Endocrine System

During periods of infection or illness, insulin-dependent patients may require additional insulin
to compensate for increased blood glucose levels. Fluid intake should be increased, and blood
glucose levels should be monitored frequently until fever subsides.
Symptoms of type 1 diabetes in children include weight loss, polyuria, polydipsia, irritability,
and behavior changes. Breath may smell “fruity” due to buildup of ketones.
Patients newly diagnosed with diabetes require A1C screening every 3 months until control is
achieved. It is important that parents know the signs and symptoms of both hypoglycemia and
hyperglycemia. Snacks with increased physical activity are needed due to increased glucose
utilization. A snack before bed is recommended to help stabilize blood glucose levels overnight
and prevent hypoglycemia.
Diagnostic criteria for diabetes mellitus (DM) is an A1C ≥6.5%, a fasting plasma glucose (FPG)
≥126 mg/dL, or a random blood glucose >200 mg/dL. An A1C between 5.7% and 6.4% indicates
prediabetes.
Hemoglobin A1C (HbA1C) is a lab test used to monitor the long-term effectiveness of
treatment in patients with diabetes mellitus. It provides an average of blood glucose levels over
the past 2 to 3 months, reflecting overall glycemic control.
Elevated A1C (normal range: 4.0-5.6%), and risk factors (BMI, sedentary lifestyle) are
consistent with a diagnosis of type 2 diabetes.
In the frail elderly population, an A1C level of up to 8.0% is acceptable. The A1C should be
reassessed in 6 months.
GLP-1 receptor agonists (Semaglutide) are a class of injectable medications that enhance
glucose-dependent insulin secretion, suppress glucagon secretion, and slow gastric emptying.
These medications have been shown to reduce A1C levels by approximately 1% without
significantly increasing the risk of hypoglycemia. Switching the patient to an SGLT2 inhibitor
Jardiance (empagliflozin) may be considered as an alternative to GLP-1 receptor agonists,
but these medications are contraindicated in patients with significant renal impairment and
may increase the risk of genital and urinary tract infections.
Hyperosmolar hyperglycemic state HHS, a rare but potentially serious complication of type 2
diabetes mellitus. The condition is characterized by very high blood sugar levels without
significant ketones, and early symptoms of the disorder can include extreme thirst, dry mouth,
confusion, and lethargy. does not present with ketones or acidemia.
Hypoglycemia presents trembling, sweating, irritability, dizziness, headache, and/or blurred
vision.
Metformin is considered the first-line therapy for type 2 diabetes, as it is effective in lowering
blood glucose levels, has a low risk of hypoglycemia, and has additional benefits in reducing
cardiovascular risk.

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DPP-4 inhibitors like sitagliptin can enhance the effects of metformin, providing better
glycemic control.
Strenuous activity can contribute to hypoglycemic episodes, and the patient may need a lower
dose of lispro prior to practice.
Metabolic syndrome may be diagnosed if patients meet at least three of five criteria: waist
greater than 40 inches in males or 35 inches in females; fasting glucose greater than or equal to
100 mg/dL; high-density lipoprotein (HDL) cholesterol below 40 mg/dL in males and 50 mg/dL
in females; triglyceride level of 150 mg/dL or greater; and a systolic BP greater than 130 mmHg
and/or a diastolic BP greater than 85 mmHg.
The USPSTF recommends that patients aged 35 to 70 years who have a BMI ≥25 who are from
a population at elevated risk for diabetes (e.g., Black, American Indian, Hispanic), should be
screened for prediabetes and type 2 diabetes. The USPSTF also recommends screening for Asian
American patients in this age range who have a BMI ≥23
Dawn phenomenon is an early-morning rise in blood glucose due to the body's natural release
of counter-regulatory hormones such as cortisol and growth hormone. Shifting the timing of the
NPH insulin, which has an intermediate duration of action, can provide a better overlap with this
physiologic increase in glucose, thereby reducing the early-morning hyperglycemia.
Somogyi effect is a rebound phenomenon in which hypoglycemia during the night triggers a
release of counter-regulatory hormones, leading to hyperglycemia in the morning. This
phenomenon often occurs in those receiving insulin treatment.
People with diabetes often have reduced sensation in their feet, which can make it difficult for
them to feel small objects inside their shoes. Although patients should wash their feet daily, they
should avoid soaking, which can worsen drying of the skin. Applying moisturizer after washing
the feet is appropriate but not applying it between the toes.
moisture-retaining dressing and inspecting the wound daily. Moist wound healing principles are
commonly used in the care of diabetic foot ulcers, as they promote a conducive environment for
healing. Daily inspection helps in early detection of any signs of complications.
Increased thirst, frequent urination, and unexplained weight loss, along with elevated fasting
blood glucose (normal range: 70-100 mg/dL) and positive ketones in the urine, point toward a
diagnosis of type 1 diabetes.
Cushing's syndrome presents with symptoms such as weight gain, facial rounding, and easy
bruising, central obesity, thinning skin, purple striae, hypertension, and diabetes. A cortisol urine
test would be more relevant to conditions affecting cortisol production, such as Cushing's
syndrome. Ketoconazole (decreased cortisol) is most commonly used as a short-term treatment
for Cushing's syndrome. Mifepristone is used for Cushing's syndrome treatment, but only in
certain cases. Cushing's disease due to a pituitary adenoma is to refer for transsphenoidal surgery
Addison's disease can lead to low blood sugar levels but typically presents with other symptoms
such as fatigue, weight loss, and hyperpigmentation. Carrying an emergency injection of

