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Block 9 Board Review. Endocrine/Rheum 14Feb14 Chauncey D. Tarrant, M.D. Chief of Residents 13-14. Pediatrics In Review Articles. Type 1 DM Hypothyroidism in Children Kawasaki Disease Index of Suspicion. Quiz( zes )!!!. Type 1 DM.

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block 9 board review

Block 9 Board Review

Endocrine/Rheum

14Feb14

Chauncey D. Tarrant, M.D.

Chief of Residents 13-14

pediatrics in review articles
Pediatrics In Review Articles
  • Type 1 DM
  • Hypothyroidism in Children
  • Kawasaki Disease
  • Index of Suspicion
slide5

1. You see a 12-year-old boy with a complaint of frequent urination. His mother is concerned because her father

has had type 2 diabetes mellitus for several years. Urinalysis in the office shows the presence of glucose. You

suspect that the boy may have type 1 diabetes mellitus because he also has

A. Acanthosisnigricans.

B. An elevated body mass index.

C. Hispanic heritage.

D. Hypertension.

E. Weight loss.

slide6

1. You see a 12-year-old boy with a complaint of frequent urination. His mother is concerned because her father

has had type 2 diabetes mellitus for several years. Urinalysis in the office shows the presence of glucose. You

suspect that the boy may have type 1 diabetes mellitus because he also has

A. Acanthosisnigricans.

B. An elevated body mass index.

C. Hispanic heritage.

D. Hypertension.

E. Weight loss.

slide7

2. A 6-year-old girl is admitted for new-onset hyperglycemia (ie, a fasting blood glucose level greater than 250 mg/dL). She has had symptoms for approximately 2 weeks and looks ill. The most appropriate of the following serum levels to measure first is

A. Autoantibodies.

B. Electrolytes.

C. Insulin.

D. lipids.

E. Transaminases.

slide8

2. A 6-year-old girl is admitted for new-onset hyperglycemia (ie, a fasting blood glucose level greater than 250

mg/dL). She has had symptoms for approximately 2 weeks and looks ill. The most appropriate of the following

serum levels to measure first is

A. Autoantibodies.

B. Electrolytes.

C. Insulin.

D. lipids.

E. Transaminases.

slide9

3. You are reviewing dosage and management of insulin with a 9-year-old girl who weighs 35 kg and has had type 1 diabetes mellitus for several years. You calculate her total daily dose of insulin; she states she is receiving 25 units per day. The following statement that is true and relevant to her dosage is that

A. After diagnosis of type 1 diabetes mellitus, the “honeymoon phase” lasts approximately 24 months.

B. Approximately 50% of the total daily insulin prescribed is long acting, with the other 50% being short acting.

C. The “mixed-split” regimen of insulin dosing allows for greater flexibility in diet than the “basal–bolus” regimen.

D. Prepubertal children tend to require a higher total daily dose of insulin.

E. The usual total daily dose of insulin is between 2 and 3 units/kg per day.

slide10

3. You are reviewing dosage and management of insulin with a 9-year-old girl who weighs 35 kg and has had type 1 diabetes mellitus for several years. You calculate her total daily dose of insulin; she states she is receiving 25 units per day. The following statement that is true and relevant to her dosage is that

A. After diagnosis of type 1 diabetes mellitus, the “honeymoon phase” lasts approximately 24 months.

B. Approximately 50% of the total daily insulin prescribed is long acting, with the other 50% being short acting.

C. The “mixed-split” regimen of insulin dosing allows for greater flexibility in diet than the “basal–bolus” regimen.

D. Prepubertal children tend to require a higher total daily dose of insulin.

E. The usual total daily dose of insulin is between 2 and 3 units/kg per day.

slide11

4. A 3-year-old boy presents to the emergency department in diabetic ketoacidosis (ie, a blood sugar level of 450mg/dL). You resuscitate him with isotonic solution and admit him to your intensive care unit for monitoring. He is treated with normal saline and insulin at a rate of 0.1 unit/kg per hour. His blood glucose level gradually falls to 180 mg/dL, but ketosis persists, and the serum bicarbonate concentration is 13 mg/dL. At this time, the most appropriate medical management is to

