Transcript peiris---diabetes-kingpin-presentations-mod

Endocrine &
Diabetes Quiz
Kelli Jones RN, CDE
Tammy Monk FNP
The Diabetes Unit
Mountain Home VAMC
Introduced by
Alan Peiris MD(Lon), FRCP(Lon)
“Nothing will ever be
attempted if all possible
objections must first be
overcome”
Samuel Johnson (1709-1784)
Sean
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40 year old male
BMI 30 kg/m2
Type II Diabetes
Meds
 Breakfast: insulin aspart 10 units
 Lunch: insulin aspart 10 units
 Supper: insulin aspart 10 units
 HS Glargine 35 units
8 am
1 pm
6 pm
10:30pm
110
300
280
156
126
210
286
145
130
267
217
196
Sean
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Problem: High Blood Sugars After Meals
Possible Causes
 Too much carbohydrates at meals
 Not enough insulin with meals
 Insulin to carbohydrate ratio is wrong
 Not counting carbohydrates correctly
 Not using insulin: Forgetting
 Site of injection
 Snacking before lunch or dinner
Which of the following treatment options
would you consider for Sean?
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A.
B.
C.
D.
Increase glargine dose by 2 units.
Increase aspart with breakfast and lunch
Decrease glargine dose.
No changes are warranted
Sean
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Options
Increase the aspart insulin before breakfast/lunch
 Increase the insulin to carbohydrate ratio
 Decrease a carbohydrate at breakfast/lunch
 Increase activity after breakfast and lunch

Dorothy
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59 year old female
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Gestational diabetes
Fatigue
Sedentary
Family history of Diabetes
BMI: 31
Type II Diabetes
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FPG: 145 mg/dl
A1C: 8.5 %
Meds
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None
Dorothy
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•
•
•
•
Considerations:
Should she be started on one or two medications for
diabetes?
Significance of gestational diabetes?
Does her weight influence therapy?
What % of gestational diabetics will develop diabetes
- 53% in 8 years
What would be the most appropriate initial
therapy for Dorothy?
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A. Advise strict diet and exercise
B. Initiate insulin glargine 20 units at bedtime.
C. Implement lifestyle modification counseling
& start her on metformin only.
D. Implement lifestyle modification counseling
& consideration of combination therapy with
two oral agents.
Jim
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72 year old male
Unable to exercise: Joint pain
BMI: 36
Type II diabetes
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A1C: 8.0%
Meds
 Metformin 850mg tid
 Glipizide 10mg bid
8 am
6 pm
186
90
210
132
156
128
What other data would be helpful to determine
the best treatment options for Jim?
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A. Glucose readings before meals and bedtime.
B. A 2-3am blood sugar within the last month
C. A 3-5 day food diary
D. Both B and C
Once nocturnal hypoglycemia is ruled out what
would be the best treatment recommendation?
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A. Increase glipizide to 20mg twice a day
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B. Start a basal dose of insulin such as glargine or
detemir.
C. Consider a third oral hypoglycemic agent.
D. No medication change is warranted.
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
Callie
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24 year old female
Fever/Weight loss
 Recent confusion
 N/V & abd pain
 Muscle cramps
 Heat intolerance
 Nervousness
 Fatigue
Height: 5’4”
Weight: 122 lbs
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Signs
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Medical History
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Tachycardia- 140 bpm
Basal crepitations
LE edema
Fine Muscle Tremor
Disoriented
Goiter
Family History
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Hashimotos thyroiditis
Callie
What would be the best plan of care?
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A. Direct admit to ICU.
B. Obtain TSH, Free T4 and admit to med-surg
floor.
C. Obtain TSH, Free T4 only
D. Obtain TSH, Free T4 and direct admit to
ICU and supportive care
Callie
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Assessment: Thyroid Storm
Plan
Admit to ICU
 TSH, Free T4 and T3
 Treatment should not be delayed
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
Mortality rates can be as high as 10-30%
Jody
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65 year old Female
Complaints:
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Swelling All over
Dry Skin
Dry Hair
Height: 5’6”
Weight 200 lbs
Signs
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Non pitting edema
Puffy Face
Periorbital edema
Lips swollen
Coarse facial features
Coarse Hair and eyebrows
Medical History
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Thyroid Surgery
Jody
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Physical Exam
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Thyroid scar at the base of neck
Lethargic
Hypotensive
Bradycardia
Hypoventilation
What would be your plan of care?
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A.
B.
C.
D.
E.
