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125 Cards in this Set
- Front
- Back
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Primary Hypothyroidism
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Disorder of thyroid gland
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Most common cause of primary hypothyroidism?
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Hashimoto thyroiditis
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Causes of primary hypothyroidism?
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Hashimoto thyroiditis
Radiation or surgical resection of thyroid (CA or hyperthyroidism) Iodine deficiency Subacute thyroiditis Cretinism - congential Lithium - medication De Quervians Thyroiditis - viral infection of thyroid Post partum hypothyroidism Medications |
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Secondary Hypothyroidism
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Disorder of pituitary gland (TSH deficiency) or hypothalamus
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Causes of secondary hypothyroidism
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Neoplasm of pituitary or hypothalamus
Sheehan's syndrome Radiation or surgical resection of pituitary TB Pituitary CA |
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Sheehan's syndrome
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Cause secondary hypothyroidism
- Infarct and necrosis of pituitary due to postpartum shock/hemorrhage |
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Hashimoto's lab findings?
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Anti-thyroid peroxidase antibodies
Antithyroglobin antibodies |
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Hypothyroidism signs and symptoms?
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Weight gain
Dry skin Hair loss/COARSE hair Fatigue Constipation Cold intolerance Depression Decreased concentration/memory Arthraglia/myalgia Menorrhagia |
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Physical exam findings of hypothyrodism?
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Bradycardia
Hypotension Edema Goiter Cool dry skin Periorbital edema Carpel tunnel syndrome Decreased deep tendon reflex Brittle nails Slow speech |
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TSH and free T4 levels in primary hypothyroidisim
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TSH: increased by 2 times normal
Free T4: decrease |
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TSH and free T4 in secondary hypothyroidism
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TSH: decrease
Free T4: decrease |
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Suspect primary hypothyroidism and gland is without nodules...radiology is/is not required?
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IS NOT ABSOLUTELY REQUIRED
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Normal TSH levels?
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0.7 - 5.3 mu/ml
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Free T4 levels?
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1.25 - 6.5 mu/ml
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What test would you use to determine the thyroid size, texture or if there is cysts or solid nodules?
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ultrasound - picture of thyroid
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What is used to determine "cold" hypofunctioning and "hot" hyperfunctioning areas?
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Radioactive iodine uptake
COLD - appear as holes in exam, nonfunctioning thyroid HOT - produce excess hormones --> DARK |
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What does a "cold nodule" suggest?
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Possible CANCER - doesn't determine if malignant or not
**determined by radioactive iodine uptake |
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How do you determine pathologic diagnosis in hypothyroidism?
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FINE NEEDLE ASPIRATION - determines if its benign or malignant
US used to guide proceedure OFFICE |
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Why don't you want to suppress TSH too much in therapy?
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Risk of osteoporosis, cardiac arrhythmia, LVH
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Young adults with NO cardiac abnromalities how would you treat their hypothyroidism?
When should you recheck their TSH elvels to make sure its working? How much do you increase their dose by? What is the typical dose given to treat hypothyroidism in this patient? |
LEVOTHYROXINE (synthetic T4)
at 75 micrograms/day Recheck after 6 - 8 weeks Increase by 25 micorgrams per until TSH is NORMALIZED and symptoms improved 100 micrograms/day |
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How would you treat an elderly patient or a patient with cardiac abnormalities?
What dose would you start out at? What dosage increment would you increase by and when would you do this? |
START LOW AND GO SLOW
25 micrograms/day Increase by 12.5 micorgrams/day increments EVERY 8 weeks until normalize and symptoms improve |
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How would you treat a patient with hypothyroidism with normal TSH levels but symptomatic?
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ADD 12.6 micrograms of T3
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How would you follow up for a patient with hypothyroidism there TSH levels are:
*Remain ELEVATED *SUPPRESSED |
*Elevated --> INCREASE DOSE
*Suppressed --> DECREASE DOSE |
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What is the goal of levothyroxine replacement therapy?
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NORMALIZATION of TSH!
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1 mg equals _____ in micrograms?
25 mg equals _____ in micrograms? |
1/1000 micograms or ug or mcg
0.025 mcg |
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What is a severe sequela of hypothyroidism?
