Endocrine System Disorders

• Objective:
• The goal is to draw conclusions about common and life-threatening patient disorders associated with the endocrine system.
• Overview of Endocrine Disorders:
• Hypothyroidism
• Hyperthyroidism
• Diabetes
• Diabetic ketoacidosis
• Cushing syndrome

Hypothyroidism

• Indicates a lower level of thyroid hormone circulating in the bloodstream than the body requires for homeostasis.
• The condition is noted by its constellation of symptoms.
• Dysfunction of the thyroid may be related to dysfunction of the hypothalamus, the pituitary, or the thyroid gland itself.
• The most common cause is autoimmune.

Signs and Symptoms

• Symptoms are nonspecific and include cold intolerance, weight gain, fatigue, lethargy, weakness, hair loss, depression, menstrual irregularities, and enlargement of the thyroid gland (goiter).

Physical Exam

• Vital signs may reveal bradycardia.
• Diastolic hypertension is possible.
• Other signs include thin nails, thin hair, peripheral edema, and a palpably enlarged thyroid.

Tools

• Thyroid function tests (TSH/free T4) are used.
• EKG is an option if arrhythmia occurs.

Differential Diagnosis

• Includes hyperthyroidism, mononucleosis, anemia, goiter, and adrenal disease.

Actions

• Routine evacuation is necessary.
• Referral to PCM/Endocrinology as soon as possible.
• The first-line medication is Levothyroxine/Synthroid.
• The goal is to get the TSH between 0.5-5.0mU/L.
• TSH should be repeated in 4-6 weeks.
• ER transfer is only appropriate if evidence of profound hypothyroidism is noted, such as bradycardia, low blood pressure, or arrhythmia.
• Follow-up actions: return immediately if symptoms worsen.

Hyperthyroidism

• Occurs when there is excess thyroid hormone circulating in the blood.
• The most common cause is Graves' disease, an autoimmune disorder.
• Thyroid storm is a variation of hyperthyroidism with severe symptoms potentially leading to coma and death from cardiovascular collapse.

Signs and Symptoms

• Include nervousness, heat intolerance, weight loss, diarrhea, and menstrual irregularities.

Focused History

• Includes family history of thyroid disease, erectile dysfunction, and decreased libido.

Physical Exam

• Vital signs may show tachycardia with arrhythmia.
• Other signs include upper eyelid retraction, lid lag, exophthalmos ("bug-eyed"), fine tremor of the hands, hyperreflexia, and a diffusely enlarged thyroid.

Tools

• EKG is an option if arrhythmia is noted.

Differential Diagnosis

• Includes hypothyroidism, adrenal disease, diabetes, orbital tumor, and thyroid storm.

Actions

• Routine evaluation is helpful if vital signs are normal, but hyperthyroidism is still suspected
• Discuss the preceptor's initiation of an oral beta-blocker (atenolol, metoprolol).
• Referral to PCM/Endocrinology is important when the first opportunity arises.
• Immediate EVAC or transfer should be initiated if in the event of a thyroid storm is noticed
• Supportive care should be administered while awaiting transport.
• Avoid strenuous activity and work should be continued in a cooler environment.
• Return to the clinic for worsening symptoms, heart palpitations, chest pain, or eye pain.

Diabetes Mellitus (DM)

• Type 1 is an autoimmune disease, usually manifesting in childhood, resulting in reduced insulin production.
• Type 2 is a chronic disease, usually of adulthood, resulting in cellular insulin resistance.
• Long term results in vascular disease related to hyperglycemia and inflammation.
• Conditions can be cardiovascular disease, kidney disease, retinopathy, and neuropathy as a result of microvascular disease.

Diabetes Mellitus (DM) Type 1

• Signs and Symptoms include The 3 P's:
• Polyuria (excessive urination)
• Polydipsia (excessive thirst)
• Polyphagia (excessive hunger)
• Additional symptoms for DM Type 1 are weight loss and Malaise.

DM Type 1

• Focused history consists of the following:
• Frequent urination
• Excessive thirst
• Recent illness -Family history of Type 1 DM

DM Type 2

• Signs and Symptoms are most often none
• May have polyuria and polydipsia if serum glucose is very high.

DM Type 2

• The Focused history consists of the following:
• History of hypertension, hyperlipidemia
• Diet and activity

DM Type 1

• Physical Exam:
• Variable vital signs, often present in Diabetic ketoacidosis (DKA) so will have tachycardia and possibly hypotension
• Skin changes (acanthosis nigricans)
• Candidiasis (oral or frequent vaginal infections).

