Diabetes Mellitus

Diabetes SOAP

2/8

Video & Symbols

Candy racer #2

Type 2 diabetes (T2DM) → genetic & environmental factors cause insulin resistance &
defective insulin secretion (most common type of DM)

Candy racer #2:

Type 2 diabetes (T2DM) → genetic & environmental factors cause insulin resistance &
defective insulin secretion (most common type of DM)

Prize "INSIDE" egg encountering RESISTANCE:

in T2DM, genetic & environmental factors → insulin resistance → beta-cells initially respond
w/ ↑insulin secretion

Empty prize "INSIDE" egg:

T2DM develops in pts w/ underlying defective insulin secretion → beta cells can‘t keep up
with ↑demand in the setting of insulin resistance → beta-cell “burnout” → RELATIVE insulin
deficiency → hyperglycemia

Candy racer #1:

Type 1 diabetes mellitus (T1DM) is caused by autoimmune destruction of pancreatic beta
cells → absolute insulin deficiency → hyperglycemia

Antibody wrench in cracked BETAscotch wheel:

Type 1 diabetes mellitus (T1DM) is caused by autoimmune destruction of pancreatic beta

cells → absolute insulin deficiency → hyperglycemia

Empty INSIDE egg at #1 car:

Type 1 diabetes mellitus (T1DM) is caused by autoimmune destruction of pancreatic beta

cells → absolute insulin deficiency → hyperglycemia

MoODY prince:

Maturity Onset Diabetes of the Young (MODY) = monogenic diabetes inherited in autosomal
dominant pattern → non-insulin dependent DM before age 25

Domino shutters:

Maturity onset diabetes of the young (MODY) = monogenic diabetes inherited in autosomal
dominant pattern → non-insulin dependent DM before age 25

MoODY kid pointing at Type 2 car:

MODY presents with NON-insulin dependent DM (like T2DM but insulin resistance isn’t a
factor)

Cystic syrup, pancreas sponge, and Fe weights:

diseases that damage the pancreas (e.g. cystic fibrosis, chronic pancreatitis,
hemochromatosis) can cause insulin-dependent diabetes (2/2 injury to pancreatic beta cells)

Oversized candy racer #2:

most pts w/ T2DM are overweight or obese → insulin resistance (Demographics)

Adult candy racer #2:

insulin resistance increases with age → T2DM more common in adults (but can affect obese
children) (Demographics)

Multicultural candies:

T2DM is more prevalent among certain races/ethnicities (Native American, Hispanic/Latino,

Asian/Pacific Islander, African American) (Demographics)

Skinny young candy racer #1:

Type 1 diabetes mellitus (T1DM) most often presents in children or adolescents (but can
present in adults); most have a thin body habitus (2/2 catabolic state) (Demographics)

Lesson

Diabetes Mellitus

Diabetes Management

2/8

Video & Symbols

"seasonA1 Candy" sign

monitor Hemoglobin A1c (HbA1c or A1C) every 3 months (“seasonal”) in pts requiring
treatment adjustments (every 6 months if well controlled) (1)

"seasonA1 Candy" sign:

monitor Hemoglobin A1c (HbA1c or A1C) every 3 months (“seasonal”) in pts requiring
treatment adjustments (every 6 months if well controlled) (1)

7-shaped car spoiler:

goal A1C for most adults with T1DM or T2DM is <7% (2)

Happy child with 6.5 car:

consider A1C goal <6.5% in healthier patients (e.g. without comorbidities, short duration of
diabetes, T2DM managed with lifestyle or metformin only) (3)

Eating thin end of vascular snake at the 6.5 car:

intensive glycemic control can ↓ MICROvascular complications (e.g. retinopathy, neuropathy,
nephropathy); MACROvascular complications best prevented with lifestyle modification (e.g.
smoking cessation, BP control, ↓ cholesterol, weight loss) (4)

Old, sickly hag behind "8" wheel wagon:

goal A1C <8% in pts with more health problems (e.g. history of severe hypoglycemia, limited
life expectancy, multiple comorbidities, etc.) (5)

Prize "INSIDE" egg:

INSULIN therapy is the mainstay treatment of T1DM and may be used in T2DM

"INSIDE" egg on scale highlighted 0.2-0.4:

for a new type 1 diabetic, weight based-dosing of insulin is based on total daily dose (TDD)
of 0.2-0.4 units/kg/day (6)

Basal half of egg with "long lasting" jawbreaker:

50% of TDD = long-acting (basal) insulin (e.g. glargine, detemir 1-2x/day; degludec 1x/day)
(7)

