What do you need to teach patient about taking synthroid?
Do not take with any other medication
What adjustment needs to be made in pregnant person on synthroid?
Need to adjust UP the dose 33%
When is TSH checked after adjustment?
Wait 8 weeks to check after dose adjustment
What is starting dose of adult of synthroid?
What is starting dose of elderly of synthroid?
What does Armour thyroid originate from?
Animal product, pig. Be cautious of religious beliefs.
What does Goiter mean?
Enlarged thyroid gland
What medications can cause chance of hypothyroid disease?
Amiodarone, lithium, interferon
What is the best tests to draw for thyroid assessment?
TSH and FREE T4
Another name for Graves disease?
Graves is a form of thyrotoxicosis hyperthyroidism
What is treatment for graves associated ophthalmopathy?
Diuretics and prednisone. If sever, XRT or surgical decompression
Diseases associated with Graves�?
Other autoimmune disorders: pernicious anemia, DM, MG
What change on CBC is noted in Graves?
What is non-thyroid laboratory abnormalities noted in elevated TSH?
Elevated LDL, Leukopenia, elevated CAD risk
What is most common worldwide cause of hypothyroidism?
Worldwide, it is iodine deficiency
What is myxedema skin disorder?
Abnormal deposits of mucin on skin and cutaneous and dermal edema secondary to increased deposition of connective tissue components in subcutaneous tissue as seen in various forms of hypothyroidism and Graves'
Where is myxedema noted on body?
Pretibial and facial non-pitting edema
Myxedema seen in hyper or hypo thyroid?
Hypothyroidism. Treatment with synthroid may resolve.
What medications will render synthroid inactive?
Iron, calcium, aluminum antacids, carafate
What medications can increase synthroid metabolism and cause drop in T4?
Dilantin, Rifampin, Carbamazepine, Phenobarbital
What thyroid problem can cause gynecomastia?
What thyroid problem can cause thyroid bruit?
Hypothyroidism and pregnancy? When is TSH checked? Dose adjustment needed?
TSH checked every trimester and 6 weeks post partum. Will need 33% increase in dose during pregnancy
Diagnosis of Diabetes fasting blood glucose?
> 126 after 8 hour fast
Diagnosis of Impaired Fasting Glucose?
> 100 after 8 hour fast
Diagnosis of Diabetes Oral Glucose Tolerance Test?
> 200 after 75 Gram Glucose Load
Diagnosis of PreDiabetes Oral Glucose Tolerance Test?
140-199 after 75 Gram Glucose load
Diagnosis of Diabetes based on A1C?
Diagnosis of Pre-Diabetes based on A1C?
A1C 6 to 6.4%
What is the ADAs goal for glucose control A1C?
What is the ADAs goal for glucose control for Fasting glucose?
90-130 after 8 hour fast
What does A1C 7.0 calculate to with average plasma glucose?
What does A1C 10.0 calculate to with average plasma glucose?
When is blood sugar monitored with Insulin Pump therapy?
What is the BIDS therapy for diabetes?
Bed time insulin, Daytime Sulfonylurea
What does hyperinsulinemia due to blood vessels and HTN?
What causes Cushings Disease, rather than syndrome?
Tumor of Pituitary Gland that causes increased ACTH which increases cortisol and adrenal androgens. A Corticotrophic pituitary adenoma.
What can cause Addisonian Crisis?
An Adrenal crisis. Often due to abrupt cessation of long term corticosteroids. Life threatening due to acute adrenal insufficiency.
Signs of Addisonian Crisis?
Severe hypotension, circulatory collapse.
Treatment for Addisonian Crisis?
IVF, IV glucocorticosteroids
What skin manifestation is seen in Addisons disease?
What is caused by long term corticosteroid use?
What happens with long term corticosteroid use to cells and tissue?
See protein catabolism, loss of adipose and lymph tissue. Decreased collagen will cause easy bruising, skin friability and thin/atrophic skin
Cushings syndrome can lead to?
HTN, Insulin resistance, DM
What is visceral neuropathy?
Complication of DM. Causes hand/feel anhidrosis (non-sweat), dysphagia, anorexia, GERD, constipation or diarrhea, pupil constriction
What is Somatic Neuropathy?
Complication of DM. Changes in sensation of feet and hands. Palsy of CN 3 with eye pain headache (cant move eyeballs). Pain or loss of sensation to chest.
Macrocirculation changes in DM?
Early onset of arthrosclerosis, PAD, gangrene
Microvascular changes in DM?
Diabetic retinopathy with retinal ischemia. Vision loss. Nephropathy with HTN. Albuminuria. Edema. Progressive Renal Failure
What happens, pathologically, in the diabetic neuropathy process?
Blood vessel walls of nerves thicken cause less nutrients to get to nerves. Sorbitol forms and accumulates in Schwann Cells and impairs nerve conduction. Demyelization of schwann cells, no nerve insulation- no nerve conduction.
What disease is patient at risk for if they have hyperthyroidism?
Osteoporosis. Treat accordingly and prophylax.
Examples of microvascular DM damage?
Examples of macrovascular DM damage?
CAD, CVA, BV damage
Target organs susceptible to damage from DM?
Eyes, heart, vascular, kidney, peripheral nerves
What is a normal HgA1c?
What is the next step when urine is positive for microalbuminuria?
Perform 24 hour urine for protein/creatinine
What changes are noted in feet sensation with DM?
