The Endocrine System Wally Grabowski, MD REMO #549 AMC Emergency Medicine Department.

The Endocrine SystemThe Endocrine System

Wally Grabowski, MDWally Grabowski, MD

REMO #549REMO #549

AMC Emergency Medicine AMC Emergency Medicine Department Department

Lecture OverviewLecture Overview

The Big Picture - The system as a The Big Picture - The system as a wholewhole

The Players - A gland-by-gland lookThe Players - A gland-by-gland look When good glands go bad - When good glands go bad -

Endocrine emergenciesEndocrine emergencies

Consists of several glands located in various parts Consists of several glands located in various parts of the bodyof the body

Specific GlandsSpecific Glands• HypothalamusHypothalamus• PituitaryPituitary• ThyroidThyroid• ParathyroidParathyroid• AdrenalAdrenal• KidneysKidneys• Pancreatic IsletsPancreatic Islets• OvariesOvaries• TestesTestes

The Endocrine System - Big The Endocrine System - Big PicturePicture

Hypothalamus

Endocrine GlandsEndocrine Glands Controls many body functionsControls many body functions

• exerts control by releasing special chemical exerts control by releasing special chemical substances into the blood called substances into the blood called hormoneshormones

• Hormones Hormones affect other endocrine glands or body affect other endocrine glands or body systemssystems

Ductless glandsDuctless glands Secrete Secrete hormoneshormones directly into bloodstream directly into bloodstream

• HormonesHormones are quickly distributed by bloodstream are quickly distributed by bloodstream throughout the bodythroughout the body

HormonesHormones

Act on target organs elsewhere in bodyAct on target organs elsewhere in body Control/coordinate widespread processes:Control/coordinate widespread processes:

• HomeostasisHomeostasis

• ReproductionReproduction

• Growth & DevelopmentGrowth & Development

• MetabolismMetabolism

• Response to stressResponse to stress Overlaps with the Sympathetic Nervous SystemOverlaps with the Sympathetic Nervous System

HormonesHormones

Hormones are classified as:Hormones are classified as:• ProteinsProteins• Polypeptides (amino acid derivatives)Polypeptides (amino acid derivatives)• Lipids (fatty acid derivatives or steroids)Lipids (fatty acid derivatives or steroids)

HormonesHormones

Amount of hormone reaching target tissue Amount of hormone reaching target tissue directly correlates with concentration of directly correlates with concentration of hormone in blood.hormone in blood.• Constant level hormonesConstant level hormones

Thyroid hormonesThyroid hormones

• Variable level hormonesVariable level hormones Epinephrine (adrenaline) releaseEpinephrine (adrenaline) release

• Cyclic level hormonesCyclic level hormones Monthly: Reproductive hormonesMonthly: Reproductive hormones Daily: CortisolDaily: Cortisol

The PlayersThe Players

PituitaryPituitary HypothalamusHypothalamus ThyroidThyroid ParathyroidParathyroid AdrenalAdrenal GonadsGonads

The Pituitary GlandThe Pituitary Gland

Pituitary GlandPituitary Gland

Small gland located on stalk hanging from base of Small gland located on stalk hanging from base of brain - brain - AKAAKA

““The Master Gland” The Master Gland” • Primary function is to control other glands.Primary function is to control other glands.

• Produces many hormones.Produces many hormones.

• Secretion is controlled by hypothalamus in base of Secretion is controlled by hypothalamus in base of brain.brain.

Pituitary GlandPituitary Gland Two areasTwo areas

• Anterior PituitaryAnterior Pituitary• Posterior PituitaryPosterior Pituitary

Structurally, functionally differentStructurally, functionally different

Pituitary GlandPituitary Gland Anterior PituitaryAnterior Pituitary

• Thyroid-Stimulating Hormone (TSH)Thyroid-Stimulating Hormone (TSH) stimulates release of hormones from Thyroidstimulates release of hormones from Thyroid released when stimulated by TSH or coldreleased when stimulated by TSH or cold abnormal conditionsabnormal conditions

