Nine Things Hospitalists Need to Know about Treating Patients with Endocrine Disorders
“Say the TSH [thyroid-stimulating hormone] is up because the patient is recovering from an acute illness,”
Dr. Florez says. “All of a sudden you were looking for hyperthyroidism, but now you have a high TSH, so that initiates a workup for hypothyroidism.” But that is not the proper course, because a high TSH is not uncommon in a person getting over an illness.
Once the TSH comes back high, you’ve ruled out hyperthyroidism as the reason for the atrial fibrillation.
The matter should be considered settled, he said. “No reason to get all excited about pursuing a hypothyroidism diagnosis,” Dr. Florez says. If thereis any concern, the thyroid function tests could be repeated in the outpatient setting when the patient is no longer acutely ill.
Misdirected concerns about hypothyroidism should also be avoided.
For example, a patient presents with altered mental status, which can be brought about by myxedema coma, or profound hypothyroidism.
If the TSH comes back low—eliminating hypothyroidism as a problem—a hospitalist should not embark on a hyperthyroidism diagnosis, Dr. Florez says. It’s probably just sick euthyroid causing the abnormal TSH level.
“What you need to do is work on the reasons for altered mental status,” he says. “You’ve already exonerated myxedema coma. Move on, and then have the thyroid test pursued as an outpatient to ensure it normalizes.”
—Thomas R. Collins
Slow Down
“Not every type 2 or type 1 patient is alike. They all have different insulin requirements. Some patients are on oral meds with type 2 diabetes, some are on one insulin shot a day, [and] some are on several insulin injections a day,” Dr. Anderson says. “It’s managing that glucose in that individual and trying to optimize their therapy.”
Plenty of factors in the hospital might get in the way of that optimal care, he adds. Is a patient NPO (nothing by mouth) before a surgery? Feeling too nauseous to follow the appropriate eating schedule? Has a meal been delivered late by the meal service?
“The hospital introduces an incredible layer of complexity to the care of the patient with type 2 diabetes,” Dr. Anderson says. “That’s why it’s really important for everybody who takes care of people with diabetes in the hospital to be pretty savvy about this.”
Hospitalists shouldn’t be lulled into complacency just because diabetes is usually non-life-threatening. Often, patients with diabetes are admitted for a completely different condition.
“And by the time [providers] get to diabetes as an issue, they may just say ‘diabetes, sliding scale, check A1C as a reflex,’ and then not take the time to think about what is this person’s regimen,” Dr. Florez says.
All the details about that person’s eating status and insulin requirements should be tended to carefully.
“I don’t think diabetes is rocket science,” Dr. Florez says. “But it does require attention.
I think it’s not so much [hospitalists’] level of expertise as it is the time and the pressures and the stresses. They have to actually slow down and give the diabetes some thought.”
—Thomas R. Collins
References
- Omar AS, Salama A, Allam M, et al. Association of time in blood glucose range with outcomes following cardiac surgery. BMC Anesthesiol. 2015;15(1):14.
- Han HS, Kang SB. Relations between long-term glycemic control and postoperative wound and infectious complications after total knee arthroplasty in type 2 diabetics. Clin Orthop Surg. 2013;5(2):118–123.
- Garber JR, Cobin RH, Gharib H, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 2012;18(6):988-1028.
- Supit EJ, Peiris AN. Interpretation of laboratory thyroid function tests for the primary care physician. South Med J. 2002;95(5):481-485.
