of Thermoregulatory Center.
All are important tests to do in Myxedema Coma except
• A) Chest x-ray• B) EKG• C) ABG• D) Serum Calcium• E) Serum Cortisol• F) CK
All are part of the Diff. Dx of Myxedema Coma except
• A) Hypothermia.• B) Respiratory failure.• C) CO2 Narcosis.• D) Hyponatremia.• E) Cocaine overdose.• F) CHF• G) Stroke• H) Narcotic overdose• I) Hypoglycemia
All the following are causes of Primary Adrenal Insufficiency except
A) Idiopathic- ( autoimmune adrenalitis)B) Infiltrative disease ( Sarcoid )C) Adrenal Hemorrhage/ InfarctD) Steroid therapyE) Granulomatous infectious ( TB, Fungal )F) Metastatic involvement ( lung, breast, colon)G) Bilateral Adrenalectomy
All the following are causes of Secondary Adrenal Insufficiency except
A) Chronic suppression by exogenous steroids.B) Ingestion of Rifampin.C) Withdrawal of steroids too rapidlyD) Head traumaE) Hypothalamic tumorsF) Pituitary tumors
All may be found in Primary Adrenal Insufficiency except
• A) Hyperpigmentation of palms, creases, nipples.
• B) Stiff ears with hard nodules in males.
• C) Long toe nails.
Adrenal Crisis
• The following are present except:• A) Hyponatremia• B) Hyperkalemia• C) Hypercalcemia• D) Hypoglycemia• E) Azotemia ( BUN )• F) Metabolic Alkalosis• G) Low voltage EKG
Case
• 50 year old male , presents with new onset of diabetes- weight loss, polyuria, polydypsia, increased appetite, fatigue.
• Blood glucose 22.0, no acidosis, no ketones in the urine.
• VS stable
NEW ONSET DIABETES
• How would you treat the newly diagnosed diabetic in the ED?
• What choice of Medications do you have?• How do those medications work?
Diabetic Ketoacidosis
Describe the key findings of Diabetic Ketoacidosis and how are they manifested Physiologically?
Common factors for DKA -except
• A) Infection• B) MI• C) Stroke• D) Cocaine use• E) Hyperthyroidism• F) Pancreatitis• G) Trauma• H) Non compliance with Insulin in diabetic
DKA
• Discuss the treatment rational for the use of • A) Insulin• B) Sodium Bicarbonate• C) Potassium• D) IV fluid
Excessive NaHCO3 administration can lead to all but
• A) Spinal Fluid Alkalosis.• B) Hypokalemia• C) Impaired O2 / Hb dissociation• D) Rebound Alkalosis• E) Na overload.
Precipitants can be any of the following except
• A) Pneumonia• B) MI• C) Stroke• D) Pulmonary Embolus• E) Pancreatitis• F) Water intoxication• G) GI bleed• H) Medications ( Thiazides, dilantin, lasix)
NKHHC
• What is the difference in treatment of the Non Ketotic Hyperglycemic Hypersomolar patient vs the DKA ?
HYPOGLYCEMIA- The following are causes of hypoglycemia except
• A) Alcohol.• B) ASA.• C) Hemodialysis.• D) Lack of caloric intake.• E) Sulfonylureas.• F) Gastroparesis• G) Insulinomas
Signs and Symptoms of Hypoglycemia are except:
• A) Sweating.• B) Increased urination• C) Weakness.• D) Confusion.• E) Anxiety• F) Tachycardia