How do you treat? OUTCOME? |
MYXEDEMA COMA
- Severe hypothyroidism complicated by: *Severe Hypothermia *Hypotension *Bradycardia **MENTAL STATUS CHANGE - including COMA! * Hyperventilation *Unresponsiveness TREAT: - SUPPORTIVE immediately: Assisted ventillation Warming devices Volume repletion for hypotension glucocorticoids if adrenal insufficiency is suspected OUTCOME: - DEATH - even if treated early! ***NOT dementia or stroke!!! |
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What is the medication used to treat myxedema?
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*IV levothyroxine - 500 mcg bolus and then 1.8 mcg/kg/day!!!!
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When do you want to take levothyroxine?
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IN AM 1/2 hour before EATING!
*B/c certain foods and meds block absorption: - soy - ferrous sulfate - antacids - sucralfate |
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What medications increase metabolism of thyroxine and reduce bioavailable levels?
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ANTI-SEIZURE MEDS
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What is the cause of decreased response to levothyroxine in elderly?
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INCONSISTENT USE
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What are the ABC's of Initial Pregnancy Evaluation?
A B C D E F G H I |
A: alcohol use and importance of abstinence
B: bleeding C: contractions, cigarrettes D: diet, drugs (prescription/illegal) E: estimated date of confinement, edema F: feeling, father, family support G: gestational age, growth (normal) H: history (PMH) (gravidty/parity/abortus) i: infection |
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How do you calculate a women's expected date of confinement?
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1st day of last (normal) menstrual period, add 7 days, then count back 3 months
**Change year if needed |
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A 22 y/o female describes breast tenderness, fatigue, morning nausea. The first day of her LMP was September 1st.Urine hCG is positive. What is her EDC.
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EDC is June 8th.
EDC is calculated by adding 7 days to the 1st day of the LMP, then counting back 3 months. |
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Identify a bacterial (other than strep), a viral and a non-infectious differential for pharyngitis
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a. Bacterial – H.I.B., Gonococcal, Diptheria, peri-tonsilar abscess.
b. Viral – Mononucleosis, Coxsackie virus, Influenza, Rhinovirus. C. Non-infectious – GERD, Thyroiditis, Post nasal drip with allergies, foreign body, cancer. |
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Identify 3 differential diagnosis for chronic cough (must include at least 1 non-respiratory etiology)
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Asthma
COPD Pertussis T.B. GERD CHF ACE inhibitor |
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. Identify at least 4 differentials for a chief complaint of “chest pain” ( must include a dermatological, musculoskeletal, G.I. and pulmonary etiology)
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Shingles
Costrochondritis G.E.R.D. Pleuritis Pulmonary Embolism Pnuemothorax Pnuemonia Pericarditis Angina/CAD |
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Identify 3 diagnosis in the differential of right flank pain in a male
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Renal lithiasis
Urolithiasis Pylonephritis Cholycystitis Low back strain Shingles Testicular torsion Epididimytis |
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Identify at least 3 groups at higher risk for T.B
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Recent immigrants from high prevalence countries.
Residents of high risk congregate settings: nursing homes, prisons, mental institutions HIV infected patients (or other immunodeficient conditions Drug abusers Homeless Health care workers who serve high risk pop. |
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Identify 3 conditions in the differential for fatigue in an adult female
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Hypothyroidism
Anemia Depression Hypoglycemia Mononucleosis Pregnancy Sleep deprivation Poor nutrition |
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Identify 3 conditions in the differential for joint pain
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Viral infection (i.e. Mono)
Septic arthritis Rheumatoid Arthritis Osteoarthritis Gout Ankylosing spondylitis Reiter’s syndrome Psoriatic arthritis SLE Fibromyalgia |
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Identify at least 3 reversible/treatable causes of “dementia”
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Neurosyphilis
Hypothyroidism B12/folate/thiamine deficiency Normal pressure hydrocephalus Delirium ( from infection, uremia, hepatic encephalopathy, electrolyte disturbance) Pseudodementia from depression |
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Identify at l east 3 factors which increase the risk that cancer is the cause of low back pain
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1. History of cancer( i.e.. Prostate, ovarian)
2. Unexplained weight loss 3. Age over 50 4. failure to improve after 1 month |
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Identify at least 3 differentials in the workup of GERD
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Peptic Ulcer Disease
Esophageal stricture Angina Esophageal Cancer Hiatal hernia Pericarditis Costrochondritis |
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Identify 4 distinguishable forms/types of diabetes
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Type 1
Type 2 Gestational Secondary Diabetes ( secondary to another illness… Cushings; Cystic fibrosis; Pancreatic Cancer) |
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Identify the probable pathophysiology of Rheumatoid arthritis
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Probable autoimmune disorder with a genetic component in which a triggering event (infection) prompts inflammation and destruction of synovial tissue ( answer must identify the autoimmune component and the inflammation of synovial tissue).