Obtain TSH, Free T4 and cortisol level
Obtain chest x-ray and EKG
Admit to ICU
A and C
A, B and C
Assessment
Myxedema
Coma
Plan
 TSH
 Free
T4
 Cortisol
 Admit to ICU
Tommy
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74 year old male
Complaints
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Anorexia
Nausea
Vomiting
Abdominal Pain
Generalized weakness
Fatigue
Lethargy
Fever
Wife notes seems confused
Height: 5’10”
Weight: 200 lbs
Tommy
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Signs: Weight Loss
Medical History:
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Recent Sepsis from UTI
Physical Exam:
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Weight loss 12 lbs
BP 92/54 Sitting
BP 84/50 Standing
Hyperpigmentation
Abdominal Tenderness
What diagnosis do you suspect?
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A.
B.
C.
D.
Hypoglycemia
Metabolic acidosis
Primary Adrenal Insufficiency
DKA
Assessment: Suspected acute adrenal insufficiency
with hemodynamic decompensation
 Plan:
 Obtain
ACTH,
cortisol, renin
and aldosterone.
 Volume Supportfluids
 Corticosteroids
James
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54 year old male
Complains:
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Headache
Sweating
Heart racing
Height: 6’0”
Weight: 159 lbs
Signs: Elevated blood
pressure & Tachycardia
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Medical History: panic attack,
tremor, recent abnormal
blood sugar elevation
Physical Exam: Orthostatic
Hypotension and Weight
Loss
Besides hypertensive emergency what
endocrine disease would you suspect?
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A.
B.
C.
D.
Pheochromocytoma
Hyperthyroidism
Myxedema
Hyperparathyroidism
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Dx of
pheochromocytoma
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

Plan:
24 Urine Metanephrines
Plasma Metanephrines
BJ
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63 year old
Complaints:
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Headache
Diplopia
Vision Changes
Fatigue
Loss of consciousness per
family
“Face looks different”
Height: 5’10”
Weight: 170 lbs
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Signs
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Ocular Paralysis and
Ptosis
Facial Nerve Paralysis
Medical History
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“Years ago was told had
small pituitary adenoma
but no imagining in 8
years or so”
What do you suspect would be the cause of the
above symptomatology?
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A.
B.
C.
D.
Complicated migraine
Hypertension
Meningeal Inflammation
Pituitary Apoplexy
Asessment : Pituitary
apoplexy,
panhypopituitism,
hemodynamic
decompensation
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Plan: Admit
Intravenous
hydrocortisone
Stat neurosurgery consult
Visual Fields
Hormone assessment
Michael
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78 year old male
Seen in ER with
complaints of Thirst
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Polyuria
Polydipsia
BMI: 31
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Signs
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Appears Ill and
dehydrated
Medical History
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HTN
Obesity
Diabetes
Michael
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Physical Exam
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Elderly male ill appearing,
altered mental status
Depressed reflexes
Dehydrated
Glucose 786 mg/dl
What is your initial management for this pt?
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A.
B.
C.
D.
E.
Fluid and electrolyte replacement
Insulin replacement
Labs to include electrolytes, ABG, EKG
Assess for causes
All of the above
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Assessment:
Hyperosmolar
Nonketotic Syndrome
(HHNS) or newly named
Hyperosmolar
Hyperglycemic
State(HHS)
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Plan
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CMP
CBC
UA/ C&S
EKG
Hydration
Insulin
Electrolyte replacement
Determine precipitating
factors
Bob
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57 year old male
Complaints:
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Unable to exercise
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“use to walk/jog 2-3 miles daily”
Awaiting knee replacement once A1C has improved
Height: 5’11”
Weight 322 lbs
BMI: 44.9
Type 2 diabetes
AIC: 8.8%
Bob
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Medications
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Glargine 75 units twice a
day
Aspart 55 units with meals
plus AC/HS correction
scale
Patient stopped
Metformin due to
diarrhea
Patient prefers not to be
on Pioglitazone due to
history of bladder cancer
h/o acute pancreatitis x2
FBS
212
199
PrePreLunch Dinner
175
192
168
212
HS
220
190
What changes in therapy should
be made at this point?
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A. Implement intensive counseling related to
lifestyle changes.
B. Increase glargine insulin and insulin aspart by
10%
C. Consider conversion to concentrated U-500
Regular insulin.
D. Add exenatide
E. A and C
Bob
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Problems:
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No physical activity
High insulin requirement without adequate glycemic control
Clearly insulin resistant
Options:
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Patient needs to consider seated exercises.
