Endocrine Disorders
Diabetes mellitus (Type 1 vs 2), DKA vs HHS, thyroid disorders, and adrenal conditions (Addison vs Cushing).
Diabetes Mellitus: Type 1 vs Type 2
| Feature | Type 1 DM | Type 2 DM |
|---|---|---|
| Onset | Usually childhood/adolescence (can occur at any age) | Usually adults > 40 (increasingly in younger populations) |
| Pathophysiology | Autoimmune destruction of beta cells → absolute insulin deficiency | Insulin resistance with relative insulin deficiency |
| Body Habitus | Usually thin | Often overweight/obese |
| Onset of Symptoms | Rapid (3 P's: Polyuria, Polydipsia, Polyphagia) | Gradual; may be asymptomatic for years |
| Ketosis Risk | High (prone to DKA) | Rare (prone to HHS) |
| Treatment | Insulin required (always) | Lifestyle changes, oral hypoglycemics (metformin first-line), may need insulin |
| C-Peptide | Low/absent | Normal or elevated |
Diagnostic Criteria
- Fasting glucose ≥ 126 mg/dL (on two occasions)
- Random glucose ≥ 200 mg/dL with symptoms
- HbA1c ≥ 6.5%
- 2-hour OGTT ≥ 200 mg/dL
- HbA1c goal: < 7% for most adults (reflects average glucose over 2–3 months)
DKA vs HHS
| Feature | DKA (Diabetic Ketoacidosis) | HHS (Hyperosmolar Hyperglycemic State) |
|---|---|---|
| Type | Primarily Type 1 | Primarily Type 2 |
| Onset | Rapid (hours to days) | Gradual (days to weeks) |
| Blood Glucose | > 250 mg/dL | > 600 mg/dL |
| Ketones | Present (fruity breath) | Minimal to absent |
| pH | < 7.35 (metabolic acidosis) | Normal or mildly decreased |
| Dehydration | Moderate | Severe |
| Key Symptoms | Kussmaul respirations, fruity breath, abdominal pain, N/V | Profound dehydration, altered LOC, seizures, neurological deficits |
| Mortality | Lower (< 5%) | Higher (up to 20%) |
| Treatment | IV fluids (NS first, then 0.45% NS), IV insulin drip, electrolyte replacement (especially K+), monitor glucose q1h. Do not stop insulin until anion gap closes (DKA) or osmolality normalizes (HHS). Add dextrose to IV when glucose reaches 250 (DKA) or 300 (HHS) | |
Hypoglycemia vs Hyperglycemia
| Aspect | Hypoglycemia (< 70 mg/dL) | Hyperglycemia (> 180 mg/dL) |
|---|---|---|
| Symptoms | Tremors, diaphoresis, tachycardia, confusion, irritability, hunger, pallor | Polyuria, polydipsia, blurred vision, fatigue, slow wound healing |
| Treatment | Conscious: 15g fast-acting carbs (4 oz juice, glucose tabs). Recheck in 15 min. Unconscious: glucagon IM or dextrose IV | Insulin as prescribed, increase fluids, exercise, monitor glucose |
Thyroid Disorders
| Feature | Hypothyroidism | Hyperthyroidism (Graves' Disease) |
|---|---|---|
| Metabolism | Everything slows down | Everything speeds up |
| Symptoms | Fatigue, weight gain, cold intolerance, constipation, bradycardia, dry skin, puffy face, mental sluggishness, menorrhagia | Weight loss, heat intolerance, diarrhea, tachycardia, exophthalmos, tremors, diaphoresis, anxiety, amenorrhea |
| Labs | TSH high, T3/T4 low | TSH low, T3/T4 high |
| Treatment | Levothyroxine (Synthroid) — take on empty stomach in morning; lifelong therapy; monitor TSH regularly | Antithyroid drugs (methimazole, PTU), radioactive iodine (RAI), thyroidectomy |
| Crisis | Myxedema coma: hypothermia, hypoventilation, hypotension, altered LOC. IV levothyroxine + corticosteroids | Thyroid storm: high fever, extreme tachycardia, delirium. Beta-blockers, PTU, cooling measures, corticosteroids |
Adrenal Disorders
| Feature | Addison's Disease (Adrenal Insufficiency) | Cushing's Syndrome (Adrenal Excess) |
|---|---|---|
| Cortisol | Decreased | Increased |
| Symptoms | Weight loss, hypotension, hyperpigmentation (bronze skin), hyponatremia, hyperkalemia, hypoglycemia, fatigue, weakness | Weight gain (truncal obesity), moon face, buffalo hump, hypertension, hypernatremia, hypokalemia, hyperglycemia, thin skin, purple striae, poor wound healing, immunosuppression |
| Treatment | Lifelong corticosteroid replacement (hydrocortisone, fludrocortisone). Increase dose during stress/illness. Wear medical alert bracelet | Reduce/discontinue exogenous steroids (taper, never stop abruptly), surgery (adrenalectomy/transsphenoidal), radiation |
| Crisis | Addisonian crisis: severe hypotension, shock, hyponatremia, hyperkalemia. IV hydrocortisone + NS + dextrose STAT | Post-op adrenalectomy: lifelong steroid replacement needed |
Key Nursing Points
- Addison's = Add steroids (low cortisol)
- Cushing's = Crushing cortisol excess (too much steroid)
- Never stop corticosteroids abruptly — taper to prevent adrenal crisis
- Teach patients to increase steroid dose during physiological stress (surgery, infection, trauma)