Question

please answer the following:

1. A nurse is teaching a patient with diabetes mellitus who asks, “why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL (3.3 mmol/L)?” How would the nurse respond?

1. “Glucose is the only fuel used by the body to produce the energy that it needs.”
2. “Your brain needs a constant supply of glucose because it cannot store it.”
3. “Without a minimum level of glucose, your body does not make red blood cells.”
4. “Glucose in the blood prevents the formation of lactic acid and prevents acidosis.”

2. Which of the following surgical procedures is appropriate for a patient with chronic pancreatitis?

1. Radical pancreatectomy
2. Sphincterotomy
3. Fistulotomy
4. Proctocolectomy

3. The nurse identifies which lab result is consistent with a client’s diagnosis of hyperthyroidism?

1. Decreased T3 and T4 levels
2. Elevated serum thyrotropin-releasing hormone (TRH) level
3. Decreased radioactive iodine uptake
4. Increased serum T3 and T4 levels

4. A nurse is caring for a patient recently diagnosed with diabetes insipidus. Which of the following medications would be appropriate for this disorder?

1. Furosemide
2. Diltiazem
3. Vasopressin
4. Growth Hormone antagonist

5. A nurse is caring for a patient recently diagnosed with thyroid cancer. Which of the following lab results will validate this diagnosis?

1. Increased Calcium
2. Increase phosphorus
3. Increased serum thyroglobulin level
4. Decreased thyroglobulin level

Answer 1

Q1] Option B : “Your brain needs a constant supply of glucose because it cannot store it.”

EXPLANATION

• Hypoglycemia occurs due to a relative excess of insulin in the blood circulation, and results in decreased blood glucose levels.
• Since the brain cannot synthesise glucose or store significant quantities as glycogen in astrocytes, the brain needs a continuous supply of glucose from the circulation.
• Facilitated diffusion of glucose from the blood into the brain is a direct function of the arterial plasma glucose concentration.
• The rate of blood-to-brain glucose transport exceeds the rate of brain glucose metabolism at normal plasma glucose levels, but it decreases and becomes limiting to brain glucose metabolism when arterial glucose concentrations fall to lower levels.
• Neuroglycopenic signs occur when the brain's dependence on glucose, coupled with its limited glycogen stores, resulting in rapid CNS dysfunction.
• If the warning signs of hypoglycemia are ignored and the blood glucose level decreases further, more severe hypoglycemia occurs, resultinf in alteration of mental function, that manifests as headache, confusion, irritability, lethargy, slurred speech, and abnormal behavior.
• CNS dysfunction related to hypoglycemia includes focal seizures, hemiplegia, involuntary movements, and patchy brain stem and cerebellar involvement.
• The medullary phase of hypoglycemia that presents with deep coma, dilated pupils, shallow breathing, bradycardia, and hypotonia, manifests at a blood glucose level of ∼ 10 mg/dl.

Q2] Option 1 : Radical pancreatectomy

Chronic pancreatitis is treated by pancreatectomy.

[ Note : Sphincterotomy, also called a lateral internal sphincterotomy, is an operative procedure used to cut the anal sphincter, for treating anal fissure.

A fistulotomy is an operative procedure used to treat fistula in ano.

Proctocolectomy refers to the surgical removal of the colon and rectum, for treating Ulcerative colitis and familial adenomatous polyposis.]

EXPLANATION

CHRONIC PANCREATITIS

Diffuse inflammatory process of pancreas involving head, body and the tail resulting in permanent structural and functional damage to the pancreas.

Causes
1. Alcohol: Alcohol stimulates pancreatic secretion rich in protein, which forms plugs in the pancreatic duct and results in stasis of secretion and stone formation.
2. Idiopathic: thought to be due to consumption of tapioca .It is also called fibrocalculous pancreatic diabetes.
3. Hereditary pancreatitis: transmitted as a Mendelian-dominant trait.
4. Cystic fibrosis: Generalised dysfunction of exocrine glands cause secretions to precipitate in the lumen.
5. Hyperparathyroidism: favours precipitation of calcium intraductally. It can also activate pancreatic enzymes.
6. Autoimmune pancreatitis: Diffuse enlargement of pancreas and narrowing of pancreatic duct is seen.