Exenatide may be contraindicated due to pancreatitis
Metformin extended release may be tolerated
Bladder cancer is a very slight, but real risk with pioglitazone
Consider conversion to concentrated U-500 Regular Insulin
Correction scale should be strengthened based on ISF
Bob
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Current Correction Scale
Blood
Glucose
BG<200
Aspart
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New Correction Scale
None
Blood
Glucose
BG<200
Aspart
None
201-250
2 units
201-250
4 units
251-300
4 units
251-300
8 units
301-350
6 units
301-350
12 units
351-400
8 units
351-400
16 units
BG>400
10 units and
call
BG>400
20 units and
call
Bob
Part 2
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57 year old male
Height: 5’11”
Weight: 322
BMI: 322
Type 2 Diabetes
A1C: 8.8%
Could not afford gas to
exercise at community
swimming pool
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Meds
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Tried Metformin
extended release –
Diarrhea returned
Does not want to try
Pioglitazone
Glargine 75 units twice a
day
Aspart 55 units with three
main meals plus AC/HS
correction scale
Bob
Part 2
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Problems
 High insulin requirement without adequate glycemic control
 Clearly insulin resistant
Option/Plan
 Patient accepts conversion to concentrated U-500 Regular
Insulin
 Smaller volume of U-500 insulin may be absorbed more
effectively
 TB syringes recommend with dosing in mLs
 Insulin pen device recommended for Aspart correction scale
to avoid U-100 syringes in home
 U-500 Dose could be initiated at a 20% reduction of TDD
and divided over 2-4 doses
James
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34 year old
Complaints:
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Facial twitching
Numbness
Tingling
Muscle cramps and
fasciculations
Irritability
“Just not myself”
Height: 5’9”
Weight: 159 lbs
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Signs:
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Medical History
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Facial Twitching
Forearm Spasms
Recent thyroid surgery for
a large goiter
Vitamin D deficiency
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(quit taking supplements)
James
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Physical Exam
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Positive Chvostek’s Sign
Positive Trousseau’s Sign
How do albumin and serum
calcium levels interact?
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A. A change in serum albumin of 1Gm/dL
changes serum calcium in the same direction by
0.8mg/dL.
B. No association
C. A decrease serum albumin increases calcium.
D. A increased serum albumin decreases
calcium.
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Assessment
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Hypocalcemia
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Plan
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Calcium
Magnesium
Albumin
Ionized Calcium
Intact PTH
Serum phosphorus
Creatinine
Andrew
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59 year old
Complaints:
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Lethargy
Mental Changes
Anorexia
Nausea
Constipation
Weakness
Arthralgias
Myalgias
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Height: 5’8”
Weight 170 lbs
Medical History
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Nephrolithiasis
HTN- on HCTZ
Andrew
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Physical Exam
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Lethargic
Weak
Monitor in ER shows short
QT interval
Possible etiologies for
hypercalcemia are:
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A. Hyperparathyroidism
B. Vitamin D intoxication
C. Malignancy
D. Prolonged immobilization & Thiazide
diuretics
E. All of the Above
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Assessment
 Hypercalcemia
Suspected
Plan
 Lab work
 Look for underlying
etiology but suspect
hyperparathyroidism
 Normal Saline for
hydration initially
 Steroids? Calcitonin?
 Bisphosphonates?
Nicholas
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19 year old male
Seen in ER for
Complaints of
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Thirst
Increased urination
Fatigue
Weight loss
Blurry vision
Height: 5’8”
Weight: 125 lbs
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Signs
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Rapid Breathing
Vomiting
Breath acetone odor
Medical History
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Upper Respiratory
Infection and possible flu
several weeks ago
Otherwise healthy
Nicholas
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Physical Exam
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Ill appearing young adult
Assessment: DKA
Plan
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Labs
Electrolytes
BUN and Creatinine
Glucose
Urinalysis
EKG
ABG’s
Start I and O flow sheet
What is the most critical concept for
DKA management?
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
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
A.
B.
C.
D.
E.
Fluid management
Insulin Management
ICU admission
Frequent lab monitoring
All of the Above
What is the spot diagnosis for this patient?
References
Diabetes Teaching Center at the University of California. 2013. [Diabetic Ketoacidosis]. Retrieved
from http://dtc.ucsf.edu/living-with-diabetes/complications/diabetic-ketoacidosis/
Health Center. n.d. [Insulin Syringe]. Retrieved from
http://www.healthcentral.com/diabetes/cf/slideshows/the-best-ways-to-avoid-high-bloodsugars/bolus-early-and-accurately-for-everything-you-eat/?ic=obnetwork
Medical Mystery. 2012. [Chovostek’s Sign]. Retrieved from
http://www.medicalmystery.org/chvosteks-sign/
Medical Mystery. n.d. [Trousseau Sign]. Retrieved from http://www.medicalmystery.org/trousseausign/
Medicine Net. 2007. [Parathyroid Gland]. Retrieved from
http://www.medicinenet.com/hyperparathyroidism/article.htm
National Institute of Diabetes and Digestive and Kideny Diseases. 2009. [Adrenal Insufficiency and
Addison's Disease]. Retrieved from http://endocrine.niddk.nih.gov/pubs/addison/addison.aspx
Nursing Crib. 2012. [Myxedema Coma]. Retrieved from http://nursingcrib.com/critical-care-andemergency-nursing/myxedema-coma/
Scripps Health. 2011. [Eyes-Bulging]. Retrieved from http://www.scripps.org/articles/3267-eyesbulging