– hyperthyroidism: too much TSH release

– hypothyroidism: too little TSH release


• Growth Hormone (GH)Growth Hormone (GH) stimulates growth of all organs and increases stimulates growth of all organs and increases

blood glucose concentrationblood glucose concentration– decreases glucose usage

– increases consumption of fats as an energy source

• Adreno-Corticotrophic Hormone (ACTH)Adreno-Corticotrophic Hormone (ACTH) stimulates the release of adrenal cortex hormonesstimulates the release of adrenal cortex hormones


• Follicle Stimulating Hormone (FSH)Follicle Stimulating Hormone (FSH) females - stimulates maturation of ova; release of females - stimulates maturation of ova; release of

estrogenestrogen males - stimulates testes to grow; produce spermmales - stimulates testes to grow; produce sperm

• Luteinizing Hormone (LH)Luteinizing Hormone (LH) females - stimulates ovulation; growth of corpus females - stimulates ovulation; growth of corpus

luteumluteum males - stimulates testes to secrete testosteronemales - stimulates testes to secrete testosterone


• ProlactinProlactin stimulates breast development during stimulates breast development during

pregnancy; milk production after deliverypregnancy; milk production after delivery

• Melanocyte Stimulating Hormone (MSH)Melanocyte Stimulating Hormone (MSH) stimulates synthesis, dispersion of melanin stimulates synthesis, dispersion of melanin

pigment in skinpigment in skin

Pituitary GlandPituitary Gland Posterior PituitaryPosterior Pituitary

• Antidiuretic hormone (ADH)Antidiuretic hormone (ADH) Stimulates water retention by kidneysStimulates water retention by kidneys

– reabsorb sodium and water Abnormal conditionsAbnormal conditions

– Undersecretion: diabetes insipidus (“water diabetes”)

– Oversecretion: Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

• OxytocinOxytocin Stimulates contraction of uterus at end of pregnancy Stimulates contraction of uterus at end of pregnancy

(Pitocin®); release of milk from breast(Pitocin®); release of milk from breast

The HypothalamusThe Hypothalamus

HypothalamusHypothalamus Produces several releasing and inhibiting Produces several releasing and inhibiting

factors that stimulate or inhibit anterior factors that stimulate or inhibit anterior pituitary’s secretion of hormones.pituitary’s secretion of hormones.

Produces hormones that are stored in and Produces hormones that are stored in and released from posterior pituitaryreleased from posterior pituitary

HypothalamusHypothalamus Also responsible for:Also responsible for:

• Regulation of water balanceRegulation of water balance

• Esophageal swallowingEsophageal swallowing

• Body temperature regulation (shivering)Body temperature regulation (shivering)

• Food/water intake (appetite)Food/water intake (appetite)

• Sleep-wake cycleSleep-wake cycle

• Autonomic functionsAutonomic functions

Pineal GlandPineal Gland Located within the DiencephalonLocated within the Diencephalon MelatoninMelatonin

• Inhibits ovarian hormonesInhibits ovarian hormones

• May regulate the body’s internal clockMay regulate the body’s internal clock

The Thyroid GlandThe Thyroid Gland

ThyroidThyroid

Located below larynx and low Located below larynx and low in neckin neck• Not over the thyroid cartilageNot over the thyroid cartilage

Thyroxine (TThyroxine (T44) and ) and

Triiodothyronine (TTriiodothyronine (T33))• Stimulate metabolism of all cellsStimulate metabolism of all cells

CalcitoninCalcitonin• Decreases blood calcium Decreases blood calcium

concentration by inhibiting concentration by inhibiting breakdown of bonebreakdown of bone

ThyroidThyroid Works on a feedback loop with the Works on a feedback loop with the

Anterior PituitaryAnterior Pituitary• more TSH = more Tmore TSH = more T3/43/4

• more Tmore T3/4 3/4 = = lessless TSH TSH

TSH

+

T3/4

-

Note: There are numerous other feedback loops in the endocrine system. Too many to go over here.