Loss of vibratory sense, numbness, changes in light/deep touch
Points to tell patient who exercises with diabetes?
Hypoglycemia will be seen later in the day. May need to dose down meds or have snack before exercise.
What percentage of glucose uptake is in muscle?
80%, which increases with exercise.
Specific fundoscopic exam changes in DM?
neovascularization of retina with Microaneurysms.
Secondary causes of hyperglycemia due to medication?
Niacin, Corticosteroids, thiazide diuretics
How does stress affect blood glucose level?
Increase in blood glucose. Stress causes adrenal glands to secrete cortisol, will results in increased gluconeogenesis and insulin antagonism.
How does DM affect estrogen in CAD risk?
DM negates estrogens protective effect
When does DM patient become nephrology consult?
When is ASA given in DM?
For everyone, it is either primary or secondary prevention, depending on other co-morbidities
What is Dawn Phenomenon?
Morning hyperglycemia. At dawn hours (4-8am) normally blood sugar elevates. With insulin resistance, this will results in elevated fasting blood sugar.
What causes Dawn Phenomenon to occur?
Glucagon, GH, Epinephrine and cortisol
What is the Somogyi Effect?
Nocturnal rebound hyperglycemia. Patient becomes hypoglycemic during night and body releases glucagon and cortisol to correct.
What iatrogenic RX is cause of somogyi effect?
Caused by over treating/overdosing insulin at evening or nighttime dose
How is Somogyi diagnosed?
Perform 3am blood sugar check for several weeks.
How is Somogyi treated?
Snack before bedtime, or lower or eliminate NPH evening or bedtime dose.
How often should a Type 2 DM self-monitor their own blood sugar?
Three times a WEEK
What is the inhaled insulin and what would contraindicate its use?
Exubera. Need baseline PFT and contraindicated in smoker, recent smoker, or active lung disease
What is good about the rapid acting, short duration insulins?
They decrease the chance of hypoglycemia between meals and at h.s.
How does the insulin resistant person maintain euglycemia?
Over working the pancreas causing a hyperinsulinemia state to help get more glucose into the resistant cells
Screening for DM?
FBS Q3 years if >45 and no risk factors.
What medications are increased risk for causing heat stroke?
Those drugs that cause negation of bodys attempt to increase cardiac output and vasodilation to decrease temp. TCAs, Bblockers, vasoconstrictors. Other causes are obesity, ETOH, very young and very old.
Life threatening side effects of hyperthermia?
Hyperkalemia, rhabdo, renal failure
What do plant stanols or sterols do?
What does Omega 3 fatty acid do at high doses?
How does physical activity help in diabetes?
Will decrease insulin resistance, increase HDL, and decrease triglycerides
What needs to be present to be diagnosed with metabolic syndrome?
Presence of central obesity within ethnic guidelines, as well as two or more risk factors of Triglycerides >150, HDL <40f <50m, BP >130/>85 or on HTN meds, FBS >100 or on meds
What does IR/MS do to blood vessels and plaque formation?
Contributes to pro-thrombotic and pro-atherogenic state. Also increased levels of PAI, Plasminogen activator inhibitor lead to enhanced clot formation.
What does elevated blood pressure and hyperinsulinemia in Metabolic syndrome do to kidneys?
Leads to increased renal sodium Resorption which increases intravascular volume and increases PVR.
Vascular changes in HTN and Met. Syndrome?
Endothelial dysfunction. Increased vascular smooth muscle, increased responsiveness to angiotensin II and increased sympathetic activation.
What is noted in hypertriglyceridemia?
Most likely person has insulin resistance
Lifestyle changes to help with Insulin Resistance?
These will decrease insulin resistance: Smoking cessation, Exercise, Weight loss,
Weight loss of 1-2 pounds per week can be attained by cutting how many calories?
Deficit of 500-1000 kcal/day
Anti-obesity drugs that cause malabsorption of fat? How are they taken and with side effects are there?
Orlistat (Xenical, Alli) Taken TID with meals. Fat comes out undigested and cause loose stool, GI upset
What are the two classes of Anti-obesity drugs that cause appetite suppression? How do they work and with side effects are there?
Meridia. CNS effect to increase mood and well being and decrease appetite. Elevates neurotransmitters Norepi, Serotonin, and DA. Side effects: dry mouth, constipation, disturbed sleep, HTN. Also sympathomimetics such as dexamphetamine, phentermaine work similarly. Side effects: sleep disturbances, nervousness
What neurotransmitter facilitates satiety?
Who is candidate for obesity surgery?
BMI >40. Or BMI >35 with HTN, OSA, DM, CVD, GERD, DJD, and other therapy has failed
Restricts food and calories ingested. Can lose 50% of excess weight. Low malnutrition risk because food still passes through duodenum.
How does Roux-en Y gastroplasty or Gastric bypass work?
Stomach restriction with duodenum bypass with minimal calorie absorption. Can lead to malnutrition. Can lose 75% of excess weight.
When would you consider screening for T2DM in an adolescent?
Overweight in >85 percentile plus two additional risk factors of physical signs of IR including acanthosis nigricans, HTN, dyslipidemia, PCOS, SGA at birth, +FHx, race, maternal hx of DM or gestational DM.
If a child meets criteria for screening for T2DM, when should it start and how often?
Fasting glucose at age 10 of onset of puberty. Then check every 3 years.