1. AHD Group A Rounds February 14, 2013 Endocrine Emergencies Thyroid, Adrenal, Diabetic Dr. Gary Greenberg MD FRCP EM

2. 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.

3. 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.

4. These are other symptoms of hyperthyroidism except A) Heat intolerance. B) Fever C) Diarrhea D) Reduced appetite

5. Which is the most common cause of hyperthyroidism at age < 50 ? A) Hashimotos Thyroiditis B) Graves Disease C) Multinodular Goiter

6. Graves Disease- Common findings except A) Pretibial myxedema ( mucopolysaccharide deposition ). B) Ocular Abnormalities ( lid lag, proptosis, diplopia). C) Thyroid Bruit

7. Tenderness of the thyroid gland is indicative of A) Graves Disease B) Hashimotos Thyroiditis C) Subacute Thyroditis

8. The following can induce hyperthyroidism except A) Seaweed ingestion B) IV Contrast agents C) Potato chips D) Amiodarone E) Lithium

9. The following tests should be done in suspected thyrotoxicosis except A) TSH, Free T4, T3 levels. B) Thyroid ultrasound C) Thyroid nuclear scan

10. A thyroid scan in Graves Disease will show A) Decreased uptake of radioactive iodine B) Patchy uptake with hot nodules C) Diffuse uptake

11. Initial treatment of thyrotoxicosis may include the following except A) Dexamethasone B) Propanolol C) Antithyroid drugs ( Propylthiouracil/ Methimazole ) D) Radioactive Iodine ablation

12. Thyroid Storm requires all of the following findings except A) Fever B) Tachycardia C) Altered Mental Status D) Diarrhea

13. The overresponsiveness of the sympathetic nervous system is due to A) excessive circulating catecholamines B) Excessively elevated serum T3,T4 levels C) Unknown

14. 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

15. Thyroid Storm- Diagnostic Criteria What are they ?

16. 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?

17. The Burch –Wartofsky Scoring System Describe the Scoring system:

18. Treatment Thyroid Storm Review the treatment of thyroid Storm.

19. HYPOTHYROIDISM Define this condition.

20. Common causes of Primary Hypothyroidism are the following except A) Antithyroid drugs B) Autoimmune Disorders C) Previous radioactive Iodine treatment of Graves Disease

21. Hypothyroidism Review the causes of PRIMARY HYPOTHYROIDISM SECONDARY HYPOTHYROIDISM

22. 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

23. Hypothyroidism List the signs and symptoms of severe hypothyroidism.

24. These lab tests are helpful in Hypothyroidism except A) T 3 level B) T4 level C) Elevated cholesterol D) TSH

25. These are found in Myxedema Coma except A) Temperature is often < 32 degrees C. B) Patients often shiver. C) Dysfunction of Thermoregulatory Center.

26. 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

27. 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

28. MYXEDEMA COMA- Clinical Findings What are they?

29. MYXEDEMA COMA- Treatment What is the treatment for Myxedema coma ?

30. Adrenal Insufficiency Definition of this condition:

31. All the following are causes of Primary Adrenal Insufficiency except A)Idiopathic- ( autoimmune adrenalitis) B) Infiltrative disease ( Sarcoid ) C) Adrenal Hemorrhage/ Infarct D) Steroid therapy E)Granulomatous infectious ( TB, Fungal ) F)Metastatic involvement ( lung, breast, colon) G)Bilateral Adrenalectomy

32. 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 rapidly D) Head trauma E)Hypothalamic tumors F)Pituitary tumors

33. 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.

34. Adrenal Crisis What are the signs and symptoms of Adrenal Crisis?

35. 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

36. ACTH Stimulation Test What is this test and how is it administered?

37. Treatment of Adrenal Crisis What is the treatment of Adrenal Crisis?.

38. Diabetes Describe some common presentations of complications of diabetes.

39. DIABETES Definition:

40. 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

41. 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?

42. Diabetic Ketoacidosis Describe the key findings of Diabetic Ketoacidosis and how are they manifested Physiologically?

43. 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

44. Physical exam What are the physical findings in diabetic ketoacidosis?

45. Lab Findings What are the lab findings?

46. DKA Discuss the treatment rational for the use of A) Insulin B) Sodium Bicarbonate C) Potassium D) IV fluid

47. Treatment of DKA Objectives: what are they?

48. 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.

49. Non Ketotic Hyperglycemic Hyperosmolar Coma What are its predominant features?

50. 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)

51. NKHHC What is the difference in treatment of the Non Ketotic Hyperglycemic Hypersomolar patient vs the DKA ?

52. 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

53. Signs and Symptoms of Hypoglycemia are except: A) Sweating. B) Increased urination C) Weakness. D) Confusion. E) Anxiety F) Tachycardia

54. Hypoglycemic treatment options include except A) Glucagon. B) Dextrose 50 % C) Orange juice D) Bread