Endocrine Disorders: Hypo/Hyperthyroidism, Diabetes

• Unit 5 discusses common and life-threatening endocrine disorders.
• The objective is to draw conclusions about common and life-threatening patient disorders associated with the endocrine system.

Overview of Endocrine Disorders

• Hypothyroidism is a condition where the thyroid gland doesn't produce enough thyroid hormone
• Hyperthyroidism is a condition where the thyroid gland produces too much thyroid hormone.
• Diabetes is a metabolic disorder characterized by high blood sugar levels.
• Diabetic ketoacidosis is a serious complication of diabetes that occurs when the body produces excess blood acids (ketones).
• Cushing syndrome is a hormonal disorder caused by prolonged exposure of the body's tissues to high levels of the hormone cortisol.

Hypothyroidism

• Lower levels of thyroid hormone circulate
• Homeostasis is affected
• Diagnosed by a constellation of symptoms
• Thyroid dysfunction may relate to issues with the hypothalamus, pituitary, or the thyroid gland itself
• The most common cause of hypothyroidism is autoimmune

Hypothyroidism: Signs and Symptoms

• Symptoms are nonspecific
• Cold intolerance is a common symptom
• Weight gain is another symptom
• Fatigue and lethargy are often experienced
• Weakness and hair loss are further symptoms
• Depression and menstrual irregularities may occur
• Enlargement of the thyroid gland (goiter) can be present

Hypothyroidism: Physical Exam & Tools

• Common vital sign is Bradycardia
• Diastolic hypertension is possible
• Thin nails and hair are typical
• Peripheral edema may be observed
• Palpably enlarged thyroid may be present
• Recommended tools are thyroid function tests (TSH/free T4), and EKG if arrhythmia is noted

Hypothyroidism: Assessment

• Differentials to consider include hyperthyroidism, mononucleosis, anemia, goiter, and adrenal disease.
• Hyperthyroid presents with tachycardia and weight loss
• Mononucleosis presents with abdominal pain and swollen tonsils
• Anemia presents in female patients, heavy cycles, and recent blood loss
• Goiter presents with poor diet in developing nations
• Adrenal disease presents with unusual tanning of the skin, hypotension, and weight loss

Hypothyroidism: Plan & Education

• Routine evacuation is needed
• Referral to PCM/Endocrinology at the first opportunity is required
• First-line medication is Levothyroxine/Synthroid, and the goal is to achieve a TSH between 0.5-5.0mU/L
• Repeat TSH should be tested in 4-6 weeks
• Evacuate or transfer to ER if profound hypothyroidism is observed, indicated by bradycardia, low blood pressure, or arrhythmia
• Return if symptoms worsen

Hyperthyroidism: Introduction

• There is excess thyroid hormone circulating in the blood
• A common cause is Graves’ disease, an autoimmune disorder
• Thyroid storm is a severe form of hypothyroidism potentially leading to coma, death, and cardiovascular collapse

Hyperthyroidism: Subjective & Focused History

• Signs are nervousness and heat intolerance
• Other signs are weight loss and diarrhea
• Menstrual irregularities may occur
• Family history of thyroid disease is relevant
• Erectile dysfunction and decreased libido may be present

Hyperthyroidism: Objective

• Tachycardia w/arrhythmia may be present or likely
• Look for the upper eye lid retraction and lid lag
• Exophthalmos ("bug-eyed") may be observed
• Fine tremor of the hangs may be present
• Hyperreflexia and diffusely enlarged thyroid may occur
• Consider EKG if arrhythmia noted

Hyperthyroidism: Assessment

• Hypothyroidism presents weight gain and bradycardia
• Adrenal disease presents skin tanning, weight loss and hypotension
• Diabetes often co-exists with thyroid disease
• Orbital tumor is another consideration if exophthalmos is present
• Thyroid storm presents with marked tachycardia, delirium, and fever