Pathology

There is destruction of pancreas by ductal sclerosis, ductal strictures, glandular fibrosis and calcification, both intraductal and parenchymal .

Clinical features

• Malabsorption occurs due to damage to exocrine glands resulting in steatorrhoea-10 to 15 stools per day, bulky, frothy, rich in fat, foul-smelling; and subsequent weight loss.
• Obstructive jaundice can occur due to oedema of the head of pancreas. or due to fibrous constriction of Common bile duct(CBD)
• Pain abdomen-upper abdominal pain radiating to the back in the region of L 1 and L2 due to retroperitoneal inflammation.  
• Exploratory laparotomy-many cases are diagnosed a laparotomy where irregularity and hardness involving the entire pancreas are seen.
• Diabetes-incidence of diabetes is about 10-20%. It shoulc be suspected in diabetic patients with pain abdomen.

Investigations

• Plain X-ray abdomen can demonstrate stones in the pancreatic duct or parenchymal calcification.
• USG can detect the stones, stricture, dilatation and associated cysts.
• Endoscopic retrograde Cholangio pancreatography (ERCP) - shows ductal distension, ductal stricture, Dilated pancreatic duct ,Demonstration of stones-appear as regular filling defect.
• CT scan: reveals ductal anatomy, head mass, size and configuration of pancreas.

Treatment

A] Conservative

• Pain relief by analgesics, epidural analgesia, or splanchnic nerve block. Slow release opioid skin patches are useful.
• Supplement pancreatic enzyme-diet should be low in fat and vitamin D supplements should be given.

B] Surgical  

I. Chronic pancreatitis involving tail of pancreas

• Distal pancreatectomy with removal of spleen.

2. Diffuse chronic pancreatitis with dilated (large duct) pancreatic duct

• Duct is laid open widely, strictures are cut open, stones are removed and it is anastomosed to a loop of jejunum- longitudinal pancreaticojejunostomy-Puestow's operation  
• This is a bypass procedure which preserve endocrine and exocrine functions.

3. Chronic pancreatitis with a head mass

• In this situation, doubt arises whether it is malignancy or not. Even trucut biopsy and frozen section are not foolproof.
• Hence, pancreaticoduodenectomy is advised, provided experience of the surgeon is good and the mortality rate is less than 5%.

4. Chronic pancreatitis with bile duct obstruction

• If malignancy is ruled out, a bypass procedure is the treatment of choice.
• Choledochojejunostomy is the ideal treatment.
• Pancreaticoduodenectomy can also be done.

5. Chronic pancreatitis with duodenal obstruction

• Resection of the head mass or gastrojejunostomy is the treatment of choice.

6. Chronic pancreatitis with ascites:

Treatment of choice is Puestow's operation (stenting may also relieve ascites).

7. Resection:

A duodenum-preserving pancreatic head resection is called Hans Beger's Procedure. Head-coring procedure is called Frey procedure.

[ Note : Sphincterotomy, also called a lateral internal sphincterotomy, is an operative procedure used to cut the anal sphincter, for treating anal fissure.

A fistulotomy is an operative procedure used to treat fistula in ano.

Proctocolectomy refers to the surgical removal of the colon and rectum, for treating Ulcerative colitis and familial adenomatous polyposis.]

Q3] Option D : Increased serum T3 and T4 levels

Thyrotoxicosis is the clinical manifestation of action of excess thyroid hormone at the tissue level, because of  inappropriately high elevated thyroid hormone concentrations in the circulation.

The high thyroid hormone (T3 and T4) levels in turn suppress the secretion ofThyroid stimulating hormone (TSH) levels from pituitary by feedback inhibition.

Therefore, in thyrotoicosis, the T3 and T4 levels will be high, and the TSH levels will be low.

EXPLANATION

THYROID FUNCTION TESTS

Serum T3 and T4 estimation is most commonly performed.

