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1. What is the difference between Cushing's disease and Cushing's syndrome?

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1. What is the difference between Cushing's disease and Cushing's syndrome?

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Cushing syndrome refers to the clinical manifestations resulting from chronic exposure to excess cortisol regardless of cause. Cushing disease refers to excess endogenous secretion of ACTH, it is more common for women, but men have more severe symptoms.

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2 What are the hormones affected? What are the possible causes?

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2 What are the hormones affected? What are the possible causes?

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- The adrenal gland produces too much cortisol (over a long period of time)
- Most often caused by hormone secreting tumors
- People taking cortisol-like medications such as prednisone

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1. What would you expect the lab results to look like if the pt has Addison's disease?

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1. What would you expect the lab results to look like if the pt has Addison's disease?

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Low sodium

Low levels of cortisol

High ACTH

BUN levels increased

Glucose levels low

Lymphocyte counts elevated

Hyperkalemia is seen in Addison disease and may cause mild alkalosis

CT scan so assess size of adrenal glands

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1) What is hypothyroidism? What is Hashimoto Disease? What are the hormones affected? What are the possible causes?

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1) What is hypothyroidism? What is Hashimoto Disease? What are the hormones affected? What are the possible causes?

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Hypothyroidism results from deficient production of TH by the thyroid gland. Hypothyroidism is the most common disorder of thyroid function, affects between 1% and 2% of the U.S. population, and occurs more commonly in women. It may be primary or central.

Lack of TH negative feedback on pituitary TSH secretion leading to decreased levels of T4 and T3.

The most common cause of primary hypothyroidism in the United States is autoimmune thyroiditis (Hashimoto disease), which results in gradual inflammatory destruction of thyroid tissue by infiltration of autoreactive T lymphocytes and circulating thyroid autoantibodies (antithyroid peroxidase and antithyroglobulin antibodies). This disorder is linked with several genetic risk factors and is commonly associated with other autoimmune conditions.

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2. What is Addison's disease? What hormones are affected? What is the possible causes? 

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2. What is Addison's disease? What hormones are affected? What is the possible causes? 

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Low levels of cortisol secretion

Addison’s is caused by autoimmune mechanisms that destroy adrenal cortical cells.

Inadequate stimulation of the adrenal glands by ACTH or because of primary inability of the adrenals to produce and secret the adrenocortical hormones

Sometimes there is partial dysfunction of the adrenal cortex, so only synthesis of cortisol and aldosterone or the adrenal androgens is affected

Hypofunction of the adrenal cortex may affect glucocorticoid or mineral corticoid

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The normal diurnal or circadian secretion patterns of ACTH and cortisol are lost and there is no increase in ACTH and cortisol secretion in response to a stressor. With ACTH-dependent hypercortisolism, the excess ACTH stimulates excess production of cortisol and there is a loss of feedback control of ACTH secretion. In individuals with ACTH-dependent hypercortisolism, secretion of both cortisol and adrenal androgens is increased, and cortisol-releasing hormone is inhibited. ACTH-independent secreting tumors of the adrenal cortex, however, generally secrete only cortisol. When the secretion of cortisol by the tumor exceeds normal cortisol levels, symptoms of hypercortisolism develop.

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4. Identify and explain the common manifestations of Cushing's.

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4. Identify and explain the common manifestations of Cushing's.

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- Depression
- Increased facial hair
- Thin and fragile skin (easy bruising)
- Weakness and muscle loss
- Rounded face and extra fat on the upper back and above collar bones
- Weight gain
- High blood sugar (diabetes)
- High blood pressure (hypertension)
- Thin bones (osteoporosis)
- Purple - red stretch marks

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Inadequate corticosteroid and mineralocorticoid synthesis and elevated levels of ACTH (Loss of negative feedback)

Autoimmune

Occurs when there is 90% destruction of the cortex

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Symptoms of hypocortisolism and hypoaldosteronism

Weakness and easy fatigability

Hyper-pigmentation due to increased levels of ACTH

Anorexia

Pale due to decreased blood flow

Body hair loss

Sexual disfunction

Salt craving

Depression

Low BP

Nausea, vomiting and diarrhea may develop

Hypotension that can progress to complete vascular collapse and shock (adrenal crisis)

Develops with undiagnosed disease or acute withdrawal of glucocorticoid therapy

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5. What would you expect the lab results to look like if the patient has Cushing's?

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5. What would you expect the lab results to look like if the patient has Cushing's?

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Testing for Cushing syndrome is typically done in two stages. Initial tests are used to verify that there is excess cortisol present. The second set of tests is used to determine the cause of the increased cortisol: pituitary, adrenal, or other.
1. Midnight plasma cortisol and late-night salivary cortisol measurements
2. 24 hour urine cortisol
3. Dexamethasone suppression screening test
4. Sometimes imaging tests will be done to see tumor markers, etc.