Hyperthyroidism: Plan and Education

• Routine evacuation is required if vitals are normal, but hyperthyroidism is suspected
• Discuss with preceptor initiation of oral beta-blocker (atenolol, metoprolol)
• Refer to PCM/Endocrinology at first opportunity
• Immediate EVAC or transfer is required if thyroid storm is evident
• Supportive care needed while awaiting transport
• Avoid strenuous activity
• Work should be in a cool environment
• Return to clinic for worsening symptoms, heart palpitations, chest pain, and eye pain

Diabetes Mellitus: Introduction

• Type 1 diabetes is typically an autoimmune disease usually manifesting in childhood, resulting in reduced insulin production
• Type 2 diabetes is a chronic disease, usually of adulthood, resulting in cellular insulin resistance
• Long term results in vascular disease, related to hyperglycemia and inflammation
• Cardiovascular disease and kidney disease, retinopathy, and neuropathy are a result of microvascular disease

Diabetes Mellitus (DM) Type 1: Signs, Symptoms, & History

• Common signs and symptoms include the "3 P's": polyuria, polydipsia, and polyphagia and malaise
• Polyuria is excessive urination
• Polydipsia is excessive thirst
• Polyphagia is excessive hunger
• Weight loss
• Focused history may include frequent urination, excessive thirst, recent illness, and family history of DM

Diabetes Mellitus: Subjective

• DM Type 2: Signs and Symptoms
• Often none
• May have polyuria and polydipsia if serum glucose very high
• DM Type 2: Focused History
• History of hypertension, hyperlipidemia
• Diet and activity

Diabetes: Objective, DM Type 1

• Vital signs are variable, often present in Diabetic ketoacidosis where you will see tachycardia and possibly hypotension
• Skin changes (acanthosis nigricans) may occur
• Candidiasis (oral or frequent vaginal infections)
• Labs- Point of care serum glucose, UA: positive ketones and glucose in urine
• Acutely: CBC, CMP/Blood gas (if available) to help rule out DKA
• Discuss additional labs to confirm diagnosis of DM Type 1 with your preceptor

Diabetes: Objective, DM Type 2 Tools

• Vital signs are likely to be normal except weight (obesity)
• Skin changes (acanthosis nigricans)
• Candidiasis (oral or frequent vaginal infections)
• Tools- Lab: Point of care serum glucose; UA: positive ketones and glucose in urine, Discuss additional “initial screening labs” with your preceptor
• Hemoglobin A1c, Lipid panel, Liver function tests

Diabetes: Assessment, DM Type 1

• A differential diagnosis to consider is Sepsis (fever, tachycardia, source of infection)
• Hyperthyroidism may have tachycardia, hair and nail changes, mental status changes, or fever if thyroid storm
• UTI may be present (urinary frequency, urinary urgency, positive nitrites/leukocyte esterase on urine dipstick)
• HIV should be considered with severe oral candidiasis

Diabetes: Assessment, DM Type 2

• Often incidental finding, differential dependent on presenting symptoms
• Thyroid disease: brady or tachycardia, goiter, eye findings
• UTI: urinary frequency, urinary urgency, positive nitrites/leukocyte esterase on urine dipstick
• HIV: suspect if severe oral candidiasis is present

Diabetes: Plan, DM Type 1

• Immediately EVAC or Transfer
• If unable to EVAC or Transfer- IV with fluid hydration immediately and Insulin if available and under preceptor guidance and Follow ALS protocols

Diabetes: Plan, DM Type 2

• Immediately EVAC or Transfer
• If unable to EVAC or Transfer, Check BS daily and watch for increasing symptomology, Provide a Low-carbohydrate diet and Ensure Appropriate oral hydration