The ParathyroidsThe Parathyroids

ParathyroidsParathyroids Located on posterior surface of Located on posterior surface of

thyroidthyroid Frequently damaged during Frequently damaged during

thyroid surgerythyroid surgery Parathyroid hormone (PTH)Parathyroid hormone (PTH)

• Stimulates CaStimulates Ca2+2+ release from bone release from bone

• Promotes intestinal absorption and Promotes intestinal absorption and renal tubular reabsorption of renal tubular reabsorption of calciumcalcium

ParathyroidsParathyroids UnderactivityUnderactivity

• Decrease serum CaDecrease serum Ca2+2+

Hypocalcemic tetanyHypocalcemic tetany Seizures Seizures LaryngospasmLaryngospasm

ParathyroidsParathyroids

OveractivityOveractivity• Increased serum CaIncreased serum Ca2+2+

Pathological fracturesPathological fractures HypertensionHypertension Renal stonesRenal stones Altered mental statusAltered mental status

• ““Bones, stones, hypertones, abdominal moans”Bones, stones, hypertones, abdominal moans”

Thymus GlandThymus Gland

Located in anterior chest Located in anterior chest Normally absent by ~ age 4Normally absent by ~ age 4 Promotes development of immune-Promotes development of immune-

system cells (T-lymphocytes)system cells (T-lymphocytes)

The Adrenal GlandsThe Adrenal Glands

Adrenal GlandsAdrenal Glands

Small glands located Small glands located near (ad) the kidneys near (ad) the kidneys (renals) (renals)

Consists of:Consists of:• outer cortexouter cortex• inner medullainner medulla

Adrenal GlandsAdrenal Glands Adrenal MedullaAdrenal Medulla

• the Adrenal Medulla secretes the catecholamine the Adrenal Medulla secretes the catecholamine hormones hormones norepinephrinenorepinephrine and and epinephrineepinephrine

• Epinephrine and NorepinephrineEpinephrine and Norepinephrine Prolong and intensify the sympathetic nervous system Prolong and intensify the sympathetic nervous system

response during stressresponse during stress

Adrenal GlandsAdrenal Glands Adrenal CortexAdrenal Cortex

• Aldosterone (Mineralocorticoid)Aldosterone (Mineralocorticoid) Regulates electrolyte (potassium, sodium) and fluid Regulates electrolyte (potassium, sodium) and fluid

homeostasishomeostasis

• Cortisol (Glucocorticoids)Cortisol (Glucocorticoids) Antiinflammatory, anti-immunity, and anti-Antiinflammatory, anti-immunity, and anti-

allergy effects.allergy effects. Increases blood glucose concentrationsIncreases blood glucose concentrations

• Androgens (Sex Hormones)Androgens (Sex Hormones) Stimulate sexual drive in femalesStimulate sexual drive in females


Adrenal CortexAdrenal Cortex• GlucocorticoidsGlucocorticoids

accounts for 95% of adrenal cortex hormone accounts for 95% of adrenal cortex hormone productionproduction

the level of glucose in the bloodthe level of glucose in the blood Released in response to stress, injury, or serious Released in response to stress, injury, or serious

infection - like the hormones from the adrenal infection - like the hormones from the adrenal medullamedulla


Adrenal CortexAdrenal Cortex• MineralcorticoidsMineralcorticoids

work to regulate the concentration of potassium work to regulate the concentration of potassium and sodium in the bodyand sodium in the body

The GonadsThe Gonads

OvariesOvaries Located in the abdominal cavity adjacent to the Located in the abdominal cavity adjacent to the

uterusuterus Under the control of LH and FSH from the Under the control of LH and FSH from the

anterior pituitaryanterior pituitary Produce eggs for reproductionProduce eggs for reproduction Produce hormonesProduce hormones

• estrogenestrogen

• progesteroneprogesterone

• Functions include sexual development and Functions include sexual development and preparation of the uterus for implantation of the eggpreparation of the uterus for implantation of the egg

OvariesOvaries

EstrogenEstrogen• Development of female secondary sexual Development of female secondary sexual

characteristicscharacteristics

• Development of endometriumDevelopment of endometrium ProgesteroneProgesterone

• Promotes conditions required for pregnancyPromotes conditions required for pregnancy

• Stabilization of endometriumStabilization of endometrium

TestesTestes

Located in the scrotumLocated in the scrotum Controlled by anterior pituitary hormones FSH Controlled by anterior pituitary hormones FSH

and LHand LH Produce sperm for reproductionProduce sperm for reproduction Produce testosterone -Produce testosterone -

• promotes male growth and masculinizationpromotes male growth and masculinization

• promotes development and maintenance of male promotes development and maintenance of male sexual characteristicssexual characteristics