CBC and differential – may show a high WBC count and increased number of neutrophis

Glucose tolerence test – impaired

Potassium – level decreased (hypokalemia)

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T3 & T4 have a direct affect on our metabolism.

In primary hypothyroidism, loss of thyroid function leads to decreased production of TH and increased secretion of TSH and TRH. Infiltration of thyroid autoantibodies, autoreactive T lymphocytes, natural killer cells, and inflammatory cytokines and induction of apoptosis are involved in the tissue destruction seen in Hashimoto thyroiditis. Radioactive iodine uptake is normal or elevated.

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5. What are potential complication? Discuss Addisonian crisis.

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5. What are potential complication? Discuss Addisonian crisis.

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Dehydration

Headache

Hyponatremia and hyperkalemia

Can appear suddenly (Addisonian crisis)

Addisonian Crisis: Hypotension that can progress to complete vascular collapse and shock

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Bone loss

hypertension

type 2 diabetes

frequent or unusual infections

loss of muscle mass and strength

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3) Explain the m/f? What other history or clinical findings would be indicative of hypothyroidism?

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3) Explain the m/f? What other history or clinical findings would be indicative of hypothyroidism?

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Hypothyroidism generally affects all body systems and occurs insidiously over months or years. The decrease in TH level lowers energy metabolism and heat production. The individual develops a low basal metabolic rate, cold intolerance, lethargy, and slightly lowered basal body temperature (see Figure 19-5). The decrease in the level of TH can lead to excessive TSH production, which stimulates thyroid tissue and causes goiter.

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1)What is Grave's Disease? What are the hormones affected? What are the possible causes

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1)What is Grave's Disease? What are the hormones affected? What are the possible causes

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-Hyperthyroidism.
-t affects (TH) thyroid hormone, T3/4
-Autoimmune disease from a type II hypersensitivity

Stimulation of the thyroid by antibodies directed against the TSH receptor

Thyroid Stimulating Immunoglobulins

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4) The patient's laboratory values show an elevated TSH and low T4. What does this mean?

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4) The patient's laboratory values show an elevated TSH and low T4. What does this mean?

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This means a primary hypothyroid disorder because the TSH is elevated but the T4 is low. This means the thyroid itself is not responding to the elevated TSH levels (Feedback loop).

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5) What source of fatigue is the nurse practitioner evaluating with the CBC, T4, and TSH?

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5) What source of fatigue is the nurse practitioner evaluating with the CBC, T4, and TSH?

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CBC - Check for Anemia. Anemia is commonly associated with Hashimoto's disease.

Hypothyroidism - Decreased T4.
Energy production in the body requires certain amounts of thyroid hormones, a drop in hormone production leads to lower energy levels, causing you to feel weak and tired.

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the stimulation of the thyroid by antibodies (thyroid stimulating immunoglobulins) directed against the TSH receptor.

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The characteristic sign of severe or long-standing hypothyroidism is myxedema,which results from the altered composition of the dermis and other tissues. The connective tissue fibers are separated by large amounts of protein and mucopolysaccharide. This complex binds water, producing non pitting, boggy edema, especially around the eyes, hands, and feet and in the supraclavicular fossae . The tongue and laryngeal and pharyngeal mucous membranes thicken, producing thick, slurred speech and hoarseness.

Myxedema coma, a medical emergency, is a diminished level of consciousness associated with severe hypothyroidism. Signs and symptoms include hypothermia without shivering, hypoventilation, hypotension, hypoglycemia, and lactic acidosis. Older individuals with comorbid conditions, such as pulmonary or urinary infections, congestive heart failure, or cerebrovascular accident, and with moderate or untreated hypothyroidism are particularly at risk for developing myxedema coma. It also may occur after overuse of narcotics or sedatives or after an acute illness in hypothyroid individuals. Symptoms of hypothyroidism in older adults should not be attributed to normal aging changes.

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3) what would you expect the lab results to look like for this patient?

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3) what would you expect the lab results to look like for this patient?

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High TSH,
High TH
High T3
High T4

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Excessive sweating.

Heat intolerance.

Increased bowel movements.

Tremor (usually fine shaking)

Nervousness, agitation, anxiety.

Rapid heart rate, palpitations, irregular heart rate.

Weight loss.

Fatigue, weakness.

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1.What is diabetes mellitus? What are the hormones affected?

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1.What is diabetes mellitus? What are the hormones affected?

