Dr. Robert R. Kimmel , MD

A new lump in the neck requires accurate assessment and diagnosis. These cases are typically referred to otolaryngologists, oncologists and endocrinologists depending on initial suspicions. Health providers use history, risk factors, and hands-on physical diagnostic methods first, followed usually by some combination of CT, ultrasound, fiberoptic, nuclear, and biopsy procedures. Lab tests (typically blood, urine) are used to guide the diagnostic sequence. Your history of hypothyroidism suggests the possibility of thyroid nodules or cysts, but tumors of other types, both primary and metastatic, must be considered. The bubbling sound is difficult to interpret, but could represent impingement.

A simple question that requires a complex answer. When blood sugar is low, one must determine whether the glucose value is really accurate, and then whether it is significant given the circumstances. Finger stick glucose, referred to as capillary plasma glucose, or CPG, can be measured using a glucometer and a tiny drop of blood obtained by pricking the fingertip with a lancet. Continuous glucose monitoring systems measure glucose using a subcutaneous sensor probe placed on the arm or other body surface. These devices measure glucose in what is called the interstitial fluid, not blood from capillaries.

Glucometers, glucose sensors, although improving, vary widely in price, technology, precision, and accuracy. None currently perform like clinical laboratory technology that processes blood drawn from a vein. Precision and accuracy at low blood glucose levels are especially limited in point-of-contact meters and sensors. Plus, sampling from a vein is more representative of the general circulation than sampling subcutaneous tissue in fingers and arms.

Low deoxycorticosterone by itself, with normal aldosterone and cortisol, and no symptoms other than fatigue, probably has no significance. The real question is, why was it ordered? It is usually ordered to see if it is high. Ask your doctor what he or she was looking for.

There are numerous causes for growth arrest and weight lifting is not likely to be the cause. He needs to be seen by a pediatric endocrinologist who can do a thorough evaluation.

The TSH range for the second trimester is 0.55-2.73. Your TSH of 0.23 is slightly lower (but normal for the first trimester), meaning that your thyroid hormone levels (T3 and/or T4) could be a little too high. Alternatively, your hCG might be a little higher than normal, which could also produce this result. So, you don't necessarily have a problem. However, you could also have some form of autoimmune thyroiditis. In any case, I recommend seeing an endocrinologist and having blood drawn for TSH, free T4, free T3, TSI, TRAb, anti-TPO and anti-thyroglobulin, plus, of course, a physical exam for signs of thyroid disease.
Hope this helps.

If this is a dark, velvety rash, then it may be acanthosis nigricans, which is a hallmark of insulin resistance. Check with your doctor to get a hemoglobin-A1c test, which will tell the healthcare provider how high your blood sugars have been on average over the past several months. Acanthuses nigricans can also be associated with obesity, some malignancies, and certain genetic disorders. The condition can also be familial, and even caused by drug reactions. So you will have to seek medical attention to determine the cause of this rash in your case.

As with any medical problem, evaluation for possible thyroid problems starts with the history and review of bodily systems. The doctor is looking for symptoms and risk factors compatible with a thyroid disorder. Risk factors include family history, especially for first-degree relatives, exposure to ionizing radiation and certain medications, and exposure to iodine. The physical exam may yield further clues for a thyroid problem. But the evaluation quickly turns to laboratory tests because the findings at history and physical examination are frequently non-specific and overlap with those of other non-thyroidal disorders.

Basic laboratory evaluation of the thyroid includes thyroid stimulating hormone (TSH), free T4, free T3 and appropriate antibodies, such as anti-thyroglobulin, anti-thyroid peroxidase (anti-TPO), or, in cases of suspected Graves disease, thyroid stimulating immunoglobulin (TSI), and TRAb (thyrotropin receptor antibodies. Sometimes erythrocyte sedimentation rate (ESR) is added in cases of thyroiditis due to viral infection

The physical exam is often non-specific and can underestimate the size and texture of the thyroid in many cases. Thyroid ultrasound (US) has become the standard imaging technology that serves as a significant extension of the physical examination.

In some cases it becomes necessary to measure and image the regional function of the thyroid gland to find nodules and regions that produce too much or too little thyroid hormone (so-called "hot" and "cold" nodules or regions, respectively) using radioactive iodine (RAI) tracers. These are called RAI uptake studies. These nuclear medicine tests can determine whether the thyroid is either making excessive thyroid hormone, or releasing stored thyroid hormone due to injury.