1. Serum T3: Normal levels-1.5-3.5 nmol/L

• Most (80%) T3 is produced by deiodination of T4 in the liver, muscle, kidney and anterior pituitary.
• T3 is 3 to 4 times more potent than T4.
• The half-life of T3 is approximately 24 hours, whereas half-life of T4 is about 7 days.

Levels of T3, T 4 and TSH in some common conditions

Disease	T3	T4	TSH
Hyperthyroidism (Thyrotoxicosis)	Increased	Increased	Suppressed or undetectable.
Hypothyroidism (peripheral causes i.e., thyroid gland problems)	Low	Low	Increased
Hypothyroidism (Central cause i.e., problems of pituitary gland or hypothalamus)	Low	Low	Low

2. Serum T4: Normal levels-55 to 150 nmol/L

• They are measured by radioimmunoassay.
• In euthyroid state, T4 is the predominant hormone produced by the thyroid.
• Total T4 levels reflect output from the thyroid gland.
• Both T3 and T4 increase cell metabolism, normal growth, facilitate normal mental development and increase local effects of catecholamines.

3. Serum TSH (thyroid stimulating hormone)

0.3-5 IU/ml of plasma.

4. Serum thyroglobulin

• It is produced by thyroid tissue only. Hence, the levels should be low after total thyroidectomy.
• The most important use of this test is to monitor patients after total thyroidectomy for well-differentiated carcinoma.
• It is not normally released into circulation in large amount but increases suddenly in thyroiditis, Graves' disease or toxic multinodular goitre (MNG).

5. Serum cholesterol:

It is increased in hypothyroidism and decreased in hyperthyroidism.

6. Thyroid autoantibody levels:

More than 90% of the patients with Hashimoto's thyroiditis and 80% of patients with Graves' disease have antibodies which are called as 'LATS' (long acting thyroid stimulator).

The detection of these antibodies help in the diagnosis of such cases and also to suspect these diseases before clinical manifestation.

Q4] Vasopressin

EXPLANATION

Antidiuretic hormone (ADH) or Vasopressin is secreted mainly by supraoptic nucleus of hypothalamus, and transported to posterior pituitary through the nerve fibers of hypothalamo-hypophyseal tract, by means of axonic flow.

Antidiuretic hormone has two actions:

1. Retention of water

• Major function of ADH is retention of water by acting on kidneys. It increases the facultative reabsorption of water from distal convoluted tubule and collecting duct in the kidneys.
• In the absence of ADH, the distal convoluted tubule and collecting duct are totally impermeable to water. So, reabsorption of water does not occur in the renal tubules and dilute urine is excreted.
• This leads to loss of large amount of water through urine. This condition is called diabetes insipidus and the excretion of large amount of water is called diuresis.

2. Vasopressor action

• In large amount, ADH shows vasoconstrictor action.
• Due to vasoconstriction, the blood pressure increases.
• ADH acts on blood vessels through V1A receptors.

The most common form of treatment for diabetes insipidus is desmopressin (DDAVP), a synthetic form of the hormone Vasopressin.   Desmopressin may be administered by pill, nasal spray, or injection.

Q5] Option C : Increased serum thyroglobulin level

Thyroglobulin (TG) is a glycoprotein produced exclusively by the thyroid follicular cells. TG is stored as colloid within the thyroid follicles, iodinated and degraded to thyroxin and tri-iodothyronine. The whole process is controlled by the thyroid stimulating hormone (TSH) secreted from pituitary.

TG can be elevated in any thyroid pathology. Serum TG level is proportional to the thyroid mass rather than the type of pathology.

Increased thyroglobulin levels are seen in

1. Untreated and metastatic differentiated thyroid carcinomas.
2. Metastases after initial treatment.
3. Hyperthyroidism  
4. Subacute thyroiditis
5. Some cases of benign adenoma

Decreased thyroglobulin levels are seen in :

1. Thyrotoxicosis factitia
2. Goitrous hypothyroidism in infants

Thyroglobulin testing is primarily used as a tumor marker to

• evaluate the effectiveness of treatment for differentiated thyroid cancer and
• monitor for recurrence.