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Production or response to insulin is impaired; abnormal metabolism of carbs, increased glucose (serum/urine)
Hormone: insulin, amylin

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Exophthalmos - bulging eyes
-Orbital connective tissue accumulates, inflames and becomes edematous, resulting in the exophthalmos

Grave's Dermopathy
-Subcutaneous swelling on the anterior portions of the legs and by indurated and erythematous skin

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-Polyuria: osmotic diuresis (glucose in urine)
-Weight loss: no glucose = body burns fat (ketones), osmotic diuresis
-Fatigue: poor use of food products (metabolic)

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6) which of Ms. R's symptoms may not be resolved with treatment of her hyperthyroidism?

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6) which of Ms. R's symptoms may not be resolved with treatment of her hyperthyroidism?

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bulging eyes

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2. Compare / contrast type 1&2 diabetes mellitus. Include age of onset and what's happening in the body. What are possible causes?

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2. Compare / contrast type 1&2 diabetes mellitus. Include age of onset and what's happening in the body. What are possible causes?

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Type 1: autoimmune destruction of pancreatic islets. <30y/o, peak = 0-14y/o
Type 2: insulin resistance, >40 y/o. Possible causes: genetics, environmental, overweight, inactive

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The immune system attacks the muscles and fatty tissues around and behind the eye, making the eyes swollen.

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8) what does Ms. R's tight collars neck mass suggest?

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8) what does Ms. R's tight collars neck mass suggest?

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she has goitre

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9) Explain "thyroid storm" or thyrotoxicosis.

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9) Explain "thyroid storm" or thyrotoxicosis.

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Life threatening health condition. Manifested by increased HR, increased BP and increased temperature which can raise to dangerously high levels. Without immediate treatment condition can be fatal. Thyroid storm can cause CHF, mitral valve collapse, atrial tachycardia, and fibrillation.

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3.Considering DK's presenting hx and physical data, what form of diabetes mellitus is indicated?

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3.Considering DK's presenting hx and physical data, what form of diabetes mellitus is indicated?

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Type 1

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5. What are potential acute complications? Compare and contrast diabetic ketoacidosis and non-hyperosmolar.

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5. What are potential acute complications? Compare and contrast diabetic ketoacidosis and non-hyperosmolar.

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DKA: life-threatening (body starts breaking down fat for energy which produces ketones; causes blood to be acidic). Onset is caused by extreme hyperglycemia. Seen in type 1 diabetes
HHS: occurs without production of ketones. Onset is also caused by extreme hyperglycemia. Seen in type 2 diabetes

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6. DK needs to understand the S&S of hypoglycemia so that she can quickly intervene to prevent life-threatening complications. How can she recognize hypoglycemia and what should she do when it occurs?

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6. DK needs to understand the S&S of hypoglycemia so that she can quickly intervene to prevent life-threatening complications. How can she recognize hypoglycemia and what should she do when it occurs?

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M/f: sweating, shaking, tachycardia, weakness, nausea, feeling "jittery"
What to do: eat sugary food/drink juice

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7. What immediate and long-term therapy will DK need to manage her disorder?

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7. What immediate and long-term therapy will DK need to manage her disorder?

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Immediate: insulin, fluids
Long-term: diet, insulin

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8. DK must frequently monitor her own glucose levels to evaluate her diabetic control. What range of blood glucose should she be advised to aim for?

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8. DK must frequently monitor her own glucose levels to evaluate her diabetic control. What range of blood glucose should she be advised to aim for?

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Normal range: 3.6-6.9

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9. DK's HCP plans to routinely monitor glycosylated hemoglobin levels (HbA1c). What information can be gained from this lab test?

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9. DK's HCP plans to routinely monitor glycosylated hemoglobin levels (HbA1c). What information can be gained from this lab test?

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Reflects mean glycaemia for the past 2 months reflecting the half-life of hemoglobin

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10. DK should be aware of the potential acute and long-term complications of diabetes. What are they?

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10. DK should be aware of the potential acute and long-term complications of diabetes. What are they?

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Acute: hypoglycemia (insulin shock), DKA, HHS
Chronic: microvascular retinopathy, nephropathy, neuropathy, HTN/heart disease, infection of the skin, cognitive issues

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- Baseline vitals
- Neuro/ Mini Mental
- Nutrition
- Abd.
- Family history
- Skin
- Medications

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Main clinical manifestations of hypothyroidism:

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Main clinical manifestations of hypothyroidism:

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- fatigue
- lethargy
- personality and mental changes
- decreased cardiac output
- SOB on exertion
- decreased activity intolerance

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- Activity intolerance r/t muscle stiffness, SOB on exertion
- Impaired gas exchange r/t respiratory depression
- Impaired skin integrity r/t edema, dry ans scaly skin
- Disturbed body image r/t weight gain secondary to hypothyroidism