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What is the key distinction between primary and secondary etiologies of hypothyroidism and give an example of each.
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Primary – disorder of the thyroid gland (hashimotos, irradiation or surgical removal of thyroid gland, congenital (cretinism), iodine deficiency
Secondary – disorder of the hypothalamus or pituitary gland.(Pituitary neoplasm, hypothalmic neoplasm, pituitary necrosis (Sheehan’s sydrome) |
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Identify the etiological agent that most frequently causes Tuberculosis in humans
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Mycobacterium tuberculosis
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Identify which type of kidney stone is most common.
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Calcium stone (72%)
Struvite stones (16%) Uric Acid stones (10%) Cystine stones (1%) |
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Identify at least 4 key risk factors which contribute to coronary artery disease
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Dyslipidemia (also high fat/cholesterol diet)
Smoking Hypertension Diabetes Obesity Male or postmenopausal female Inactivity hyperhomocysteinemia |
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Identify the two general pathophysiologic processes occurring in Asthma
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Hyperirritability/reactivity of the tracheo-bronchial tree leading to Broncho-constriction
Airway Inflammation (must include both broncho-constriction and inflammation) |
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Identify the bacterial etiological agent which causes “strep throat”
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Group A beta-hemolytic streptococcus (strep pyogenes)
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Identify at least 3 of the American Rheumatism Assoc. criteria for diagnosing Rheumatoid Arthritis
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Morning stiffness > 60 min.
Arthritis (pain, stiffness) in 3 or more joints Arthritis in wrists and hands Symmetrical arthritis Rheumatoid nodules Elevated Rheumatoid Factor (RF) Radiographic changes (bone erosions/decalcifications) Systemic symptoms – weakness, fatigue, weight loss Four or more of the above are diagnostic for RA |
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Identify 3 lifestyle/behavioral factors which contribute to or worsen GERD
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Large meals
Recumbency after meals (eating too close to bed time) Alcohol Tobacco Caffiene Certain foods: chocolate; citrus; tomato; saturated fats; fried foods |
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Identify the key pathophysiological difference between type 1 and type 2 diabetes
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Type 1 DM – Insulin deficiency due to a probable autoimmune destruction of pancreatic Beta cells
Type 2 DM – Insulin resistence |
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Identify the key pathophysiological abnormalities found in the brains of Alzheimer’s patients
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B –Amyloid plaques between neurons
Neurofibrillary tangles within neurons Decrease in Acetylcholine availability in synapse |
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Identify at least 3 Musculoskeletal causes of low back pain
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Muscle strain
Disk herniation (with or without nerve compression) Osteoarthritis Compression fracture (spondilolysis) Multiple Myeloma Potts disease (TB of the spine) Fibromyalgia Ankylosing Spondylitis |
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A patient presents with symptoms clearly associated with GERD. They are otherwise well. (no weight loss, dysphagia or bleeding). What lab/radiological study is necessary for diagnosis
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None – GERD can be diagnosed clinically.
Labs/Radiology only necessary when: diagnostic uncertainty; no improvement with treatment; alarm symptoms… dysphagia, hematoemesis, unintended weight loss |
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Identify two lab values diagnostic of DM
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Fasting blood glucose > 126 mg/dl on two occasions
Random blood glucose > 200 mg/dl on two occasions 2 hour GTT blood glucose > than 200 mg /dl 2 hours after 75 mg glucose oral load Hgb A 1C is informative but not regarded as diagnostic |
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What type of study/evaluation is most informative in identifying the functional status of a patient with dementia
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Neuropsychological testing
Physical self maintenance scales or functional activities questionnaire (CT is informative of the structure of the brain and to rule out differentials, but yields nothing on patient functional status) |
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Your middle aged male patient describes fatigue, dry skin, cold intolerance, forgetfulness and constipation. You suspect primary hypothyroidism. What is the most important initial screening test and what general results would you expect.