We emphasize that not all alf these tests may be required in every case, and indeed, the diagnosis can frequently be made by history, physical and the first round of blood tests. While treatment may be started after minimal initial diagnosis, it is becoming standard to include thyroid US at baseline evaluation because nodules frequently coexist with other thyroid diseases. After lab tests, thyroid US, and if needed, RAI uptake and scan, the diagnosis will be confirmed. A logical care plan then can be recommended to include hormonal, nutritional or drug therapy, and fine-needle biopsy as indicated.

There are other tests such as blood or urine iodine, erythrocyte selenium, deiodinases, thyroid binding globulin, thyroglobulin, reverse T3, and basal core body temperature, that have specialized uses, but are seldom needed.

Insulin is not usually a one-way street, unless your pancreas can no longer make enough insulin. Deficiency of insulin happens when the beta cells in the pancreas are destroyed by the immune system, drugs, toxins, and severe diseases of the pancreas. More often there is a resistance to the effects of insulin caused by infection, stress, inflammation, pain and numerous drugs, especially prednisone and similar steroids. Obesity, overeating and inactivity also contribute to.insulin resistance. So if some of these problems can be overcome, you have a good chance of backing off insulin.

First morning blood sugars can be elevated for several reasons. A common reason is that sugars are high at bedtime the prior evening and remain above normal throughout the night, usually due to inadequate insulin coverage of the dinner meal and evening/bedtime snacks. Other common reasons include stresses during the night, such as pain, insomnia, frequent nocturia or frequent awakening for any reason, acute infection and some steroid regimens. Growth hormone is higher in the morning, as well, and in the setting of inadequate insulin, could lead to higher morning blood sugars ("dawn phenomenon"). Elevated morning sugars once were thought to result from rebound from nocturnal hypoglycemia ("Somogyi effect"), but this notion has been discredited.

Anxiety due to medications for diabetes usually results from low blood sugar (hypoglycemia) or blood sugar level that is decreasing too rapidly (even if not actually low). Hypoglycemia, usually defined as blood sugar below 70 mg/dL, can result from too much insulin, sulfonylurea (like glipizide, glyburide, glimeperide), or meglitinide (like repaglinide (Prandin), nateglinide (Starlix)) and SGLT2 inhibitors (like Jardiance, Farxiga, Invokana). On the other hand, some anti-diabetic medications are less likely to cause low blood sugar. These include DPP4 inhibitors (like Januvia, Onglyza, Tradjenta), GLP1 receptor agonists (like Byetta, Bydureon, Trulicity, Ozempic and Victoza) as well as acarbose (Precose) and metformin. However, even these drugs can cause low blood sugar when taken in combination or as overdose. Lows also can occur when diabetic medications are not adjusted for exercise or significant decrease in food intake. Combining diabetic medications with alcohol is especially dangerous since alcohol inhibits the ability of the liver to make glucose fast enough in response to a low. Determining the cause of anxiety due to medications for diabetes requires a bit of detective work, so it would be best not to "go it alone" and to discuss your blood sugar patterns with your health care provider. Your doctor will find it most helpful if you check blood sugars upon arising and at bedtime, before and 2 hours after eating, any any time you feel anxiety, apprehension, rapid heart rate, sweating, excessive hunger, unusual fatigue or sleepiness, lightheadedness, sudden or profound weakness.

I would first determine whether your mother is still making insulin. If so, there may be new medications or combinations that would help. Otherwise she would be limited to insulin or drugs that can lower blood sugar but don't depend on insulin. I would make sure she is doing everything possible in the way of lifestyle changes such as diet, exercise, weight and stress control. Also, I would make sure she has no occult infection that may be causing high sugar levels due to insulin resistance. Finally I would make sure she is not on drugs like cortisone or prednisone, and numerous others, which can increase insulin requirements dramatically.

Answer: Starting on insulin does not have to be a one-way street. Patients can often work down and off of insulin, depending on the reason for starting insulin, how long the person has had diabetes, the type of diabetes, and how difficult it has been to control blood sugars. Individuals who cannot make insulin will not be able to stop insulin unless they receive and new pancreas. This group includes those individuals with established Type 1 diabetes, following pancreatic resection or destruction and many adults with latent autoimmune diabetes.

Stopping insulin is sometimes possible if an individual has not had diabetes for more than 10 years and blood sugars haven't been too high for too long. Taking strong measures to reduce insulin resistance, such as losing weight, increasing exercise, treating infections, addressing the causes of chronic stress and pain, treating sleep apnea and, if possible, getting off of medications such as steroids If a patient is on basal insulin and doesn't need mealtime coverage, taking these measures will reduce, and sometimes eliminate, the need for injecting insulin.