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hydrocortisone for situations of stress or illness that may precipitate an adrenal crisis is a crucial
aspect of self-management. The patient may need increased sodium in the diet. Daily oral
administration of hydrocortisone to replace cortisol and fludrocortisone to replace aldosterone.
Reactive hypoglycemia, in which blood glucose levels drop within a few hours after eating.
Prediabetes is associated with a fasting blood glucose level in the range of 101 to 125 mg/dL.
Diabetic ketoacidosis (DKA) (Kussmaul breathing). Blood glucose, reduced blood pH, positive
ketones in the urine, and low serum bicarbonate levels
Diabetic retinopathy is a frequent long-term complication in patients with type 1 diabetes, and
an annual dilated eye examination is the standard recommendation for early detection.
In patients with diabetes, one goal for treatment should be maintaining blood pressure below
130/80 mmHg. Above that level, antihypertensive therapy is recommended.
Normal amylase level is 40 to 137 U/L, and normal lipase level is <160 U/L.
Liraglutide (Victoza) increases risk for pancreatitis, which would cause an increase in
pancreatic enzymes.
A tuning fork test (128 Hz) is a noninvasive, practical, and commonly used assessment to
evaluate vibratory sensation in the feet, which can be diminished or absent in peripheral
neuropathy
Primary hyperaldosteronism is a disorder characterized by excessive production of the
hormone aldosterone from one or both adrenal glands. Diagnosis typically involves screening
with measurement of the ARR. An elevated ARR is indicative of primary hyperaldosteronism
and often leads to further confirmatory testing.
The patient's symptoms of fatigue, weight gain, and cold intolerance, along with an elevated
TSH level and low free T4 level, are indicative of primary hypothyroidism. Hashimoto's
thyroiditis is the most common cause of hypothyroidism, characterized by autoimmune
destruction of the thyroid gland.
Levothyroxine is the medication of choice, and is commonly prescribed, for the management of
hypothyroidism
Hypothyroidism, a thyroid-hormone deficit, can cause symptoms such as weight gain, cold
intolerance, constipation, and menstrual abnormalities. Diagnostic criteria include thyroid-
stimulating hormone (TSH) >5.0 mU/L, low free T4, and low T3. Because the patient's free T4
and T3 levels are normal, the diagnosis is subclinical hypothyroidism.

TPO antibodies is the gold standard for confirming Hashimoto's thyroiditis.