⅔ and ⅓ of the Nutty Peanut + Hazelnut bar:

NPH (intermediate acting insulin) can be used for basal insulin dose (⅔ basal dose in the
morning and ⅓ basal dose in the evening) (8)

Eating out of top half of egg:

Eating out of top half of egg: 50% of TDD = rapid- or short-acting (preprandial, bolus) insulin
(e.g. regular, lispro, aspart, glulisine) administered before meals (9)

Fast candy pump:

some type 1 diabetics can be managed with an insulin pump (continuous infusion of rapid
acting insulin)

Mystery ratio candy bucket:

pre-mixed insulins include Humalog Mix 75/25 and Novolin 70/30 (rapid acting/intermediate
acting) → usually formulated to give 2x/day before meals (more convenient)

Escaping kid doing pull up:

T2DM management should begin with lifestyle changes (diet, exercise, weight loss) (10)

"Start" at the metaphor:

metformin (oral) is the preferred initial agent for the treatment of T2DM → initiate at time of
diagnosis + lifestyle interventions (11)

Lesson

Diabetes Mellitus

Chronic Diabetes Complications SOAP

2/8

Video & Symbols

Chronic candy clock

complications of diabetes are related to the consequences of chronic hyperglycemia →

microvascular and macrovascular complications

Chronic candy clock:

complications of diabetes are related to the consequences of chronic hyperglycemia →

microvascular and macrovascular complications

Thin candy snake tail:

MICROvascular complications of chronic DM (e.g. nephropathy, retinopathy, and

neuropathy)

Thick candy snake head:

MACROvascular complications of chronic DM (e.g. CAD, PAD, cerebrovascular disease)

Candy kidney coffee contraption:

diabetic kidney disease (DKD) is a microvascular complication of chronic DM → #1 cause of
ESRD in the US (DKD)

Early overactive "Grounds Filter Rate":

earliest renal abnormality in DM = glomerular HYPERfiltration → ↑GFR (more common in

T1DM) (DKD)

Thick scaly nodular knot:

diabetic nephropathy → GBM thickening, mesangial expansion + Kimmelstiel-Wilson

nodules, glomerulosclerosis (DKD)

Chronically shriveled kidney raisin:

diabetic nephropathy → progressive chronic kidney disease (DKD)

High pressure steam:

most pts with T1DM develop HTN a few years after first sign of kidney disease (e.g.
albuminuria); many pts with T2DM develop HTN BEFORE signs of kidney disease (HTN
increases risk and progression of DKD) (DKD/Vitals)

Album of the Earl of Donut with "30-300" bite mark over the 24hr sun:

persistent albumin excretion of 30-300 mg/24hr = “moderately increased albuminuria”

(earliest sign of DKD)(DKD/Labs)

"30" album photo over Credit card:

spot urinary albumin to creatinine ratio (UACR) 30-300 mg/g = “moderately increased
albuminuria” (can be used instead of 24hr urine collection) (urine dipstick can only detect
protein excretion >300/day!) (DKD/Labs)

Angry "300" king Duncan:

albumin excretion >300 mg/24hr (or UACR >300 mg/g on random sample) = “severely
increased albuminuria” (DKD/Labs)

Elevated BUN bag and credit card:

severely ↑albuminuria is usually accompanied by ↓GFR → ↑BUN and creatinine → CKD

(CKD = presence of kidney damage [e.g. albuminuria OR ↓ kidney function [i.e. ↓ eGFR for
≥3 months) (DKD/Labs)

Diabetic Kidney Disease DDx clipboard:

For further workup of Diabetic Kidney Disease, see Nephrotic Syndrome SOAP,
Glomerulonephritis SOAP, & CKD SOAP
"Control the (kidney) Candy!":

manage DKD w/ glycemic control (A1C<7 for most patients; A1C<6.5 for young healthy
patients; A1C<8 for older adults with long-standing disease/comorbidities) → delay
onset/progression of albuminuria and ↓GFR (less effective w/ overt proteinuria) (DKD/Plan)
(1)

Lesson

Diabetes Mellitus

Acute Diabetes Complications SOAP

2/8

Video & Symbols

Bacteria lanterns + torn “INSIDE” mat + empty gas tank

DKA and HHS are often precipitated by infection, inadequate insulin therapy, and
dehydration

Bacteria lanterns + torn “INSIDE” mat + empty gas tank:

DKA and HHS are often precipitated by infection, inadequate insulin therapy, and
dehydration

Candy key in “1” car:

