Diabetes Management: The Most-Tested Endocrine Topic

Diabetes mellitus questions appear throughout the NCLEX. Type 1 vs. Type 2: Type 1 is autoimmune destruction of beta cells (requires insulin, typically younger onset, prone to DKA), Type 2 is insulin resistance (may use oral hypoglycemics, typically older onset, prone to HHS). Know insulin types: rapid-acting (lispro/aspart — onset 10-15 min, give with food), short-acting (regular — onset 30-60 min, only insulin given IV), intermediate (NPH — onset 1-2 hr, cloudy, can be mixed), long-acting (glargine/detemir — no peak, cannot be mixed). DKA vs. HHS: DKA = Type 1, glucose 300-800, ketoacidosis, Kussmaul respirations; HHS = Type 2, glucose >600, severe dehydration, no significant ketosis.

Thyroid Disorders: Hypo vs. Hyperthyroidism

The NCLEX loves comparison questions between hypothyroidism and hyperthyroidism. Hypothyroidism (Hashimoto's): decreased metabolism — weight gain, bradycardia, cold intolerance, fatigue, constipation, dry skin, mental sluggishness. Treatment: levothyroxine (take on empty stomach, monitor TSH). Severe form: myxedema coma (hypothermia, bradycardia, altered LOC — IV levothyroxine + IV corticosteroids). Hyperthyroidism (Graves'): increased metabolism — weight loss, tachycardia, heat intolerance, anxiety, tremors, exophthalmos. Treatment: antithyroid drugs (PTU, methimazole), radioactive iodine, thyroidectomy. Severe form: thyroid storm (extreme hyperthermia, tachycardia — beta-blockers + PTU + corticosteroids, cooling measures). Post-thyroidectomy: monitor for hypocalcemia (Chvostek's, Trousseau's) and laryngeal nerve damage (hoarseness).

Adrenal and Pituitary Disorders

Adrenal disorders present as paired opposites. Addison's disease (adrenal insufficiency): decreased cortisol/aldosterone — hypotension, hyperkalemia, hypoglycemia, bronze skin, weight loss, salt craving. Treatment: lifelong corticosteroid replacement, stress dosing, medical alert bracelet. Adrenal crisis: life-threatening — IV hydrocortisone, aggressive fluid resuscitation. Cushing's syndrome (excess cortisol): hypertension, hyperglycemia, hypokalemia, moon face, buffalo hump, central obesity, immunosuppression, poor wound healing. Pituitary disorders: Diabetes insipidus (decreased ADH — polyuria, dilute urine, hypernatremia — treat with desmopressin/DDAVP), SIADH (excess ADH — fluid retention, dilutional hyponatremia — fluid restriction). Pheochromocytoma: catecholamine-secreting tumor — severe hypertension, tachycardia, headache, diaphoresis — alpha-blockers before beta-blockers preoperatively.

Metabolic Emergencies and Electrolyte Crises

Endocrine emergencies require rapid recognition and intervention. DKA management: IV insulin drip, aggressive fluid resuscitation (NS initially), potassium replacement (do NOT give insulin until K+ >3.3), monitor glucose hourly, transition to SubQ insulin when gap closes. HHS management: similar fluid resuscitation but insulin requirements may be less. Thyroid storm: cooling measures (not aspirin — displaces thyroid hormone from protein), PTU, beta-blockers, corticosteroids. Adrenal crisis: IV hydrocortisone 100mg bolus, NS fluid resuscitation, identify trigger. Hypoglycemia: conscious = 15g fast-acting carbohydrate (Rule of 15), unconscious = glucagon IM or D50 IV. Severe hypocalcemia: IV calcium gluconate (slowly, with cardiac monitoring).