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TSH (thyroid stimulating hormone). (Many providers also include free T4 in the initial screen).
In primary hypothyroidism, TSH would most likely be elevated and free T4 would be low |
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What would be the 2 most important tests in the initial evaluation of a patient in a moderate risk group with suspected T.B.
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Mantoux skin test with PPD (purified protein dirivative ) read after 48 – 72 hours.
Chest X ray |
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What additional respiratory test can be confirmatory for T.B.
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Three consecutive morning sputums for acid fast bacillus staining and culture
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What are the two most definitive tests to evaluate for renal/ureteral lithiasis
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Non-contrast helical C.T. (95 % sensitive and specific)
Intravenous Pyelography (64 – 87 % sensitive and 92-94% specific) |
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A 37 y/o female with recurrent cough and wheezing has the following Pulmonary Function Test results:
FEV1 – 62% pre-bronchodilator FVC – 90% FEV1/FVC – 69% FEV1 – 83% post bronchodilator Does type of airway disease pattern does this represent? |
Obstructive airway disease
Obstructive airway disease patients usually have lowered FEV1 (under70%) and normal or high FVC. The FEV1/FVC ratio is low (under 70%) Restrictive Airway disease patients usually have somewhat better FEV1 but lower FVC. Also, they tend to have a higher FEV1/FVC ratio. |
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A 10 year old patient with a CC of “sore throat” has the following symptom/signs:
Fever 101.5 F Absent cough and no rhinorrhea Tender anterior cervical nodes Hypertrophic tonsils with exudate Strawberry tongue No chronic fatigue, posterior cervical adenopathy or splenic tenderness No allergies What is your next step: |
Treat empirically for strep. Pharyngitis
Several of the above signs/symptoms correlates with a positive throat culture. If you have 4-5 correlates, the likelihood of strep is increased. It is acceptable to treat empirically in this case. Also, you avoid the confound of a potential false negative step test. |
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Your 44 year old male patient presents with LBP after heavy lifting two days ago. No loss of bowel or bladder control. No radiculopathy or weakness. No history of CA. No dysuria or fever.
What is the imaging test of choice? |
None!
Plain films do not correlate well with symptoms, nor with prognosis. MRI is usually indicated in patients with significant neuro-abnormalities who are candidates for nerve blocks or surgery. |
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Your 55 year old male smoker presents with a 9 month hx of intermittent chest tightness. Symptoms are only with exertion, relieved by rest and are not getting worse. He is not symptomatic now. He has no hx of MI and no sx of CHF. He is on no meds and is ambulatory. Resting EKG is normal. What is your initial test of choice?
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Exercise (treadmill) EKG stress test with Bruce protocol.
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A 28 year old male with 2 kidneys has a 3mm stone in the right ureter. His condition is as follows
Drinking well Urinating well Otherwise healthy Pain is moderate ( 6 of 10 on pain scale). UA negative for infection No allergies How will you treat him next? Identify 3 elements: : |
Oral analgesics with narcotic/tylenol combination.
Consider Antiemetic Strain urine Consider Urology referral Close outpatient follow-up. |
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A 57 year old male has recently been diagnosed with stable angina. His condition is as follows:
Stage 1 hypertension Moderate dyslipidemia Non-smoker No allergies Not on any medications currently. No Hx. Of asthma, diabetes or MI Pulse rate of 95 Identify 4 classes of medicines important to consider in this patients care |
Aspirin (anti-platelet)
Beta blocker Statin (HMG CoA reductase inhibitor) Nitrates (nitroglycerine) – available on a PRN basis |
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Homeless/mentally ill.
Positive PPD (> 12mm of induration) Negative chest Xray No signs and symptoms of T.B. Otherwise healthy. Non-drinker. Normal LFTs What is your diagnosis and how would you treat? |
Latent tuberculosis
Involvement of the local public health dept. Isoniazid 5mg/kg/day up to 300mg/day for 6-9 months Direct observed therapy Monthly clinical assessments. |
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What medication and dosage would you use for the following patient?
