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Old 10-20-2011
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Question Three Endocrinology Questions

A 67-year-old man comes to your office complaining of weight gain, lethargy, and cold intolerance. His blood pressure is 155/95 mm Hg. After these findings you began therapy with levothyroxine. Now, 6 months later, the patient returns for further follow-up and reports feeling much more energetic. Provided that he has responded appropriately to the medication and that his TSH normalizes, what effect would you expect to see on his blood pressure and lipid profile?

A. Decreased blood pressure, decreased LDL, and decreased triglycerides
B. Decreased blood pressure, increased LDL, and increased triglycerides
C. Increased blood pressure, decreased LDL, and decreased triglycerides
D. Increased blood pressure, increased LDL, and increased triglycerides
E. No change in blood pressure or lipid profile

The correct answer is A. Hypothyroidism has important effects on the cardiovascular system. Both blood pressure and lipid profile are adversely affected. Paradoxically, low levels of circulating thyroxine will actually elevate blood pressure. The process is mediated through an increase in peripheral vascular resistance. The effect is most pronounced in those with established hypertension. Hypothyroidism also decreases heart rate and myocardial contractility, lowering overall cardiac output. However, the increase in peripheral vascular resistance is more prominent, resulting in an overall increase in mean arterial pressure. A screening TSH to rule out hypothyroidism is a routine part of the workup for secondary causes of hypertension. Hypothyroidism also decreases lipid clearance from the blood by the liver, resulting in elevated serum total, LDL, and triglyceride fractions. In a prospective study, 4.2% of those with hyperlipidemia were found to have hypothyroidism. Only those patients with a serum TSH concentration above 10 mU/L had a significant reduction in the serum cholesterol concentration during thyroid hormone replacement. The effect of thyroid hormone replacement in the setting of subclinical hypothyroidism is usually small and varies considerably. Because of these two effects, both blood pressure and lipid profiles should improve during thyroid hormone replacement. Choices B, C, D, and E all describe cardiovascular changes that would be unexpected.


A 64-year-old man comes to the clinic for follow-up. He has a 9-year history of type II diabetes, an 8-year history of hypertension, and a 6-year history of hypercholesterolemia. He reports no specific complaints since his last visit 1 year ago. He now exercises regularly, playing singles tennis three times per week during the summer and swimming three or four times per week in winter. He tries to maintain a low-salt diet and has been taking his medicines regularly. Currently he takes metformin 1,000 mg BID, glyburide 20 mg QD, atorvastatin 10 mg QD, and enalapril 10 mg BID. He reports checking his finger-sticks sporadically and notes blood glucose readings of 90 to 140 mg/dL. On his last visit his hemoglobin A1c was 6.8%. Physical examination reveals a well-developed elderly man in no distress with a pulse of 68/min and blood pressure of 118/76 mm Hg. The remainder of his physical examination is unremarkable.

Which of the following is the most appropriate intervention at this time for the patient’s diabetes?
A. Check full laboratory studies, including renal function, in 1 year
B. Initiate low-dose evening NPH insulin
C. Recheck hemoglobin A1c in 3 months
D. Schedule renal ultrasound
E. Start glipizide 5 mg QD

The correct answer is B. This case highlights the need to understand the appropriate management of diabetes mellitus based on results of hemoglobin A1c testing. Both the American Diabetes Association and the American College of Endocrinology recommend improved glycemic control when the hemoglobin A1c is greater than or equal to 7%. Inasmuch as this patient is near maximal dose of insulin secretagogue/sulfonylurea (glyburide) as well as insulin sensitizer (metformin), the next step would be the addition of a thiazolidinediones, an alpha-glucosidase inhibitor or the addition of insulin.
Action needs to be taken with this patient now, so waiting for labs in either 3 months (choice C) or 1 year (choice A) is incorrect. It is true that hemoglobin A1c values should be followed in 3 months. Yet, given that he has maximized lifestyle changes and also maximized his current drug regimen, this patient should be started on an additional agent before rechecking his long-term glucose control.
This patient most likely has already developed some degree of diabetic nephropathy, given his mild renal insufficiency and proteinuria. However, a renal ultrasound (choice D) will shed no new light on his current clinical situation. It would be more important to quantify the degree of proteinuria with a 24-hour urine protein or albumin collection.
Adding an additional insulin secretagogue/sulfonylurea (choice E) will not improve his blood glucose control because he is already on the maximal dose of a similar agent.


A 31-year-old diabetic man comes into the emergency department requesting a prescription and “social services.” He states that he recently lost his job and became homeless. As a result he hasn’t taken his insulin in 2 days. He denies any nausea, vomiting, or abdominal pain. You decide to check his bedside glucose and ask him to give you a urine specimen to check for ketones. On his way back from the bathroom he starts vomiting. The nurse notifies you that his blood glucose is so high that the bedside machine reads “high” and does not give an actual value. Bloods are drawn and sent off to the laboratory, which eventually report a glucose level of 855 mg/dL. His serum bicarbonate is 8 mEq/L and you calculate his anion gap to be 34. Which of the following should be included in the initial treatment?

A. Glucagon by intravenous drip
B. Insulin by intravenous drip
C. Intravenous bicarbonate until normalized
D. Judicious use of intravenous fluids to avoid volume overload
E. Supplemental phosphorus in the form of potassium phosphate
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I got the first one wrong i didnt know that hypothryroid causes a increase in BP i knew it causes braydycardia so i thought it would decrease BP.


