Endocrine System


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M16_F1.jpg"}},{"insert":"\n\n"},{"insert":"Winter has arrived, with the usual colds and pneumonias in tow.\n\n\u0022Maybe this wasn\u0027t the best day to begin cutting back on coffee,\u0022 you think while walking toward the ER.\n\nA few seconds later, the alarm sounds\u2026\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M16_F2.jpg"}},{"insert":"\n\n"},{"insert":"You arrive in the ER and see a young woman lying unconscious and intubated.\n\nThe paramedics inform you that Saoirse, 21 years old, is a regular at your hospital. She was diagnosed with type 1 diabetes mellitus five years ago.\n\nHer medical records show that she is on basal insulin twice a day and short-acting insulin before the three main meals, based on carbohydrate counting. Her diabetes is poorly controlled due to inadequate adherence to medication.\n\nHer BP is 80\/54 mmHg and pulse 110 bpm, with rapid sighing respirations. She weighs 50 kg.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M16_F3.jpg"}},{"insert":"\n\n"},{"insert":"A blood gas analysis shows:\n\nSaturation: 99% (on 100% oxygen) \r\npH: 7.05 (7.35-7.45) \r\npO2: 103 mmHg (75-100) \r\npCO2: 30 mmHg (35-45) \r\nBicarbonate: 8 mmol\/L (18-22) \r\nABE: -20.1 mEq\/L (-2 to +2) \r\nK+: 5.9 mmol\/L (3.5-5) \r\nNa+: 149 mmol\/L (135-145)\nCl-: 107 mEq\/L (96-106)\r\nGlucose: 405 mg\/dL (65-110)\nAnion gap: 34 mEq\/L\n\nA urine dipstick analysis is positive for ketone bodies.\n\nYou realize that Saoirse may have diabetic ketoacidosis and order a complete blood count and blood cultures to exclude potential precipitating causes.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M16_F5.jpg"}},{"insert":"\n\n"},{"insert":"A puzzled look from the nurse causes you to recheck the treatment guidelines.\n\nDespite Saoirse\u0027s serum sodium corrected for hyperglycemia being 156 mEq\/L, the initial fluid of choice is isotonic saline. After the first liter, you can switch to hypotonic saline if her sodium levels are still high.\n\nWhile perusing through the guidelines, you also realize that bicarbonate is not indicated right now.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M16_F6.jpg"}},{"insert":"\n\n"},{"insert":"\u0022Does she really need bicarbonate?\u0022 your intern asks.\n\nYou recall the guidelines and delete the prescription for bicarbonate, forcing a smile and saying that you were just checking to see if she was paying attention.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M16_F7.jpg"}},{"insert":"\n\n"},{"insert":"As per current guidelines, you decide to start Saoirse on isotonic saline.\n"}]}


{"ops":[{"insert":"Now that the fluids are in, you turn your attention to insulin therapy.\n\nWhat will you order?\n"}]}
1. A bolus of regular insulin
2. A continuous infusion of regular insulin
3. A bolus of regular insulin, followed by a continuous infusion


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M16_F11.jpg"}},{"insert":"\n\n"},{"insert":"\u0022Do you agree with giving a bolus?\u0022, you quiz the medical students doing a rotation with you.\n\nA highly eager student chirps out, \u0022You can\u0027t catch us, doctor! If the insulin infusion can be started without delay, the initial insulin bolus is not necessary\u0022\n\n\u0022Excellent! You know the guidelines inside-out!\u0022 you smile at her.\n\nAfter all, who would believe that you yourself didn\u0027t have such a good grasp of them?\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M16_F10.jpg"}},{"insert":"\n\n"},{"insert":"\u0022Do you agree with starting an infusion immediately?\u0022 you quiz the medical students doing a rotation with you.\n\nA highly eager student chirps out that while some guidelines state that the appropriate treatment is to begin with an insulin bolus, there has been some controversy regarding that point.\n\n\u0022Excellent!\u0022 you say, highly pleased.\n\n\u0022If the insulin infusion can be started without delay, the initial insulin bolus is not necessary.\u0022\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M16_F12.jpg"}},{"insert":"\n\n"},{"insert":"A re-evaluation of Saoirse\u0027s blood gases after an hour shows the following:\n\nSaturation: 99% (on 100% oxygen) \r\npH: 7.20 (7.35-7.45) \r\npO2: 92 mmHg (75-100) \r\npCO2: 36 mmHg (35-45) \r\nBicarbonate: 13.6 mmol\/L (18-22) \r\nABE: -12.8 mEq\/L (-2 to +2) \r\nK+: 5.3 mmol\/L (3.5-5) \r\nNa+: 143 mmol\/L (135-145)\nCl-: 100 mEq\/L (96-106)\r\nGlucose: 394 mg\/dL (65-110)\nAnion gap: 29.4 mEq\/L\n\nHer BP is now 110\/76 mmHg and her pulse is 89 bpm.\n"}]}