A. Add bicarbonate to IV fluids, continue insulin infusion.

B. Add bicarbonate to IV fluids, discontinue insulin infusion.

C. Add dextrose to IV fluids, continue insulin infusion.

D. Add dextrose to IV fluids, discontinue insulin infusion.

E. Discontinue IV fluids, change to subcutaneous insulin.

slide12

4. A 3-year-old boy presents to the emergency department in diabetic ketoacidosis (ie, a blood sugar level of 450mg/dL). You resuscitate him with isotonic solution and admit him to your intensive care unit for monitoring. He is treated with normal saline and insulin at a rate of 0.1 unit/kg per hour. His blood glucose level gradually falls to 180 mg/dL, but ketosis persists, and the serum bicarbonate concentration is 13 mg/dL. At this time, the most appropriate medical management is to

A. Add bicarbonate to IV fluids, continue insulin infusion.

B. Add bicarbonate to IV fluids, discontinue insulin infusion.

C. Add dextrose to IV fluids, continue insulin infusion.

D. Add dextrose to IV fluids, discontinue insulin infusion.

E. Discontinue IV fluids, change to subcutaneous insulin.

slide13

5. A 5-year-old girl is undergoing treatment for diabetic ketoacidosis. Her level of consciousness fluctuates, she is vomiting repeatedly, and her diastolic blood pressure is 105 mm Hg. You should immediately

A. Add bicarbonate to the intravenous fluids.

B. Administer mannitol.

C. Administer potassium.

D. Infuse hypotonic saline solution.

E. Obtain neuroimaging to look for cerebral edema

slide14

5. A 5-year-old girl is undergoing treatment for diabetic ketoacidosis. Her level of consciousness fluctuates, she is vomiting repeatedly, and her diastolic blood pressure is 105 mm Hg. You should immediately

A. Add bicarbonate to the intravenous fluids.

B. Administer mannitol.

C. Administer potassium.

D. Infuse hypotonic saline solution.

E. Obtain neuroimaging to look for cerebral edema

what are the signs and symptoms of type i dm1
What are the signs and symptoms of Type I DM?
  • Classically, polydypsia, polyuria, polyphagia, and weight loss
    • Also may see nocturiaor enuresis
what is the best way to achieve good control of type 1 dm1
What is the best way to achieve good control of Type 1 DM??
  • Insulin
  • Diet
  • Exercise
  • Psychologic acceptance of the disease
slide21

What is the value of Hemoglobin A1C in the management of T1DM?

    • Give a snapshot into glucose control for the last 3-4 months
what is the honeymoon period1
What is the honeymoon period?

When endogenous insulin secretion from remaining b-cells continues, and in many cases, insulin doses must be lowered to prevent hypoglycemia.

how do you manage sick days in t1dm1
How do you manage sick days in T1DM?
  • Check BG and ketone levels q 3-4h
  • Correct with short acting insulin q 3-4 hrs even if not eating
  • DO NOT WITHOLD INSULIN
  • Encourage fluid intake (1oz per year of age per hrin sips)
  • Glc >200 sugar free fluids
  • Glc <200 sugar containing fluids
what are some long term complications for t1dm when should we screen for them1
What are some long term complications for T1DM? When should we screen for them?
  • Nephropathy
    • Age 10 and disease x5yrs
  • Neuropathy
    • Annual foot exam starting at puberty
  • Retinopathy
    • Age 10 and disease 3-5yrs
  • Macrovascular disease
what other autoimmune diseases are associated with t1dm1
What other Autoimmune Diseases are associated with T1DM?
  • Thyroid Disease
    • (20% prevalence)
  • Celiac Disease
    • (4.5% prevalence)
how do you manage hypoglycemia in diabetic patients1
How do you manage hypoglycemia in diabetic patients?
  • Glc <70g/dL; give 15g carbs (glucose tabs or candy)
  • Goal to get Glc >100g/dL
  • If not, REPEAT
  • Give 0.5 to 1mg Glucagon IM if unconscious or PO intolerant
what criteria justifies dka1
What criteria justifies DKA?
  • pH 7.3 and below
  • Bicarbonate of 15 or less
  • Glucose >200
dka treatment1
DKA treatment??
  • Plan to rehydrate over 48hrs
  • Fluid resuscitate with isotonic fluids
  • Fluids at 1.5 or 2x maintenance
    • 1/2NS +KCl and 1/2NS +Kphos
  • Add Glucose to fluids once BG <300
  • Insulin drip (NO BOLUS)
    • 0.1u/kg/hr
  • Frequent labs (ABG, Glucose, Electrolytes Q2)
dka complications1
DKA Complications??
  • Hypokalemia
  • Hypoglycemia
  • Cerebral Edema
  • Shock
what s the risk of using bicarbonate in dka1
What’s the risk of using Bicarbonate in DKA?
  • Use has been associated with cerebral edema
slide43