The PancreasThe Pancreas

PancreasPancreas

Located in retroperitoneal space between Located in retroperitoneal space between duodenum and spleenduodenum and spleen

Has both endocrine and exocrine functionsHas both endocrine and exocrine functions• Exocrine PancreasExocrine Pancreas

Secretes key digestive enzymesSecretes key digestive enzymes

• Endocrine PancreasEndocrine Pancreas Alpha Cells - glucagon productionAlpha Cells - glucagon production Beta Cells - insulin productionBeta Cells - insulin production Delta Cells - somatostatin productionDelta Cells - somatostatin production

PancreasPancreas

Exocrine functionExocrine function• SecretesSecretes

amylaseamylase lipaselipase

PancreasPancreas

AlphaAlpha Cells Cells• GlucagonGlucagon

Raises blood glucose levelsRaises blood glucose levels BetaBeta Cells Cells

• InsulinInsulin Lowers blood glucose levelsLowers blood glucose levels

DeltaDelta Cells Cells• SomatostatinSomatostatin

Suppresses release of growth hormoneSuppresses release of growth hormone

When Good Glands Go When Good Glands Go Bad Bad

Disorders of the Endocrine Disorders of the Endocrine SystemSystem

Abnormal Thyroid FunctionAbnormal Thyroid Function

HypothyroidismHypothyroidism• Too little thyroid hormoneToo little thyroid hormone

HyperthyroidismHyperthyroidism(Thyrotoxicosis / Thyroid Storm)(Thyrotoxicosis / Thyroid Storm)• Too much thyroid hormoneToo much thyroid hormone

HypothyroidismHypothyroidism

Thyroid hormone deficiency causing a decrease Thyroid hormone deficiency causing a decrease in the basal metabolic ratein the basal metabolic rate• Person is “slowed down”Person is “slowed down”

Causes of HypothyroidismCauses of Hypothyroidism::• Radioactive iodine ablationRadioactive iodine ablation

• Non-compliance with levothyroxineNon-compliance with levothyroxine

• Hashimoto’s thyroiditis - autoimmune destructionHashimoto’s thyroiditis - autoimmune destruction

HypothyroidismHypothyroidism Confusion, drowsiness, comaConfusion, drowsiness, coma Cold intolerantCold intolerant Hypotension, BradycardiaHypotension, Bradycardia Muscle weaknessMuscle weakness Decreased respirationsDecreased respirations Weight gain, ConstipationWeight gain, Constipation Non-pitting peripheral edemaNon-pitting peripheral edema DepressionDepression Facial edema, loss of hairFacial edema, loss of hair Dry, coarse skinDry, coarse skin

Appearance of Myxedema

HypothyroidismHypothyroidism Myxedema ComaMyxedema Coma

• Severe hypothyroidism that can be fatalSevere hypothyroidism that can be fatal Management of Myxedema ComaManagement of Myxedema Coma

• Control airwayControl airway• Support oxygenation, ventilationSupport oxygenation, ventilation• IV fluidsIV fluids• LaterLater

Levothyroxine (Synthroid®)Levothyroxine (Synthroid®) HydrocortisoneHydrocortisone

HyperthyroidismHyperthyroidism Excessive levels of thyroid levels cause Excessive levels of thyroid levels cause

hypermetabolic statehypermetabolic state• Person is “sped up”.Person is “sped up”.

Causes of HyperthyroidismCauses of Hyperthyroidism• Overmedication with levothyroxine (Synthroid®) - Overmedication with levothyroxine (Synthroid®) -

Fad dietsFad diets

• Goiter (enlarged, hyperactive thyroid gland)Goiter (enlarged, hyperactive thyroid gland)

• Graves DiseaseGraves Disease

HyperthyroidismHyperthyroidism Nervousness, irritable, tremors, Nervousness, irritable, tremors,

paranoidparanoid Warm, flushed skinWarm, flushed skin Heat intolerantHeat intolerant Tachycardia - High output CHFTachycardia - High output CHF HypertensionHypertension TachypneaTachypnea DiarrheaDiarrhea Weight lossWeight loss ExophthalmosExophthalmos GoiterGoiter

