Hypothyroidism & Hyperthyroidism
Prepared by: Roland Jules Bautista Naval, RN, USRN
Hyperthyroidism
Pathogenesis Hypothalamus/pituitary condition, Grave’s disease, toxic multinodular goiter/
Plummer's disease, thyroiditis, hypothyroid medication (levothyroxine), excess iodine
intake
Diagnostics High T3 & T4, low TSH
Manifestation Exophthalmos (Grave’s disease), heat intolerance, weight loss, tachycardia, HTN,
diarrhea, tremors
Management • Avoid aspirin (salicylates)
• Beta blocker
• Antithyroid hormone: methimazole (tapazole), propylthiouracil (PTU)
• Radioactive iodine
• Thyroidectomy: lugol’s solution (pre-op to prevent bleeding and thyroid storm
prevention), levothyroxine (hormone replacement therapy)
Complication • Thyroid Storm
• Accidental laryngeal damage due to thyroidectomy
• Hypocalcemia due to damaged or accidental removal of parathyroid gland
Hypothyroidism
Pathogenesis Hypothalamus/pituitary condition, Hashimoto’s thyroiditis, hyperthyroid medication
such as methimazole (tapazole), low iodine intake, thyroidectomy
Diagnostics Low T3 and T4, high TSH
Manifestation Weight gain, cold intolerance, bradycardia, hypotension, fatigue
Management Hormone replacement therapy: levothyroxine
Complication Hypoglycemia due to decreased metabolic rate
ADH will be increased due to hypotension, but could lead to hyponatremia
Myxedema coma: respiratory depression and altered mental status
Cretinism: congenital hypothyroidism
Cretinism: congenital hypothyroidism
Cushing’s Disease/Syndrome &
Addison’s Disease
Prepared by: Roland Jules Bautista Naval, RN, USRN
Cushing’s Disease/ Syndrome
Pathogenesis Cushing’s Disease (due to pituitary tumor); Cushing’s syndrome (non-pituitary cause),
adrenal tumor, small cell lung cancer/ carcinoma, prolonged steroid therapy
Diagnostics High cortisol
Manifestation Weight gain, HTN, moon face, buffalo hump, truncal obesity, purple striae,
hyperglycemia, hirsutism
Management • Hypophysectomy: surgical removal of the pituitary gland
• Adrenalectomy is the surgical removal of adrenal gland; HRT: hydrocortisone
(cortisol), fludrocortisone (aldosterone)
• Glucose monitoring
• Potassium level monitoring due to hypernatremia
• Gradual steroid withdrawal
• Medications: Metyrapone, Ketoconazole
Complication • Cardiovascular condition like HTN
• Hyperglycemia
• Osteoporosis/ fracture
• Immunosuppression
Buffalo hump/ dorsocervical fat pad Moon face, truncal obesity, and purple striae
Addison’s Disease
Pathogenesis Autoimmune condition, Ca, TB, HIV, trauma or hemorrhage in adrenal gland
Diagnostics Low cortisol, low aldosterone
Manifestation Weight loss, hypotension, hypoglycemia, bronze skin due to excess ACTH which
can stimulate melanin production
Management Hormone Replacement Therapy (HRT): hydrocortisone, fludrocortisone
IV hydrocortisone, Dextrose 5% & 0.9% Normal Saline (NaCl)/ D5NS for
Addisonian crisis
Complication Addisonian crisis: hypotension, DHN, hypoglycemia, hyponatremia; hyperkalemia
Syndrome of Inappropriate
Antidiuretic Hormone (SIADH) &
Diabetes Insipidus
Prepared by: Roland Jules Bautista Naval, RN, USRN
Diabetes Insipidus
Pathogenesis Hypothalamus/ pituitary gland condition
Kidney disease
Diagnostics Low ADH
Low urine specific gravity (normal: 1.005 to 1.030)
Low urine osmolality (normal: 300 to 900 mOsm/kg)
Hypernatremia
Manifestation Polyuria (at least 3 liters per day), polydipsia, DHN, hypotension,
Management Desmopressin (vasopressin)
DHN management
Hypotonic IV solution
Complication Altered neurological status
Hypovolemic shock
Hypernatremia may lead to hypokalemia
