Endocrinology

• Elective and Site Director: Dr. Katie Jackson (kathryn.e.jackson@health.slu.edu)

• Pediatric endocrinology faculty

  • Dr. David Dempsher

  • Dr. Mark Eddy

  • Dr. Katie Jackson

  • Dr. Susan Myers

  • Dr. Maggie Siska

• Division administrator: Belma Gebeljic (belma.gobeljic@health.slu.edu) and Rachel Lovell (rachel.lovell@health.slu.edu)

• +/- Residents (pediatric, family medicine, internal medicine) and/or fourth year medical student on elective (2-4w)

• +/- Third year clerkship or career exploration student (1w)

• Multidisciplinary healthcare team providers: nurse practitioners, nurses, social workers, dietitians

• Contact Dr. Jackson at least a week before starting to discuss your rotation goals, objectives, strategies, as well as any schedule requests. Endocrinology activities and schedule are personalized based on interest and can include endocrine, diabetes, lipid, and Prader Willi clinics, as well as inpatient/consult service. Clerkship and CE students typically spend all or most of the endocrinology block in clinic.

• Review the Learners on Pediatrics Spreadsheet for other learners scheduled in your setting.

  • • Consider touching base with any outgoing learners and/or those scheduled with you.

    • Use the "insert comment" feature. We will go through to finalize

      • Blue team tab (elective students). Once you determine which week/s you will spend on the inpatient/consult service, add your name to the days you will be with the blue team.

      • Endocrinology tab. Designate experiences you wish to participate in during a given half day. Often multiple options: clinics, intern academic half day (for M4s) are available. Potential considerations include your own goals and interests, presence of other learners, how busy a clinic is (Eg. if two clinics held during a given half day session, you might want to pick one with greater number of patients), variety of experience, and/or continuity with a specific attending. We request no more than 2 learners per clinic/attending.

        • The expectation for all mini electives is a full work week in clinic potentially with a caveat that on half days a clinic is not held, you may be assigned to other tasks etc at the discretion of the site director.

• Individual Study

  • Endocrinology individual study resources

Dress code. White coat required

Presenting Problems

• Ambiguous genitalia

• Hypoglycemia

• Poor weight gain/growth

Diagnoses

• Adrenal insufficiency

• Cushing’s syndrome

• Diabetes mellitus type 1 and type 2

• Diabetes insipidus

• Growth hormone deficiency

• Hirsutism

• Hypoaldosteronism

• Hypoparathyroidism

• Hypothyroidism

• Hyperthyroidism

• Polycystic ovarian syndrome

• Precocious puberty

• Pseudohypoaldestoronism

• Pseudohypoparathyroidism

• Short stature

• Syndrome of inappropriate ADH secretion (SIADH)

• Obesity

Common Inpatient Diagnoses

• Diabetic ketoacidosis

• Insulin management

• Adrenal crisis

*Topics recommended for early review in bold

Location: Cardinal Glennon Ambulatory Care Center (ACC): ground floor

• • Physician room is next to exam room 25 and patient rooms are exam rooms 81-85.

Endocrine Clinic

• • • Mon AM, Wed AM/PM, Thur AM, Friday AM for urgent visits only

    • EPIC: CG ACC Endo

Diabetes Clinic

• • • Mon AM, Tue AM, Thursday PM, Friday AM for urgent visits only

    • EPIC: ACC Diabetes

Lipid Clinic

• • • 2nd and 4th Thursday of the month, AM

    • Epic: CG ACC Endo IGT/Lipid Clinic

Prader Willi Clinic

• • • 2nd Wed of the month AM

    • EPIC: CG ACC URG Prader Willi

• On the first day come to clinic ~20 min before the first patient is scheduled to allow for site orientation. Check EPIC to confirm clinic schedule.

General Information about the Clinic

• Pink sheet

  • Each patient or guardian fills out the pink sheet upon arrival to clinic. The front side is a questionnaire which asks about who gives insulin at home, locations of insulin injections, hypoglycemic episodes and frequency, goal glucose range, activity/exercise, grade in school, last eye exam, etc.

  • The back of the pink sheet includes details on the patient’s current insulin regimen

• Dexcom reports, if applicable

  • Most of the information is not needed at the MS4 level, but the front page gives the lowest and highest glucose level in the past two weeks, which can be helpful when taking an interval history from the patient and assessing overall glucose control.

  • The report breaks down glucose levels by day of the week, time of day, etc, which is helpful for finding trends based on the current insulin regimen.

• Each patient is seen by a dietician annually, which takes place as part of their time in Diabetes Clinic. It will say “RD to see” on the main clinic screen in the comment section. It’s useful to sit in on this if the attending wants you to because you can save the patient time from repeating that portion of the history (also a great opportunity to observe what other members of the healthcare team do during the visit)

• There is a group of people who might see the patient during their clinic appointment. This includes a diabetes educator nurse, dietician, and psychologist in addition to the endocrinologist.

• Insulin needs to be injected at different sites (e.g. arms, abdomen, buttocks, thighs) in order to avoid skin abnormalities that might affect absorption or lead to infection.

• The insulin reservoir in an insulin pump needs to be changed every 2-3 days.

• Clinic notes often include a comment for when the patient should check their urine for ketones. It might read “check for ketones when glucose >300 and feeling ill”

• Common comorbidities with type 1 diabetes: Celiac disease and autoimmune thyroid disease. Patients are regularly screened for both.

Recommendations to help clinic flow and give comprehensive presentations:

• Write the patient’s blood pressure at the top of the pink sheet. Epic gives percentiles for systolic and diastolic - make note if abnormal

• Once A1C result is back, write it down at the top of the pink sheet

• Check the growth tab for any weight loss or weight gain that does not track along the curve

• For interval history and ROS, obtain the following information and write notes directly on the pink sheet:

  • Any concerns since last visit? How does the patient and/or guardian feel about control of diabetes?