5. Which of the following statements regarding congenital hypothyroidism is true?

A. Goiter is a common feature seen in infants who have hypothyroidism.

B. Males are affected more commonly than females.

C. Most neonates show clinical features of hypothyroidism at birth.

D. Preterm infants often have abnormal screening results due to delayed rise in T4 values.

E. The most common cause is maternal antibody-mediated hypothyroidism.

slide44

5. Which of the following statements regarding congenital hypothyroidism is true?

A. Goiter is a common feature seen in infants who have hypothyroidism.

B. Males are affected more commonly than females.

C. Most neonates show clinical features of hypothyroidism at birth.

D. Preterm infants often have abnormal screening results due to delayed rise in T4 values.

E. The most common cause is maternal antibody-mediated hypothyroidism.

slide45

6. A 2-week-old neonate born at 36 weeks’ gestation is receiving antibiotic therapy and ventilator support for presumed pneumonia and sepsis. Thyroid studies are performed because the neonatal screening result was abnormal. These studies reveal low total T4, low T3, low TSH, and normal free T4 values. Of the following, the most likely cause of these findings is:

A. Autoimmune thyroiditis.

B. Central hypothyroidism.

C. Nonthyroidal illness (euthyroid sick syndrome).

D. Thyroid aplasia.

E. Thyroxinedyshormonogenesis.

slide46

6. A 2-week-old neonate born at 36 weeks’ gestation is receiving antibiotic therapy and ventilator support for

presumed pneumonia and sepsis. Thyroid studies are performed because the neonatal screening result was

abnormal. These studies reveal low total T4, low T3, low TSH, and normal free T4 values. Of the following,

the most likely cause of these findings is:

A. Autoimmune thyroiditis.

B. Central hypothyroidism.

C. Nonthyroidal illness (euthyroid sick syndrome).

D. Thyroid aplasia.

E. Thyroxinedyshormonogenesis.

slide47

7. Which of the following clinical features is most likely to be present at birth in a neonate who has

congenital hypothyroidism?

A. Bradycardia.

B. Increased muscle tone.

C. Jitteriness.

D. Microcephaly.

E. Normal for gestational age weight and length.

slide48

7. Which of the following clinical features is most likely to be present at birth in a neonate who has

congenital hypothyroidism?

A. Bradycardia.

B. Increased muscle tone.

C. Jitteriness.

D. Microcephaly.

E. Normal for gestational age weight and length.

slide49

8. You are evaluating a 10-year-old girl who has constipation and a recent decline in school performance.

Thyroid studies ordered as part of your evaluation reveal the following: low total T4, low free T4, low TSH,

and low T3 values. A TRH stimulation test results in elevation of the TSH to normal values. Which of the

following is the most likely cause of her symptoms?

A. Ectopic thyroid gland.

B. Hashimoto thyroiditis.

C. Hypothalamic tumor.

D. Inborn error of thyroid metabolism.

E. Thyroid-binding globulin deficiency.

slide50

8. You are evaluating a 10-year-old girl who has constipation and a recent decline in school performance. Thyroid studies ordered as part of your evaluation reveal the following: low total T4, low free T4, low TSH, and low T3 values. A TRH stimulation test results in elevation of the TSH to normal values. Which of the

following is the most likely cause of her symptoms?