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Subclinical hypothyroidism-an elevated TSH level (normal adult range: 0.4-4.0 mIU/L) with
normal levels of free T4 (normal adult range: 0.8-1.8 ng/dL). The normal range for T3 is
typically 1.2 to 3.1 pg/mL, and the normal range for T4 is typically 4.5 to 11.2 mcg/dL. In most
cases, the initial treatment plan will involve withholding therapy and rechecking levels in 4 to 6
months to assess for improvement. The decision to start levothyroxine is individualized and is
often reserved for cases in which rechecking TSH and free T4 shows no improvement (or
worsening).
Secondary hypothyroidism is a rare condition caused by a dysfunction in the pituitary gland or
hypothalamus, which results in a decreased production of TSH or thyrotropin-releasing hormone.
In secondary hypothyroidism, both TSH and T3 and T4 levels are usually low.
Patients taking levothyroxine should be taught potential signs of overmedication, which can
include heart palpitations, increased heart rate, weight loss, heat intolerance, diarrhea, and
tremors. The drug must be used with caution in patients with hypertension. Levothyroxine is
contraindicated in patients with recent acute myocardial infarction or acute myocarditis; its use
requires caution with other cardiovascular disorders.
Iodine is a central component of thyroid hormones. Deficiency leads to hypothyroidism and its
associated symptoms, such as weight gain.
Typical values for an infant of this age are T4 in the range of 8.0 to 21.8 mcg/dL and TSH in the
range of 1.2 to 13.1 mU/L.
The infant's symptoms of poor feeding, constipation, prolonged jaundice, hoarse cry, large
fontanelle, distended abdomen, and dry, mottled skin is congenital hypothyroidism. The
appropriate treatment for congenital hypothyroidism is immediate initiation of levothyroxine
therapy.
Cystic fibrosis is less likely, as it would typically present with chronic respiratory symptoms and
greasy, foul-smelling stools.
Phenylketonuria would present with a musty odor in urine or sweat, and while it can lead to
intellectual disability if left untreated.
Galactosemia may present with feeding difficulties, but it would also typically include
symptoms such as vomiting and lethargy after milk feedings.
In the context of a solitary, firm thyroid nodule, the most appropriate initial evaluation should
include obtaining an ultrasound of the neck and thyroid gland. This imaging modality helps in
characterizing the nodule's size, shape, composition, and other features, which can guide the
decision on whether a biopsy is needed. Assessing thyroid function with serum TSH and free T4
levels is typically performed, but it is not the primary diagnostic step in assessing a thyroid
nodule for potential malignancy. Performing a fine-needle aspiration biopsy is an essential step
but only after ultrasound assessment has identified suspicious characteristics. Ordering a serum
calcitonin level would not be the first-line approach without specific indicators for medullary
thyroid cancer.

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Untreated hyperthyroidism can lead to hypothyroidism, as the thyroid gland may become
exhausted and unable to produce adequate levels of thyroid hormone.
Graves' disease is an autoimmune condition that leads to hyperthyroidism. Symptoms of
palpitations, tremors, weight loss, and increased appetite, combined with the physical
examination findings of a diffusely enlarged thyroid gland and eye changes (ophthalmopathy),
Methimazole generally the first-line pharmacologic, propylthiouracil may be considered if
methimazole is ineffective. RAI or thyroidectomy result in complete destruction or removal of
the thyroid gland and are generally reserved for when more conservative measures fail or are
inappropriate due to severity of the condition.
Methimazole is a medication used to reduce the production of thyroid hormone in the treatment
of hyperthyroidism, such as in Graves' disease. Propranolol is sometimes prescribed as an
adjunct to alleviate symptoms such as palpitations or tremors. Methimazole therapy is limited in
duration. Agranulocytosis is a potential side effect of methimazole, so patients should be
instructed to report fever, fatigue, or other signs of infection that could indicate the presence of
this dangerous condition. Thyroid function tests are performed periodically during therapy to
evaluate effectiveness, and prothombin time is also periodically evaluated because the drug may
promote bleeding.
Thyroid storm is a severe, life-threatening manifestation of hyperthyroidism, presenting with a
distinct clinical picture of severe agitation, fever, tachycardia, and other systemic manifestations.
An excessively high dosage of methimazole would contribute to hypothyroid symptoms.
The most appropriate first step in treating growth hormone deficiency is to initiate subcutaneous
recombinant human growth hormone, which helps in growth and development by replacing the
deficient hormone.
Octreotide is a first-line treatment for acromegaly, a condition characterized by excessive
growth hormone production, pegvisomant is used as a second-line treatment for acromegaly.
Bromocriptine and cabergoline are used for the treatment of prolactinomas.
Central precocious puberty, characterized by early activation of the hypothalamic-pituitary-
gonadal axis. Central precocious puberty is the most common form of precocious puberty and
presents symptoms of early sexual maturation. symptoms, such as development of pubic hair and
breast tissue, advanced skeletal maturation, elevated LH level, and positive response to a GnRH
stimulation test
Peripheral precocious puberty is less common and is typically caused by an underlying
condition such as a tumor or congenital adrenal hyperplasia.
The appropriate initial diagnostic step for the patient's symptoms, which are suggestive of
hyperprolactinemia, is to assess serum prolactin levels. This will confirm the elevation of
prolactin and guide further evaluation.