The second question i dont agree with the answer In the explanation itself it states that tighter glycemic control when hbA1c is 7% or MORE since his is only 6.8% i feel he doesnt warrant adding anything else to his tx plan yet. I would have chosen to follow up on him HbA1c lvls in 3 months and if then i saw a furthur increase then i would say to add insulin to his therapy.


the third question il choose B its DKA he needs large volume IV normal saline and IV insulin . also his potassim lvls should be monitored and KCL given if if goes under 5.
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Quote:
Originally Posted by docnas View Post


The second question i dont agree with the answer In the explanation itself it states that tighter glycemic control when hbA1c is 7% or MORE since his is only 6.8% i feel he doesnt warrant adding anything else to his tx plan yet. I would have chosen to follow up on him HbA1c lvls in 3 months and if then i saw a furthur increase then i would say to add insulin to his therapy.

.

Guy has 9 year history of DM and is taking medicines regularly...
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The correct answer is B. This patient presents with diabetic ketoacidosis (DKA). It is generally accepted that the ideal way to administer insulin is by continuous infusion of small doses of regular insulin through an infusion pump. This approach appears to be more physiologic in producing a more linear fall in serum glucose and ketones. It is also associated with fewer complications of hypoglycemia, hypokalemia, and hypophosphatemia.
Glucagon (choice A) may be used in cases of hypoglycemia to raise the blood glucose.
Acidotic patients routinely recover from DKA without alkali therapy (choice C). No studies to date have shown a benefit of using bicarbonate in the treatment of DKA.
Rapid fluid administration is the single most important initial step in the treatment of DKA (choice D). The average adult patient has a water deficit of 100 mL/kg. Fluid restores intravascular volume and normal tonicity, and lowers serum glucose and ketones.
There is no established role for initiating IV potassium phosphate in the initial treatment of DKA (choice E). Significant hypophosphatemia tends to develop many hours into therapy after the patient is admitted.
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Old 10-21-2011
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@ Drnrpatel please dont take any of this as criticism towards you . Im just trying to understand the question in the syntax of why i m wrong and how would prevent making the same type of mistake again.


I read over the answer and question again ( a few times to be honest to make sure i didnt miss anything) and on reading the question i had come to the same conclusion. And also in the answer it had noted factors which arent even mentioned in the question

Heres the 2 points that screw me up in that answer



This patient most likely has already developed some degree of diabetic nephropathy, given his mild renal insufficiency and proteinuria.

==>Theres no mention of anything about protienuria in the question though.

Both the American Diabetes Association and the American College of Endocrinology recommend improved glycemic control when the hemoglobin A1c is greater than or equal to 7%

And again coming to this part of the HbA1c yes his lvls arent good they are on the high side and he has lots of additional risk factors but thats not part of the criteria when using HbA1c it simply says greater than or equal to 7%
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Quote:
Originally Posted by docnas View Post
@ Drnrpatel please dont take any of this as criticism towards you . Im just trying to understand the question in the syntax of why i m wrong and how would prevent making the same type of mistake again.


I read over the answer and question again ( a few times to be honest to make sure i didnt miss anything) and on reading the question i had come to the same conclusion. And also in the answer it had noted factors which arent even mentioned in the question

Heres the 2 points that screw me up in that answer



This patient most likely has already developed some degree of diabetic nephropathy, given his mild renal insufficiency and proteinuria.

==>Theres no mention of anything about protienuria in the question though.

Both the American Diabetes Association and the American College of Endocrinology recommend improved glycemic control when the hemoglobin A1c is greater than or equal to 7%

And again coming to this part of the HbA1c yes his lvls arent good they are on the high side and he has lots of additional risk factors but thats not part of the criteria when using HbA1c it simply says greater than or equal to 7%
I am not getting what is your question.
Still , I think it is about HbA1c.
HbA1c whenever less than 7, treatment dose either increased and/or other drug is added.
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HbA1c SHOULD be under 7 anything UNDER 7% means the glyceming control is good ( normal is i think is 4-6%) only if above it is when we are concerened.
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American Diabetes Association recommends that the HbA1c be below 53 mmol/mol (7.0%) for most patients.[17] Recent results from large trials suggest that a target below 53 mmol/mol (7%) may be excessive: Below 53 mmol/mol (7%) the health benefits of reduced A1C become smaller, and the intensive glycemic control required to reach this level leads to an increased rate of dangerous hypoglycemic episodes.
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My bad. It's insomnia effect that I am screwing simple HbA1c.

Bloody Kaplan.

Answer must be C.

I am really grateful to you docnas for drawing my attention to it and STICKING to it.

Thank you.
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dont worry bro we have all been there specially when our exam comes near.

as for thanking me its not necessary i am thanking you for all the questions you are putting making me think about things i had already covered to make sure did i really get it or not.


As for sticking to a point i thinks its my being hard headed and ADD i tend to be stuborn sometimes and wont admit being wrong till u hit me with cold hard specific facts before il even consider being wrong

But yeah it was a simple point and getting it wrong(atleast according to the origional answer) had me scared as i was worried that my whole concept of the treatment plan for DM was wrong . Its a very important topic in step 2 so its something i wanted to have down 100% without doubt
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