HyperthyroidismHyperthyroidism TreatmentTreatment

• Airway/Ventilation/OxygenAirway/Ventilation/Oxygen

• ECG monitorECG monitor

• IV access - Cautious IV fluidsIV access - Cautious IV fluids

• Acetaminophen for feverAcetaminophen for fever

• BetaBeta-blockers-blockers

• Consider benzodiazepines for anxietyConsider benzodiazepines for anxiety

• PTU (propylthiouracil)PTU (propylthiouracil) Usually short-term use prior to more definitive Usually short-term use prior to more definitive

treatmenttreatment

• SSKI® (potassium iodide)SSKI® (potassium iodide)

Thyroid Storm/ThyrotoxicosisThyroid Storm/Thyrotoxicosis

Severe form of hyperthyroidism that can be Severe form of hyperthyroidism that can be fatalfatal• Acute life-threatening hyperthyroidismAcute life-threatening hyperthyroidism

CauseCause• Increased physiological stress in hyperthyroid Increased physiological stress in hyperthyroid

patientspatients

Thyroid Storm/ThyrotoxicosisThyroid Storm/Thyrotoxicosis

Severe tachycardiaSevere tachycardia Heart FailureHeart Failure DysrhythmiasDysrhythmias ShockShock HyperthermiaHyperthermia Abdominal painAbdominal pain Restlessness, Agitation, Delirium, ComaRestlessness, Agitation, Delirium, Coma

Thyroid Storm/ThyrotoxicosisThyroid Storm/Thyrotoxicosis ManagementManagement

• Airway/Ventilation/OxygenAirway/Ventilation/Oxygen• ECG monitorECG monitor• IV access - cautious IV fluidsIV access - cautious IV fluids• Control hyperthermiaControl hyperthermia

Active coolingActive cooling AcetaminophenAcetaminophen

• Inderal (beta blockers)Inderal (beta blockers)• Consider benzodiazepines for anxietyConsider benzodiazepines for anxiety• Potassium iodide (SSKI®)Potassium iodide (SSKI®)• Propylthiouracil (PTU)Propylthiouracil (PTU)

Abnormal Adrenal Function Abnormal Adrenal Function

HyperadrenalismHyperadrenalism• Excess activity of the adrenal glandExcess activity of the adrenal gland

• Cushing’s Syndrome & DiseaseCushing’s Syndrome & Disease

• PheochromocytomaPheochromocytoma Hypoadrenalism (adrenal insufficiency)Hypoadrenalism (adrenal insufficiency)

• Inadequate activity of the adrenal glandInadequate activity of the adrenal gland

• Addison’s diseaseAddison’s disease

HyperadrenalismHyperadrenalism

Primary Aldosteronism Primary Aldosteronism • Excessive secretion of aldosterone by adrenal cortexExcessive secretion of aldosterone by adrenal cortex

Increased NaIncreased Na++/H/H22OO

• PresentationPresentation headacheheadache nocturia, polyurianocturia, polyuria fatiguefatigue hypertension, hypervolemiahypertension, hypervolemia potassium depletionpotassium depletion

HyperadrenalismHyperadrenalism Adrenogenital syndromeAdrenogenital syndrome

• ““Bearded Lady”Bearded Lady”

• Group of disorders caused by adrenocortical Group of disorders caused by adrenocortical hyperplasia or malignant tumorshyperplasia or malignant tumors

• Excessive secretion of adrenocortical steroids Excessive secretion of adrenocortical steroids especially those with androgenic or estrogenic effectsespecially those with androgenic or estrogenic effects

• Characterized byCharacterized by masculinization of womenmasculinization of women feminization of menfeminization of men premature sexual development of childrenpremature sexual development of children

HyperadrenalismHyperadrenalism Cushing’s SyndromeCushing’s Syndrome

• Results from increased adrenocortical secretion of Results from increased adrenocortical secretion of cortisolcortisol

• Causes include:Causes include: ACTH-secreting tumor of the pituitary ACTH-secreting tumor of the pituitary

(Cushing’s disease)(Cushing’s disease) excess secretion of ACTH by a neoplasm within excess secretion of ACTH by a neoplasm within

the adrenal cortexthe adrenal cortex excess secretion of ACTH by a malignant growth excess secretion of ACTH by a malignant growth

outside the adrenal gland (esp small cell lung ca)outside the adrenal gland (esp small cell lung ca) excessive or prolonged administration of steroidsexcessive or prolonged administration of steroids