DM Type 1

• Tools:
• Point of care serum glucose should be tested
• Positive ketones and glucose in urine
• CBC, CMP/Blood gas (if available) to help rule out DKA Acutely
• Discuss additional labs to confirm diagnosis of DM Type 1 with your preceptor

DM Type 2

-Physical Exam: Vital signs are likely to be normal except weight (obesity) -Skin changes (acanthosis nigricans) -Candidiasis (oral or frequent vaginal infections)

DM Type 2

• Tools:
• Lab: Point of care serum glucose
• UA: positive ketones and glucose in urine
• Discuss additional “initial screening labs” with your preceptor

DM Type 1

• Differential:
• Sepsis: fever, tachycardia, source of infection
• Hyperthyroidism: tachycardia, hair and nail changes, mental status changes, fever if thyroid storm
• UTI: urinary frequency, urinary urgency, positive nitrites/leukocyte esterase on urine dipstick
• HIV: suspect if severe oral candidiasis is present

DM Type 2

• Differential:
• Often incidental finding, the differential dependent on presenting symptoms
• Thyroid disease: bradycardia 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

DM Type 1

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

DM Type 2

• Immediately EVAC or transfer
• If unable to EVAC or transfer:
• Check BS daily and watch for increasing symptomology
• Low-carbohydrate diet
• Appropriate oral hydration
• DM Type 1
• DM Type 1 This is a life-long problem.
• Strict adherence to medication regimen, diet and exercise can reduce mortality and morbidity
• Carbohydrate counting
• Follow-up Actions: Will be completed per hospital staff

DM Type 2

• 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
• Reduce carbohydrate intake
• Return daily for blood sugar checks, UA dipstick until EVAC or transfer

Diabetic Ketoacidosis (DKA)

• DKA is 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.

DKA

-Signs and Symptoms:

• The 3 P's: polyuria, polydipsia, polyphagia
• Lethargy
• Confusion
• Abdominal pain
• Focused History:
  • Recent illness
  • Weight loss
  • History of diabetes w/nonadherence to med regimen
  • Family history of DM Type 1

DKA

• Physical Exam: -Vital signs: tachycardia, hypothermia, hypotension, rapid and deep breathing -Altered mental status -Acetone “fruity” breath -Abdominal exam may be tender to palpation

DKA

• Tools: -UA: positive ketones and glucose in urine -Fingerstick glucose: 350-900 mg/dL

DKA

• Differential: -Drug overdose: consider environment, exposures -Pancreatitis: PE findings, history, ETOH use -Shock: recent illnesses/exposures -Hyperosmolar hyperglycemic state: non-compliance with medication regimen -Actions: -IV FLUIDS IMMEDIATELY
• Immediately EVAC or transfer
• If unable to EVAC or transfer: -Supportive care (BLS/ACLS) -Insulin if available under preceptor guidance -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.
• Cushing Syndrome is a constellation of symptoms associated with prolonged exposure to corticosteroids.
• Exposure is usually due to supraphysiologic doses of systemic corticosteroids prescribed to treat other medical conditions.
• Cushing's Disease- caused by “endogenous” overproduction of cortisol by the adrenal glands.
• Usually due to a pituitary adenoma (tumor) secreting ACTH.
• May be the result of the adrenal glands secreting cortisol independent of ACTH.

Signs and Symptoms for Cushing Syndrome Early

• Hypertension
• Insomnia -Anxiety, emotional lability, and even frank psychosis
• Fatigue
• Menstrual irregularities
• Hyperglycemia

Signs and symptoms of Cushing syndrome Later

• Truncal obesity
• Purple striae on the abdomen
• Thin skin
• Moon face
• Buffalo hump
• Muscle weakness
• Osteoporosis

Cushing Syndrome

• Focused History: -Corticosteroid use -Headaches -Family history of pituitary disease -Weight gain
• Physical Exam: -Vital signs looking for hypertension -Altered mental status -Skin changes -Body composition changes -Muscle wasting/Weakness

Labs

• Elevated serum glucose
• CBC may show leukocytosis (“demargination" of WBCs)

Differential

-Cushing's disease: consider adenoma, vision changes, headaches, etc. -Cushing's syndrome: current or recent use of corticosteroids -Diabetes: associated high blood sugar, visual disturbances, slow wound healing -Thyroid disease: goiter, tenderness to palpation at base of anterior neck -Electrolyte disturbance: lab findings, mental status

Actions:

• Limit prescribed corticosteroid dose and duration to only what is necessary.
• When higher doses or prolonged durations used, wean patient ("taper”) off steroids:
• Rapid reduction in steroid dose without replacement can cause Addisonian crisis (not enough cortisol)
• f the body is getting steroid from an exogenous source, it will cease production until it is needed again
• If no history of corticosteroid use discuss case with your preceptor -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 or increase dosage without provider consultation -Return if symptoms worsen

Follow up

• Return to clinic in 1 week if no improvement

Summary of Endocrine Disorders

• Hypothyroidism
• Hyperthyroidism
• Diabetes mellitus
• Diabetic ketoacidosis
• Cushing syndrome

Objective

• Draw conclusions about common and life-threatening patient disorders associated with the dental and endocrine body systems.