  • Covid vaccination status

  • Recent illness

  • Energy level

  • Exercise / activity

  • Appetite

  • Sleep

  • Bowel movements

  • Nocturia, polyuria, polydipsia -- especially if diabetes does not seem well-controlled

  • GI symptoms, particularly if on metformin

  • Menstrual history

  • Recent skin issues or infections

  • Issues with feet

  • Date of last dentist visit

  • Date of last eye exam

• Physical Exam

  • Neck exam - lymph nodes, thyroid

  • Ophthalmoscope exam

  • Dental exam

  • Acanthosis (neck, underarms)

  • Abdominal exam

  • Insulin injection sites - check for induration, erythema, edema, etc.

  • Check the current Dexcom site and/or insulin pump

  • Complete foot exam done by the attending once per year

• Additional information you might need to obtain

  • Meal times and snack times

  • Trends in hypoglycemic or hyperglycemic episodes

  • Compliance with insulin regimen, particularly with teens

Chart Review

If you know which provider you will be working with, chart review can be done the night before because access to a computer is sometimes limited in the work room. The clinic schedule can be very busy, so if you don’t know which provider, wait until the day of clinic.

Before entering the patient room, review the following.

• Patient name and age

• Type 1 vs type 2 diabetes

• Date/year of diagnosis

• Any hospitalizations (particularly with DKA) since the last clinic visit

  • If hospitalized for DKA, what was the insulin regimen at time of discharge?

• Are they on an insulin pump?

  • There are 2 main types of pumps used - Omnipod and T-slim.

  • Omnipod is a tubeless pump system with an insulin containing pod that attaches directly to the skin. It is easier for kids to change out, but harder to make adjustments to the dosing regimen. T-slim is a pump with a tube that goes into the skin and delivers insulin. The pump itself is a small device with a touch screen that patients attach to their clothing. It is more complicated to change out, but patients can change insulin dosing directly on the pump’s touch screen.

• Insulin regimen - 4 components

  • Long acting insulin (Lantus or Basaglar) dose

  • Short-acting (Humalog or NovaLog) dose with meals. Written as an insulin:carb ratio. For example, 1 unit insulin per 10 grams carbohydrates (patients should be carb-counting meals and snacks)

  • Target: This is the goal blood sugar level.

  • Correction/sensitivity/ISF (insulin sensitivity factor). This tells patients/guardians how to dose additional insulin when blood sugar is above the target level. It is typically used to adjust mealtime dosing, but patients may correct outside of mealtimes if they have persistently high blood sugars.

    • E.g. Can be written as 1 unit per 50/150, meaning for every 50 above 150 glucose reading (150 being the target), give one additional unit of insulin.

  • Regimen for a pump is written differently. The clinic note will give pump settings and a basal rate. Insulin pumps only deliver short acting insulin which is why they require a basal rate. The basal rate will often change at different times of the day.

• On metformin?

• Does the patient have a Dexcom?

  • Dexcom is a continuous glucose monitoring system. It is a skin sensor that sends glucose readings to a device and/or app every 5 minutes and can alert a patient or guardian if a reading is too low or too high.

  • Nursing staff will print out a Dexcom report upon a patient's arrival to clinic which includes data from the past 2 weeks.

  • If the patient has a T-slim insulin pump it can communicate directly with the Dexcom to make real time adjustments to insulin levels based on the glucose readings.

• Date of last clinic visit and most recent hemoglobin A1C

Seeing new consults is a great opportunity to take a history, perform a thorough physical exam, and to work on an assessment, differential, and recommendations. Elective students will often spend a week on the inpatient/consult service. Both elective students and others have an opportunity to be involved in endocrinology consults outside of that time period. Let the inpatient attending know you are interested in seeing new consults, share your contact information, and ask him or her to let you know about any consults that might come during your time on endocrinology.

• Endocrinology serves as the primary team for endocrine patients on blue team. They are a consulting service for other hospitalized patients.

• In the morning the endocrine inpatient/consult team (attending, +/- elective resident, and/or student) meets to discuss all patients: primary and consult. They then join blue team in their conference room (4N) to discuss floor patients on the endocrine service. Starting time is variable as blue team rounds with hematology-oncology service first.

• Students on the endocrine inpatient/consult service should pick patients to primarily follow which includes pre-rounding, working with the team to come up with an assessment and plan, and presenting the patients during endocrine team round, +/- blue team rounds. In order to minimize overlap with purple team students and interns, those on the inpatient/consult service should primarily pick endocrine patients not on the blue team.

• EPIC: EPIC Systems lists > CG Resident Treatment Teams > CG endocrinology

• Medical Documentation

  • Document a consult (initial or follow up) for each encounter

  • Route note to the supervising physician (resident or attending)

  • End each note with: “Discussed with Dr. X (attending)” so the team knows that they can act on plan.

  • Support your recommendations citing primary literature, review article, or a textbook.

Experience in diabetes clinic is active observation only for clerkship students. You are encouraged to follow individual patients through each part of the multidisciplinary clinic session to observe the interchange of information between nurse, dietician and physician, and the summing up of the case and recommendation for future diabetes care.

After actively observing 1-2 patient visits in general endocrine clinic, you may see a patient independently. Third year students are encouraged but typically not required to document in endocrine clinic.

4th year students may be asked to write notes on individual patients for practice and review by the attending. You will not be expected to write notes on all patients.

Endocrine case conference

• Tuesdays 3PM

• Hussmann Conference room

*Elective and endocrine clinic week students strongly encouraged to participate. Optional for others