A. Ectopic thyroid gland.

B. Hashimoto thyroiditis.

C. Hypothalamic tumor.

D. Inborn error of thyroid metabolism.

E. Thyroid-binding globulin deficiency.

what are the consequences of untreated hypothyroidism in the neonate1
What are the consequences of untreated hypothyroidism in the neonate?
  • Lower IQ/decreased intellectual development
what are the signs and symptoms of untreated congenital and aquired hypothyroidism1
What are the signs and symptoms of untreated congenital and aquired hypothyroidism?
  • Lethargy
  • Hypotonia
  • Hoarse cry
  • Feeding problems
  • Constipation
  • Macroglossia
  • Umbical hernia
  • Dry skin
  • Hypothermia
  • Prolonged jaundice
what are causes of congenital hypothyroidism aquired1
What are causes of congenital hypothyroidism? Aquired?
  • Congenital
    • Thyroid dysgenesis
    • Inborn errors of thyroxine synthesis
    • Maternal antibiody mediated hypothyroidism
    • Central hypothyroidism
    • Transient hypothyroidism
    • Iodide deficiency
  • Aquired
    • Primary
      • Autoimmune
      • Postablation
      • Irradiation
      • Medications
      • Late onset Congenital
    • Secondary
      • Pituitary
    • Tertiary
      • Hypothalamus
    • Miscellaneous
      • Thyroid hormone resistance
what is the prognosis of patients with hypothyroidism1
What is the prognosis of patients with hypothyroidism?
  • Depends on duration of illness and age at which treatment was started but it is generally good
what lab findings are present in tbg deficiency1
What lab findings are present in TBG deficiency?
  • Low T4
  • Low or normal free T4
  • Normal TSH
slide65

1. A 3-year-old boy has had an unremitting fever for 4 days. Which of the clinical findings below best supports Kawasaki disease (KD) as the explanation for his fever?

A. Bilateral cervical lymphnodeenlargement

B. Bilateral nonexudative conjunctivitis

C. Periungual peeling of fingers and toes

D. Tonsillar exudate

E. Vesicles on the palms and soles

slide66

1. A 3-year-old boy has had an unremitting fever for 4 days. Which of the clinical findings below best supports

Kawasaki disease (KD) as the explanation for his fever?

A. Bilateral cervical lymphnodeenlargement

B. Bilateral nonexudative conjunctivitis

C. Periungual peeling of fingers and toes

D. Tonsillar exudate

E. Vesicles on the palms and soles

slide67

2. You are aware that other conditions can cause a similar clinical pattern. In your evaluation of this child, which of the following conditions is initially most likely to be confused with KD?

A. Adenoviral infection

B. Pauciarticular juvenile arthritis

C. Rubella

D. Staphylococcal scarlet fever

E. Varicella-zoster

slide68

2. You are aware that other conditions can cause a similar clinical pattern. In your evaluation of this child, which

of the following conditions is initially most likely to be confused with KD?

A. Adenoviral infection

B. Pauciarticular juvenile arthritis

C. Rubella

D. Staphylococcal scarlet fever

E. Varicella-zoster

slide69

3. You order laboratory tests to add further diagnostic insights. Which of the following findings strengthen your impression that the child has KD?

A. Elevated erythrocyte sedimentation rate

B. Lymphocytosis

C. Microcytic anemia

D. Neutropenia

E. Thrombocytopenia

slide70

3. You order laboratory tests to add further diagnostic insights. Which of the following findings strengthen your

impression that the child has KD?

A. Elevated erythrocyte sedimentation rate

B. Lymphocytosis

C. Microcytic anemia

D. Neutropenia

E. Thrombocytopenia

slide71

4. A 3-year-old girl meets clinical criteria for KD. You realize that the greatest threat to her is coronary artery disease. The best choice for initial imaging of the coronary arteries is

A. Cardiac catheterization

B. Computed tomography

C. Magnetic resonance angiography

D. Radionuclide imaging

E. Two-dimensional echocardiography

slide72

4. A 3-year-old girl meets clinical criteria for KD. You realize that the greatest threat to her is coronary artery disease. The best choice for initial imaging of the coronary arteries is

A. Cardiac catheterization

B. Computed tomography

C. Magnetic resonance angiography

D. Radionuclide imaging

E. Two-dimensional echocardiography

slide73

5. Although her echocardiography shows no coronary artery lesions, you realize that the girl is at risk for

developing coronary artery disease and requires preventive therapy. The treatment that lowers the incidence of coronary artery disease in KD the most is high-dose

A. Aspirin

B. Corticosteroids

C. Cyclosporine A

D. Infliximab

E. Intravenous immune globulin

slide74

5. Although her echocardiography shows no coronary artery lesions, you realize that the girl is at risk for

developing coronary artery disease and requires preventive therapy. The treatment that lowers the incidence of coronary artery disease in KD the most is high-dose

A. Aspirin

B. Corticosteroids

C. Cyclosporine A

D. Infliximab

E. Intravenous immune globulin

what lab abnormalities might you see in kawasaki disease1
What lab abnormalities might you see in Kawasaki Disease?
  • Leukocytosis
  • Normocytic, normochromic anemia
  • Thrombocytosis
  • Elevated ESR/CRP
  • Elevated transaminases
  • Elevated GGT
  • Sterile pyuria