32 year old female Symptoms of fatigue, dry skin, weight gain. Healthy heart. Elevated TSH, low free T4. |
Levothyroxine 75 – 100 micrograms
(answer must include correct units… 75 -100 mg is incorrect. |
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Identify agents used in the treatment of asthma including:
Agent used for acute broncho-spasms Agents that can be use in the long term management of the inflammatory process of asthma. |
Short acting inhaled beta agonist for acute broncho-spasm (albuterol)
Long term management - Inhaled glucocorticoids (fluticasone) - Mast cell stabilizers ( cromolyn sodium) - leukotriene modifiers (montelukast) - long acting beta-agonist (salmeterol) – usually used in conjuction with inhaled steroid |
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Identify 3 different classes of drugs which can be used in the treatment of rheumatoid arthritis
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NSAIDs
Low dose Oral glucocorticoids (short term and in conjunction with 1500 mg of calcium and 400 IU of vitamin D) Intra-articular steroid injections Disease modifying anti-rheumatoid Drugs (DMARDs) Cox – 2 inhibitors ( in the absence of hx of cardiovascular disease). (Answer must include DMARDs) Biological /immunomodulators |
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What pill should be prescribed to all pregnant women . Also, identify the necessary included supplement.
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Prenatal vitamins with 1mg of folic acid.
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Your adult male patient has the following condition:
Exudative pharyngitis Fever Tender anterior cervical nodes Rapid strep positive No allergies What medication and dosage would you use to treat? |
Penicillin VK 500 mg 1 po tid for 10 days or
Bicillin LA 1.2 million units IM |
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Identify two classes of medication shown to be helpful in the treatment of GERD
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Proton pump inhibitors
H2 blockers |
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Identify the major class of medication used to treat Alzheimer’s and give an example of a medication from this class
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Acetylcholinesterase inhibitors
Donepizil (Aricept) Rivastigmine (Exelon) Galantamine ( Razadyne) |
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Identify 3 different classes of oral diabetic medications
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Biguanides – Metformin
Glitazones (Thiazolidinediones) – Actos Sulfanylureas – Glipizide Alpha Glucosidase inhibitors – Acarbose |
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Identify 3 different types of insulin and give an example of each
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Short Acting (Regular, Lispro, Apart)
Intermediate acting (NPH) Long acting- (Glargine/Lantus) Combinations (regular/NPH) |
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Identify 4 different treatments for a patient with musculoskelital LBP (include two medication and two non-medication treatments)
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Medications Non-Medication
NSAID PT COX -2 Heat Tylenol Massage Narcotic/tylenol combo OMT TCA TENS SNRI Nerve Blocks Gabapentin (with Accupuncture Radiculopathy CBT |
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Identify at least 4 of the 9 tests that should be including in the initial workup of a pregnant female
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CBC
Blood type and Rh UA Pap smear Cervical culture for Gonorrhea and chlamydia VDRL (RPR) Hepatitis panel Rubella titer HIV testing |
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Identify at least 2 of the important possible sequela of strep pharyngitis
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Peri-tonsillar or retropharyngeal abscess
Scarlet fever Rheumatic fever Strep glomerulonephritis |
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Your patient has the following condition:
fever, chills, Right CVA tenderness Significant nausea and vomiting Olyguria and reduced fluid intake Elevated WBC on CBC UA positive for nitrites, leukocyte esterase, WBC and RBC. CT reveals 6mm stone in right ureter and right hydronephrosis. Identify your diagnosis and the two most important aspects of your initial treatment |
Diagnosis – Ureterolithiasis with obstruction and urinary tract infection/pylonephritis
Treatment - Admission to Emergency Department with immediate urology consultation. Must identify both obstruction and infection. Must identify need for immediate urology consultation. The combination of obstruction and infection holds a high risk for sepsis. The kidney is like an abscess and must be drained. |
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urological emergencies associated with kidney stones include:
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Anuria (absence of urination)
Bilateral obstruction with acute renal failure Unilateral obstruction in a patient with one kidney. The combination of obstruction and infection holds a high risk for sepsis. The kidney is like an abscess and must be drained. |
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Who is at high risk for gestational diabetes?