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
Pathogenesis Hypothalamus and /or pituitary gland condition, Small cell lung carcinoma
Diagnostics High ADH
High urine specific gravity (normal: 1.005 to 1.030)
High urine osmolality (normal: 300 to 900 mOsm/kg)
Dilutional hyponatremia
Manifestation Weight gain
HTN
Management Fluid restriction
Diuretics
Demeclocycline
Vaptans (Vasopressin Receptor Antagonists)
Hypertonic IV solution
Complication Altered neurological status
Hyponatremia may lead to hyperkalemia
Diabetes: I, II, Gestational
Prepared by: Roland Jules Bautista Naval, RN, USRN
Physiology
• Glucose
• Insulin
(beta cell) Cell
Pancreas Bloodstream
Liver
Glucagon
(alpha cell)
Diabetes Mellitus Type I/ Juvenile Diabetes/ Insulin-Dependent Diabetes
Mellitus (IDDM)
Pathogenesis Autoimmune disease: low insulin/does not produce insulin
Diagnostics Please refer to the diagnostics
Manifestation Polyuria, polydipsia, polyphagia, weight loss
Management Hormone replacement therapy: insulin
Complication Diabetic Ketoacidosis (DKA): fruity-scent/ acetone breath, Kussmaul breathing
Retinopathy, nephropathy, and neuropathy
Diabetes Mellitus Type II/Non-Insulin Dependent Diabetes Mellitus (NIDDM)
Pathogenesis Insulin resistance
Beta cell exhaustion/ not enough insulin
Diagnostics Please refer to the diagnostics
Manifestation Polyuria, polydipsia, polyphagia, weight loss, acanthosis nigricans
Management Lifestyle modification
OHA: metformin
Hormone replacement therapy: insulin
Complication Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)
Retinopathy, nephropathy, and neuropathy
Gestational Diabetes Mellitus (GDM)
Pathogenesis Insulin resistance due to progesterone, human placental lactogen, estrogen
Diagnostics Please refer to the diagnostics
Manifestation Polyuria, polydipsia, polyphagia, acanthosis nigricans
Management Lifestyle modification
OHA: metformin
Hormone replacement therapy: insulin
Complication Macrosomia
GDM may be resolved post-pregnancy or may lead to DM Type II
Acanthosis Nigricans
Hyperglycemia: hot and dry skin, sugar is high
Hypoglycemia: cold and clammy skin needs
candy (simple carbohydrates)
Oral Hypoglycemic Agent
• Biguanides: Metformin
• Thiazolidinediones: Pioglitazone
• Sulfonylureas: Glibenclamide, Glimepiride
• DPP-4 Inhibitors: Sitagliptin, Linagliptin
• SGLT2 Inhibitors: Dapagliflozin, Canagliflozin
• Alpha-glucosidase inhibitors: Acarbose
1. RBS:
N: 80-120 mg/dL
DM: 200 mg/dL and above
2. FBS:
N: 70-100mg/dL
DM: 126 mg/dL and above
3. Post-prandial blood sugar (2 hours after a meal):
Diagnostics N: 90-140 MG/dL
DM: 200 mg/dL and above
4. Glycosylated Hemoglobin or HbA1c (average glucose in the hemoglobin over
previous three months, hence fasting is not needed):
N: 5.7 %
DM: 6.5 % and above
5. Glucose Tolerance Test (8-hour fasting for FBS and urine sample, drink 100g
glucose solution, then blood glucose and urine will be tested after 2 and 3 hours):
N: 90-140 mg/dL
DM: 200 mg/dl and above
Continuous Glucose Monitor (CGM)
Insulin Time course Onset Peak- Duration
Hypoglycemia
risk
Lispro Rapid-acting 10-15 mins 1 hour 2-4 hours
(Humalog)
Regular Short-acting 30 mins- 1hour 2-3 hour 4-6 hours
(Humulin R)
• Neutral Intermediate- 1-2 hours 4-12 hours 16-20 hour
Protamine acting
Hagedorn
(NPH)
• Humulin N
• Ultralente Long-acting 1-2 hr No peak hours 20-30 hours
• Lantus
Insulin Risk
• Hypoglycemia
• Dawn phenomenon: 5- 6 AM prebreakfast hyperglycemia
• Somogyi effect: Hypoglycemia at 2-3 AM, Hyperglycemia at 7
AM
• Lipodystrophy: tumor-like or dimpling due to repeated insulin
injection on the same site