HyperadrenalismHyperadrenalism Cushing’s SyndromeCushing’s Syndrome

• Characterized by:Characterized by: truncal obesitytruncal obesity moon facemoon face buffalo humpbuffalo hump acne, hirsutismacne, hirsutism abdominal striaeabdominal striae hypertensionhypertension psychiatric disturbancespsychiatric disturbances osteoporosisosteoporosis amenorrheaamenorrhea


Cushing’s DiseaseCushing’s Disease• Too much adrenal hormone productionToo much adrenal hormone production

adrenal hyperplasia caused by an ACTH adrenal hyperplasia caused by an ACTH secreting adenoma of the pituitarysecreting adenoma of the pituitary

• ““Cushingoid features”Cushingoid features” striae on extremities or abdomenstriae on extremities or abdomen moon facemoon face buffalo humpbuffalo hump weight gain with truncal obesityweight gain with truncal obesity personality changes, irritablepersonality changes, irritable


Cushing’s SyndromeCushing’s Syndrome• ManagementManagement

Airway/Ventilation/OxygenAirway/Ventilation/Oxygen Supportive careSupportive care Assess for cardiovascular event requiring Assess for cardiovascular event requiring

treatmenttreatment

– severe hypertension

– myocardial ischemia


PheochromocytomaPheochromocytoma• Catecholamine secreting tumor of adrenal medullaCatecholamine secreting tumor of adrenal medulla

• PresentationPresentation AnxietyAnxiety Pallor, diaphoresisPallor, diaphoresis HypertensionHypertension Tachycardia, PalpitationsTachycardia, Palpitations DyspneaDyspnea HyperglycemiaHyperglycemia


PheochromocytomaPheochromocytoma• ManagementManagement

Supportive care based upon presentationSupportive care based upon presentation Airway/Ventilation/OxygenAirway/Ventilation/Oxygen Calm/ReassureCalm/Reassure Assess blood glucose Assess blood glucose Consider beta blocking agent - LabetalolConsider beta blocking agent - Labetalol Consider benzodiazepinesConsider benzodiazepines

HypoadrenalismHypoadrenalism

Adrenal InsufficiencyAdrenal Insufficiency• decrease production of glucocorticoids, decrease production of glucocorticoids,

mineralcorticoids and androgensmineralcorticoids and androgens CausesCauses

• Primary adrenal failure (Addison’s Disease)Primary adrenal failure (Addison’s Disease)• Infection (TB, fungal, Meningococcal)Infection (TB, fungal, Meningococcal)• AIDSAIDS• Prolonged steroid useProlonged steroid use

HypoadrenalismHypoadrenalism PresentationPresentation

• Hypotension, ShockHypotension, Shock• Hyponatremia, HyperkalemiaHyponatremia, Hyperkalemia• Progressive Muscle weaknessProgressive Muscle weakness• Progressive weight loss and anorexiaProgressive weight loss and anorexia• Skin hyperpigmentationSkin hyperpigmentation

areas exposed to sun, pressure points, joints and creasesareas exposed to sun, pressure points, joints and creases• ArrhythmiasArrhythmias• HypoglycemiaHypoglycemia• N/V/DN/V/D

HypoadrenalismHypoadrenalism

ManagementManagement• Airway/Ventilation/OxygenAirway/Ventilation/Oxygen

• ECG monitorECG monitor

• IV fluidsIV fluids

• Assess blood glucose - D50 if hypoglycemicAssess blood glucose - D50 if hypoglycemic

• Steroids Steroids hydrocortisone or dexamethasonehydrocortisone or dexamethasone florinef (mineralcorticoid)florinef (mineralcorticoid)

• Vasopressors if unresponsive to IV fluidsVasopressors if unresponsive to IV fluids

Case Study #1Case Study #1 You are dispatched to a college residence hall to see a You are dispatched to a college residence hall to see a

20-year-old female complaining of fever and a 20-year-old female complaining of fever and a fluttering in her chest. You find her awake but she fluttering in her chest. You find her awake but she appears very anxious. appears very anxious. • Airway - Open without assistanceAirway - Open without assistance

• Breathing - Slightly increased ventilatory rate; No obvious Breathing - Slightly increased ventilatory rate; No obvious abnormal sounds of breathingabnormal sounds of breathing