How would you test the pregnant woman? - Whats a positive test? |
Risk: marked obesity, history of GDM, previous large for gestational age delivery, glycosuria, polycystic ovarian syndrome, positive family hx
TEST: 3 hour 100 g oral glucose tolerance test - 2 of 4 BG must be elevated for positive test Fasting > 95 mg/dL 1 hour > 180 2 hour > 155 3 hour > 140 |
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Ketonuria is found in what type of DM patient?
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Type 1
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UTI and respiratory tract infections are common in what type of DM patient?
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Type 2
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What are the four types of micro and macrovascular complications associated with type II DM?
When do these symptoms often arise? How do you prevent microvascular complications? |
-Peripheral and autonomic neuropathy
-Retinopathy -Neuropathy -Cardiovascular INITIAL physical examination at time of diagnosis Prevention: optical glycemic control (POSTPRANDIAL), normotension, avoidance of excess sodium, protein intake |
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How do you diagnose DM?
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Ambulatory setting:
- Fasting serum BG > 126 mg/dL on two occasions - Resting (casual) BG > 200 on two ocassions 2 hour post-prandial BG - DIAGNOSTIC WHEN? > 200, 2 hours after 75 mg oral glucose |
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What are the indications to test DM with a 2 hour postload glucose tolerance test?
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- Equivocal resting BS and fasting BS
- Presence of complications or stigmata of metabolic syndrome when blood tests are NONdiagnostic |
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How would you test blood glucose levels over last three months, to monitor treatment?
What is normal, does this rule out DM? What is the goal in treatment? |
Hb A1c is NOT DIAGNOSTIC
Reflects glucose levels over last three months Normal: < 6 but DOES NOT rule out possible DM GOAL < 7 |
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What does it indicate when:
FBS < 126 mg/dL 2 GTT 140 - 190 mg/dL |
Impaired glucose tolerance test
*PRE-DM |
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What does it indicate when:
- FBS > 100 mg/dL - 2 hour GTT is b/w 100 - 126 mg/dL |
**Impaired fasting glucose
- PRE-DM |
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How would you distinguish with lab testing Type I vs. Type II DM, if equivocal setting?
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TYPE I has:
- C-Peptide: LOW - Insulin: LOW - Glutamic acid decarboxylase antiboides and pancreatic antibodies |
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What lab test would you perform to test renal function?
- When is peripheral neuropathy noted? |
Urine Microalbumin
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What is the goal in long term treatment in Type I DM?
How is this achieved? |
PRESERVATION of residual insulin production
By early physiologic insulin replacement, facilitating long term optimal glycemic control and forestalling brittleness Normal body weight important? -Optimize insulin sensitivity -Minimize insulin requirement -Minimize cardiovascular risk |
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What types of patient education should be provided in patients with DM?
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Pathophysiology of DM
Prevention of complications Home blood glucose monitoring Diet Exercise modification Proper foot care Early and appropriate minor illness management |
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When do you start outpatient treatment of insulin in DM?
How much do you start out at? |
Type I DM
- NO evidence of dehydration, omitting or DKA Insulin: 0.25 - 0.5 mcg/kg body weight/day and then titrate to patients response |
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At bedtime where should the injection site for insulin be?
Why? |
BUTTOCKS:
*INTERMEDIATE Acting -Decrease noctural hypoglycemia -Slows abosrption -Avoid 2 am counterregulatory nadir -Avoid dawn phenomenon |
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Why should you use adequate site rotation when giving insulin injections?
Which medication prevents this occurrence? |
RAA: Glulisine
LAA: Glargine and detemir |
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What is the benefit of early physiologic insulin repalcement?
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- "RESTS" the pancreas
- Decreases insulitis - inflammation of the islets of langerhang's of the pancreas - Preserves any residual B-cell function |
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What is the BID 70/30 Insulin administration?
Is it indicated? |
AM: 2/3 daily dose given in AM
(1/3 RA, 2/3 NPH) PM: 1/3 daily dose B/f supper: 1/2 dose as RA 10 pm - 1 am: 1/2 dose NPH **NOT RECOMMENDED |
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What is the QID regimen for Insulin?