DKA is most common in type 1 diabetes, and is characterized by elevated ketone levels

Clutching stomach + blowing out fruit gummies:

DKA causes nausea, vomiting, abdominal pain, and fruity breath

Soaring lollipop towers:

In DKA, serum glucose levels are high, typically reaching 350-500 mg/dL

Lemonade volcano + “Mind the gap” sign:

​Patients with DKA have an elevated anion gap metabolic acidosis

“2” car HHONK-ing:

HHS predominantly occurs in type 2 diabetes

Lethargic sloth:

Neurologic symptoms (eg, lethargy, confusion, coma) are more common in HHS than in DKA

1 Grand candybar:

In HHS, serum glucose often exceeds 1000 mg/dL

Saltwater IV helmet:

DKA and HHS should be treated with high-volume IV normal saline

DexterO’s cookies:

Dextrose should be added to the saline solution when serum glucose levels drop below 200
to 250 ​mg/dL

“3.3” bananas + ivy bunting:

Give IV KCl therapy if serum K+ <3.3 mEq/L

“INSIDE” mat + ivy gas hose:

Low-dose IV insulin therapy should be started if serum potassium ≥3.3 mEq/L

“INSIDE” mat + injecting fuel:

When switching from IV ​insulin to subcutaneous insulin, overlap them both for at least 2-4
hours

Box of bicarb + PHrosting:

Sodium bicarbonate therapy and phosphate replacement therapy are not routinely given, but
considered for select patients
Lesson

Thyroid Disease

Hypothyroidism SOAP

2/8

Video & Symbols

PRIMARY care poster with patient with untied bowtie

Primary hypothyroidism (i.e., thyroid disease) = most common type of hypothyroidism

PRIMARY care poster with patient with untied bowtie:

Primary hypothyroidism (i.e., thyroid disease) = most common type of hypothyroidism

Medical CENTER:

Central hypothyroidism = caused by diseases affecting the anterior pituitary (i.e., secondary)
or hypothalamus (i.e., tertiary)

Boxer punching pituitary-shaped bag:

Central hypothyroidism = caused by diseases affecting the anterior pituitary (i.e., secondary)
or hypothalamus (i.e., tertiary)

Torn HYPE! sign:

Central hypothyroidism = caused by diseases affecting the anterior pituitary (i.e., secondary)
or hypothalamus (i.e., tertiary)
Fatigued patient in hospital bed:

Patients with hypothyroidism commonly present with fatigue (Chief Complaint)

Overweight patient:

Many patients with hypothyroidism experience weight gain due to slowing of basal metabolic
rate (Chief Complaint)

Falling cup of ice:

Cold intolerance = classic symptom of hypothyroidism → due to decreased thermogenesis

(Chief Complaint)

Plunger:

Constipation is common in patients with hypothyroidism due to decreased GI motility (Chief

Complaint)

Brain-shaped hairnet:

Cognitive impairment (e.g., slowed mentation, decreased concentration, poor working

memory) is a common feature of hypothyroidism (Chief Complaint)

Sad face:

Patients with hypothyroidism can present with depressed mood (Chief Complaint)

Lotion bottle:

Patients with hypothyroidism may complain of dry, rough skin & coarse brittle hair (Chief
Complaint)

Hair falling out:

Patients with hypothyroidism may complain of dry, rough skin & coarse, brittle hair (Chief
Complaint)

Wrist braces:

Hypothyroidism is commonly associated with bilateral carpal tunnel syndrome → produces

numbness, tingling, & pain in median nerve distribution of fingers (Chief Complaint)

Weak, shaky arm:

Muscle involvement is common in adults with hypothyroidism (aka “hypothyroid myopathy”)

→ typically manifests as symmetric proximal muscle weakness & myalgias (Chief
Complaint)
Lesson

Thyroid Disease

Hyperthyroidism SOAP

2/8

Video & Symbols

Big red bowtie

Hyperthyroidism → ↑ Thyroid hormone (T4, T3)

Big red bowtie:

Hyperthyroidism → ↑ Thyroid hormone (T4, T3)

T4 + T3 time bombs:

↑ thyroid hormone (T4 and/or T3)

Young grave digger:

Graves’ disease → most common cause hyperthyroidism (↑ frequency: ages 20-50, female)

Antibody shovel:

Graves’ etiology → ↑ activating TSH receptor antibodies

Nodular moss:

Toxic multinodular goiter → diffuse hyperplasia thyroid follicular cells (producing thyroid
hormones)
Single giant grave:

Toxic adenoma → focal hyperplasia thyroid follicular cells (single nodule producing thyroid
hormone)