• Circulation - Rapid, strong, regular radial pulse; Skin warm Circulation - Rapid, strong, regular radial pulse; Skin warm and pinkand pink

Case Study #1Case Study #1 You direct your partner to assess vital signs while you You direct your partner to assess vital signs while you

place the patient on Oxygen 15 lpm by NRB mask. place the patient on Oxygen 15 lpm by NRB mask. Your physical exam findings are:Your physical exam findings are:• trembling, nervous trembling, nervous

• warm, flushed skinwarm, flushed skin

• clear and equal lung soundsclear and equal lung sounds Your partner relays the following vital signs to you:Your partner relays the following vital signs to you:

• Pulse - 120, regular, strongPulse - 120, regular, strong

• BP - 144/88BP - 144/88

• Ventilatory rate - 20, regular with adequate TVVentilatory rate - 20, regular with adequate TV

• Glucose - 110 mg/dlGlucose - 110 mg/dl

• ECG - Sinus tachycardia with occasional PACsECG - Sinus tachycardia with occasional PACs

What additional information regarding her history would you like to know?

Case Study #1Case Study #1 The patient states this has occurred before but never The patient states this has occurred before but never

lasted this long. She has not been ill lately other than lasted this long. She has not been ill lately other than some recurrent diarrhea and weight loss. She has some recurrent diarrhea and weight loss. She has attributed these to worrying about finals. She has no attributed these to worrying about finals. She has no significant medical history and takes no meds. She significant medical history and takes no meds. She denies use of any drugs. She has no family history of denies use of any drugs. She has no family history of pulmonary disease, diabetes or heart disease. Her pulmonary disease, diabetes or heart disease. Her mother, however, does have a problem with something mother, however, does have a problem with something in her neck for which she takes medication.in her neck for which she takes medication.

What are the two most probable diagnosis for this patient?

Case Study #2Case Study #2 You are dispatched to a residence to see a 44-year-old You are dispatched to a residence to see a 44-year-old

man who has fainted. You arrive to find him semi-man who has fainted. You arrive to find him semi-reclined in bed. He is awake and very wide-eyed but reclined in bed. He is awake and very wide-eyed but appears very tired.appears very tired.• Airway - Maintained without assistanceAirway - Maintained without assistance

• Breathing - No obvious distress; No obvious, unusual soundsBreathing - No obvious distress; No obvious, unusual sounds

• Circulation - Rapid, weak, irregular radial pulseCirculation - Rapid, weak, irregular radial pulse

Case Study #2Case Study #2• Your partner assesses vital signs while you obtain Your partner assesses vital signs while you obtain

the following history:the following history: Hx of Present Illness: For the past month, he has Hx of Present Illness: For the past month, he has

felt very weak and dizzy; He has not felt like felt very weak and dizzy; He has not felt like eating and has been losing weight. He has also eating and has been losing weight. He has also experienced N/V/D on a few days this month.experienced N/V/D on a few days this month.

Past Medical Hx: Has been fairly healthy all of Past Medical Hx: Has been fairly healthy all of his life; Three months ago he became ill with his life; Three months ago he became ill with bacterial meningitis for which he was bacterial meningitis for which he was successfully treated.successfully treated.

Case Study #2Case Study #2• Vital signs are:Vital signs are:

Pulse: 110-126, irregularPulse: 110-126, irregular BP: 92/62BP: 92/62 Ventilatory rate: 20, regularVentilatory rate: 20, regular Skin: cool, clammySkin: cool, clammy ECG: Atrial fibrillationECG: Atrial fibrillation Blood glucose: 74 mg/dlBlood glucose: 74 mg/dl

What should you include in your differential diagnosis?

Case Study #2Case Study #2• Your partner is a brand new, naïve paramedic. He Your partner is a brand new, naïve paramedic. He

comments to the patient, “That is a great tan you comments to the patient, “That is a great tan you have. Have you been on a tropical vacation lately?”have. Have you been on a tropical vacation lately?”

Now, what do you believe is the most likely diagnosis for this patient?

What is your treatment plan for this patient?

The Endocrine System Wally Grabowski, MD REMO #549 AMC Emergency Medicine Department.

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Transcript of The Endocrine System Wally Grabowski, MD REMO #549 AMC Emergency Medicine Department.