{"ops":[{"insert":"You realize that after one hour, Saoirse\u0027s glucose has gone from 405 mg\/dL to 394 mg\/dL.\n\nWhat will you do now?\n"}]}
1. Continue the current insulin infusion rate
2. Double the insulin infusion every hour until a steady glucose decline is achieved
3. Administer an additional bolus of insulin


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M16_F15.jpg"}},{"insert":"\n\n"},{"insert":"Your intern points out that Saoirse\u0027s glucose levels are not improving quickly enough. She suggests doubling the insulin infusion to improve glycemic control, to which you agree.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M16_F10.jpg"}},{"insert":"\n\n"},{"insert":"\u0022Maybe we should give a bolus?\u0022 you ponder out loud.\n\nYou intern looks surprised. \u0022Shouldn\u0027t we just double the infusion rate?\u0022 she asks.\n\nYou realize that she is right. Good thing at least one doctor on the team is familiar with the guidelines!\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M16_F7.jpg"}},{"insert":"\n\n"},{"insert":"You decide to double the insulin infusion every hour until a steady glucose decline between 50-75 mg\/h is achieved.\n"}]}


{"ops":[{"insert":"You realize that Saoirse\u0027s fluid therapy might also need to be adjusted. Glancing at the investigation results, you note again that her glucose is 394 mg\/dL and serum sodium is 143 mmol\/L.\n\nWhat will you do?\n"}]}
1. Give her another liter of isotonic saline
2. Give her another liter of hypotonic saline


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M16_F14.jpg"}},{"insert":"\n\n"},{"insert":"Your intern calculates the sodium corrected for hyperglycemia to be 150 mEq\/L.\n\nYou recall that according to the guidelines, after the first liter you can choose hypotonic saline, e.g., 1L of 0.45% NaCl, if the hypernatremia persists.\n"}]}


{"ops":[{"insert":"Saoirse\u0027s sodium corrected for hyperglycemia is 150 mEq\/L. Given the persistent hypernatremia, you decide to start her on hypotonic saline.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M16_F7.jpg"}},{"insert":"\n\n"},{"insert":"You turn your attention to Saoirse\u0027s serum potassium levels. The latest reading was 5.3 mmol\/L.\n\nWhat will you do?\n"}]}
1. Do nothing for now
2. Start K+ correction with 20 mEq/L
3. Start K+ correction with 40 mEq/L


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M16_F15.jpg"}},{"insert":"\n\n"},{"insert":"Your intern points out that since insulin promotes internalization of potassium, Saoirse\u0027s levels will probably keep falling, so it may be a good idea to start supplementation.\n\nFeeling somewhat embarrassed, you agree.\n"}]}


{"ops":[{"insert":"As insulin promotes internalization of potassium, it is a good idea to start supplementation.\n\nHowever, after discussing with your intern, you realize that 40 mEq\/L may be too much to start with.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M16_F19.jpg"}},{"insert":"\n\n"},{"insert":"You get Saoirse started on potassium correction with a 20 mEq\/L solution. Two hours later, she is conscious and doing well.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M16_F12.jpg"}},{"insert":"\n\n"},{"insert":"After an hour, Saoirse\u0027s sugars have risen to 345 mg\/dL.\n\nYou remember that the insulin infusion needs to be maintained for another 1 to 2 hours after starting subcutaneous insulin, as the latter has a delayed onset of action.\n\nThus, you subsequently add a prescription for an insulin infusion to her chart.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M16_F22.jpg"}},{"insert":"\n\n"},{"insert":"When the next blood test results arrive, you notice worsened renal functions.\n\nYou realize that diabetic ketoacidosis can cause severe dehydration and that you should have prolonged the IV fluids. Thus, you add 1L of 5% dextrose to her prescription chart.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M16_F34.jpg"}},{"insert":"\n\n"},{"insert":"Following the correct fluid and insulin therapy, Saoirse makes a good recovery. She is soon stable enough to be transferred to the medical ward. She waves bye to you as she is taken away.\n\nA short while later, your shift ends. Feeling highly satisfied with yourself, you leave the hospital for a well-deserved weekend vacation.\n\nWell done!\n"}]}

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