Flaming red bowtie:

Thyroiditis (subacute thyroiditis, painless thyroiditis, postpartum thyroiditis) → transient

hyperthyroidism

Viral capsid:

Subacute thyroiditis caused by post-viral inflammation

Baby statue:

Postpartum thyroiditis (within 1 year of childbirth or abortion)

Cancer crab + ovary mushrooms:

Ectopic hyperthyroidism → thyroid hormone production outside thyroid gland (struma ovarii,
functional thyroid cancer metastases)

T4 synthetic explosives:

Exogenous thyroid hormone (levothyroxine, supplements) → Ectopic hyperthyroidism

Contrast yin-yang:

Medication-induced hyperthyroidism → IV contrast, amiodarone

Sweaty, flushed, nervous bomb detonator:

Hyperthyroidism sx → anxiety, heat intolerance, diaphoresis, tremor

Heart watch + mud puddles:

Hyperthyroidism sx → palpitations, diarrhea

Irregularly irregular signal:

Hyperthyroidism → AFib
Lesson

Adrenal Disorders

Cushing Syndrome SOAP

2/8

Video & Symbols

Cushion moon landing

Cushing’s syndrome = signs and symptoms of Inappropriately elevated serum

glucocorticoids

Cushion moon landing:

Cushing’s syndrome = signs and symptoms of Inappropriately elevated serum

glucocorticoids

Raised "ACTHion" clapper board:

ACTH dependent Cushing’s syndrome = ↑ACTH → ↑cortisol (e.g. pituitary adenoma, ectopic
ACTH secretion)

Pituitary bag bulging with ACTH:

Cushing disease (pituitary hypersecretion of ACTH most commonly due to a PITUITARY

ADENOMA) is the most common cause of endogenous Cushing’s syndrome

Crab rover with ACTH:

Ectopic ACTH secretion by cancer (typically SCLC) → ACTH-dependent Cushing’s
syndrome

Falling/broken "ACTHion" clapper board:

ACTH-independent Cushing’s syndrome = ↑cortisol levels despite ↓ACTH (e.g. exogenous

glucocorticoids, adrenal tumor, adrenal hyperplasia)

"Exo-Genesis 1":

exogenous glucocorticoids are MOST COMMON cause of Cushing’s syndrome

Adrenal hat with "+" light and broken ACTH:

adrenal adenoma → ACTH-independent Cushing’s syndrome (↑cortisol → ↓ACTH)

Cancer crab in adrenal cave with broken ACTH:

adrenal tumors → ACTH-independent Cushing’s syndrome (↑cortisol → ↓ACTH)

Big belly:

Cushing’s syndrome presents with weight gain (Chief Complaint)

Stretch marks on delicate cushion:

skin findings of cushing’s syndrome = abdominal striae, easy bruising, and poor wound
healing (Chief Complaint)

Difficulty getting up:

Cushing’s syndrome presents with proximal muscle weakness (Chief Complaint)

Fractured bone leg of lander:

Cushing’s syndrome presents with pathologic fractures (PMHx)

Sad astronaut:

Cushing’s syndrome presents with psychiatric symptoms (e.g. depression) (Chief Complaint)

Irregular red puddles:

Cushing syndrome presents with irregular menses in women (↑cortisol → ↓GnRH from
hypothalamus) (Chief Complaint)

Bearded astronaut pointing male weapon at the cancer crab:

Cushing’s syndrome due to adrenal carcinoma may presents with hirsutism, acne, and
Virilization in women (↑androgen secretion) (Chief Complaint)
Lesson

Adrenal Disorders

Adrenal Insufficiency SOAP

2/8

Video & Symbols

Daisy Addison on the 1˚ Set

Primary adrenal insufficiency (aka Addison’s disease) = disease at the level of the adrenal
glands → ↓ production of adrenocortical hormones (e.g., glucocorticoids, mineralocorticoids,
adrenal sex steroids)

Daisy Addison on the 1˚ Set:

Primary adrenal insufficiency (aka Addison’s disease) = disease at the level of the adrenal
glands → ↓ production of adrenocortical hormones (e.g., glucocorticoids, mineralocorticoids,
adrenal sex steroids)

Broken cortex on the 1˚ Set:

Primary adrenal insufficiency (aka Addison’s disease) = disease at the level of the adrenal
glands → ↓ production of adrenocortical hormones (e.g., glucocorticoids, mineralocorticoids,
adrenal sex steroids)

Broken moon face on the 1˚ Set:

1˚AI = ↓ production of glucocorticoids (e.g. cortisol) + ↓ production of mineralocorticoids (e.g.

aldosterone)
Broken mineral crystals on the 1˚ Set:

1˚AI = ↓ production of glucocorticoids (e.g. cortisol) + ↓ production of mineralocorticoids (e.g.

aldosterone)

Broken male symbol on the 1˚ Set:

1˚AI → ↓ production of adrenal sex steroids (e.g. DHEA, androstenedione, testosterone)

Beat up pituitary and broken ACTH on the 2˚ Set:

2˚AI = disease at the level of the pituitary gland → ↓ production of ACTH

Crushed produCRH and ACTH at the 3˚ Set:

3˚AI = disease at the level of the hypothalamus → ↓CRH from hypothalamus → ↓ACTH from
pituitary

Intact mineral crystals at the 2˚ and 3˚ Sets:

2˚ and 3˚AI = ↓ cortisol but NORMAL aldosterone (intact RAAS) (-vs- ↓cortisol + ↓aldo in
1˚AI)

Chronic grandfather clock:

chronic 1˚, 2˚, and 3˚AI (insidious onset)

Tired astronaut:

chronic AI can cause fatigue (Chief Complaint)

Thin alien:

chronic AI can cause anorexia and weight loss (Chief Complaint)

Nauseated alien:

chronic AI can cause nausea/vomiting (Chief Complaint)

Punched in stomach:

chronic AI can cause vague abdominal pain (Chief Complaint)

Wrapped joints:

chronic AI can cause arthralgia (Chief Complaint)

Confused alien:

chronic AI can cause psychiatric symptoms (e.g. confusion, psychosis, and depression)
(HPI)
Lesson

Pituitary & Hypothalamic Disorders

Diabetes Insipidus

2/8

Video & Symbols

Peeing fountain

Diabetes insipidus (DI) is a failure of the kidneys to appropriately concentrate urine

Peeing fountain:

Diabetes insipidus (DI) is a failure of the kidneys to appropriately concentrate urine

Peeing and drinking with nightcap:

Polyuria (excessive urination), polydipsia (excessive thirst/drinking), and nocturia (peeing

frequently at night) = common symptoms of DI

Empty trough, dry hay + salty peanuts:

Dehydration may develop from excessive urination without appropriate replacement of

losses

Central Royal Elephant:

Central DI = lack of ADH release from pituitary gland in response to stimuli (e.g.
hypovolemia, elevating serum sodium); thirst response often impaired
Camel trapped in brain-shaped prison-cloud:

Antidiuretic hormone (ADH) causes kidneys to reabsorb free water in the collecting duct;
lack of ADH from central DI → inappropriate free water loss

Spilling wine goblet, scalpel scepter + cracked crown:

Causes of central DI = hemorrhage (e.g. Sheehan syndrome), neurosurgical complications,

head trauma

“Idiot” sign + crab seafood tower:

Causes of central DI = idiopathic, malignancy (craniopharyngioma, histiocytosis)

Rejecting camel at kidney gates:

Nephrogenic DI = kidneys fail to appropriately respond to circulating ADH; thirst mechanism

often intact

“Lift” elevator, elevated calci-YUM ice cream + fallen bananas:

Causes of central DI = Medications (e.g. lithium, demeclocycline, foscarnet, cidofovir,

amphotericin), hypercalcemia, severe hypokalemia, hereditary causes (AVPR2 receptor
mutation)

Lots o’ salty peanuts + pale yellow rain:

Hypernatremia and low urine osmolality (representing dilute urine) = findings suggestive of
diabetes insipidus (low urine Na is also present); distinguishes DI from other causes of
polyuria and polydipsia

“Leave All Water Behind”:

Water deprivation test will distinguish between central and nephrogenic DI as a cause of
polydipsia (and rule out primary polydipsia); patient is restricted from drinking water, and if
urine is concentrated during this time, the cause is primary polydipsia; if it does not
concentrate after several hours, desmopressin (DDAVP; ADH analog) is given

Camel-angel helping concentration:

During water deprivation test, for central DI, kidneys appropriately respond to desmopressin
→ urine is appropriately concentrated (as problem in central DI is ADH release, not kidney’s
ability to respond to ADH)

Dark amber outfit:

Central DI = urine osmolality increases after desmopressin administration by 50-100%

Camel-devil preventing concentration:

During water deprivation test, for nephrogenic DI, kidneys do not respond to desmopressin
appropriately → urine remains dilute (as problem in nephrogenic DI is the kidneys fail to
respond to ADH)

Lesson