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Premeal injections:
TID- short or rapid acting (80% of daily dose titrated to carb count - sliding scale) BEDTIME: Intermediate or Long acting (20% of daily dose) |
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What are the indications for continuous subcutaneous insulin infusion (CSII) or insulin pump therapy?
What type of insulin? What is the MOA? |
-Failure of multiple daily insulin injection regimens
-Exuberant dawn phenomenon -Need for convenience and flexibility -Pregnancy -Preconception RAA Insulin **Controls HEPATIC glucose output in fasting state and control hepatic glucose production at set hourly basal rates Remainder dose is titrated to carb intake |
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What type of insulin can be adjusted based on premeal, postprandial and bedtime home glucose test results?
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RAA, regular, NPH, glargine, detemir
-Total dose of 0.5 units/kg body weight |
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One unit of insulin will drop an elevated blood glucose by approximately _____?
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50 mg/dL
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If a patient is in the "honeymoon" phase you should give them what about of insulin or nothing?
To prevent? |
Newly diagnosed patient's insulin requirements may gradually decline
**Maintain a dose as low as 0.2 units/kg body weight TO prevent: insulitis and delay complete loss of B-cell function |
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How much insulin would you give if the BG is b/w 150 - 199?
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2 units!!!
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How much would you give if the BG is b/w 200 - 249?
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4 units
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How much insulin would you give if the BG is b/w 250 - 299?
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6 units
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Add ___ g of carbohydrate snack after what time period when on regular insulin?
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Peak: 2.5 h - 3.5 h
15 gram carb snack |
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Home blood glucose monitoring
- Frequency? -Sources of error? |
Frequency:
- four tests per day before meals and at bed time - Prior to driving - periodic 2 am and 4 am tests Sources of Error? - improper cleansing of finger - failure to wipe away first drop of blood when alcohol is used to clean finger - meter not calibrated to strip lot number - damaged strips from exposure to heat, light, humidity or cold |
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Most common stone in urolithiasis?
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1st: Calcium
2nd: Uric acid: gout 3rd: Struvite: proteus bacteria 4th: cystine |
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STAGHORN?
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Calculi fill and obstruct entire renal pelvis
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Risk factors for urolithiasis?
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Increased dietary: calcium and oxolate, protein, sodium, high VITAMIN C
Decreased fluid intake High: uric acid levels UTI with proteus |
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S/S urolithiasis?
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Painful - when stone is lodged and body is trying to move it along --> COLICKY PAIN AND BLEEDING
- Gross or microscopic hematuria - SEVERE AND UNILATERAL - FLANK PAIN - no cva tenderness!!! - Radiates to labia and testicle - N/V - NO FEVER |
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Does lack of gross or microscopic hematuria rule out a stone?
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NO
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What is lab is most helpful in diagnosing urolithaisis?
What imaging tool is GOLD STANDARD? - If negative? |
Urinalysis - BLOOD
Helical CT - if negative there is NO STONE!! |
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Treatment of urolithiasis?
What medication allows for passing of stone? |
Strain urine - pathology for treatment and prevention
CCB, Alpha blockers - help with passage of stone by decreasing uretral tone and allowing to pass |
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When should you refer urolithiasis to urologist?
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Stones greater than 5 mm
Patient fails a course of 2 week outpatient treatment Pain is unable to be controlled Acute renal failure |
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What are some severe complications with urolithiasis that require IMMEDIATE referral to urologist?
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SEPTIC emergency - urolithiasis and polynephritis
Anuria Bilateral stone Patient with one kidney |
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When to hospitalize a patient with urolithiasis?
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Unable to maintain oral intake due to nausea
Debilitated status due to comorbidities or extreme age Severe pain that is NOT resopnding to outpatient treatment Staghorn calcus - renal obstruction and hypdronephrosis |
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What is non-operate way to treat kidney stone?
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SHOCK WAVE LITHOTRIPSY
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Typical presentation of Angina?
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NON-REPRODUCIBLE PAIN!
Tight squeezing, pressure or dull ache Lasts 5 - 15 minutes Midsternal pain Radiates to L. shoulder, jaw, neck Levine's sign: clenched fist over sternum |
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Atypical presentation of Angina?
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SOB
Dizzy Diaphoresis Nausea Fatigue |