Diabetes: Education

• DM Type 1- This is a life-long problem and requires strict adherence to medication regimen, diet and exercise can reduce mortality and morbidity and require Carbohydrate counting
• Follow-up Actions Will be completed per hospital staff
• DM Type 2- This is likely to be a life-long problem
• Strict adherence to medication regimen, diet and exercise can reduce mortality and morbidity; lose weight and reduce carbohydrate intake
• Return daily for blood sugar checks, UA dipstick until EVAC or transfer

Diabetic Ketoacidosis (DKA): Introduction

• An emergent, life-threatening complication of diabetes mellitus that can lead to coma and death
• DKA occurs when body cells are unable to use glucose for energy and resort to the metabolism of fat to create energy

DKA: Signs, Symptoms and History

• Signs and Symptoms: The 3 P’s: polyuria, polydipsia, polyphagia; lethargy, confusion, and abdominal pain
• Focused History contains Recent illness, weight loss, history of diabetes nonadherence to medication regimen, and Family history of DM Type 1

DKA: Objective, Physical Exam & Assessment

• Common physical exam findings are Tachycardia, hypothermia, hypotension, rapid and deep breathing; Altered mental status, Acetone “fruity” breath, and abdominal exam may be tender to palpation
• Tools needed are a UA: positive ketones and glucose in urine and a fingerstick glucose: 350-900 mg/dL
• It is important to consider the differential diagnosis of Drug overdose including environment and exposures; Pancreatitis noting PE findings, history, and ETOH use/ Shock and recent illnesses/exposures/ Hyperosmolar hyperglycemic state- non-compliance with medication regimen

DKA: Plan and Education

• Deliver IV FLUIDS IMMEDIATELY
• Immediately EVAC or transfer and if unable to EVAC or transfer- Provide Supportive care (BLS/ACLS), offer Insulin if available under preceptor guidance, and Keep patient in clinic under supervision
• Follow-up Actions- EVAC or transfer, treat as appropriate

Cushing Syndrome

• "Syndromes” are constellations of symptoms that suggest the presence of a disease process and includes Cushing Syndrome a constellation of symptoms associated with prolonged exposure to corticosteroids
• Exposure is usually due to supraphysiologic doses of systemic corticosteroids
• Cushing’s Disease is caused by “endogenous” overproduction of cortisol by the adrenal glands often due to a pituitary adenoma (tumor) secreting ACTH or may be the result of the adrenal glands secreting cortisol independent of ACTH

Cushing Syndrome: Signs, Symptoms & History

• Cushing Syndrome contains a wide range of Signs and Symptoms including hypertension and mood or personality disorder/changes Early signs include headache, insomnia, anxiety, fatigue hyperglycemia and weight gain Later Signs include Truncal obesity, Purple striae on the abdomen, Thin skin, Moon face, Buffalo hump, Muscle weakness, Osteoporosis, and headache Focused History should include-Corticosteroid use and if there is a Family history of pituitary disease

Cushing Syndrome: Objective, Physical Exam & Labs

 - Vital signs will be looking for hypertension/ Look for Altered mental status/ Skin changes and Body composition changes; may see Muscle wasting/Weakness
 - Elevated serum glucose Labs: Includes Elevated serum glucose and CBC may show leukocytosis ("Demargination" of WBCs)

Cushing Syndrome: Assessment, Plan & Education

     - Primary differential diagnosis contains Cushing’s disease so consider adenoma, vision changes, headaches, etc./ Consider that this may be Current or recent use of corticosteroids
     - Other differentials diagnoses are Diabetes, Thyroid disease, and Electrolyte disturbance

• To Plan it is important to Limit prescribed corticosteroid dose and duration to only what is necessary or wean patient from drug; consider causes if there is no history
• If no history of corticosteroid use, discuss your findings with the preceptor; the patient will likely require a work up to include specialized labs and imaging studies - For Education Limit prescribed corticosteroid dose and duration to only what is necessary / will likely require work up to include specialized labs and imaging studies/ EVAC or transfer; refer to PCM/Endocrinology when feasible - Do not self-prescribe steroids - Return to clinic in 1 week if no