Flashcards in 10 Endocrinology Deck (55)
Female pt presents with galactorrhea and amenorrhea.
How to workup?
2. hypoT (leads to high TRH, stimulating prolactin)
3. DA blockers (antipsychotics)
-get TSH, Prolactin
If prolactin elevated, get MRI
bromocriptine, cabergoline (DA agonist)
-how to workup
1. high IFG-1 (GH varies too much during day, even though tumor secretes this)
2. glucose supproession test (does giving glucose lower GH?)
-what kills them
-cardiomegaly and diastolic HF
-somatostatin (octreotide) before surgery
Hormones of ant pit (5) vs post pit (2)
post pit has 2: oxytocin, ADH
ant has the rest:
GH, TSH, ACTH, LH/FSH, Prolactin
-how does it present?
-how to dx
Less important hormones lost first: LH/FSH and GH, then TSH, then ACTH (BP)
So, first is reduced libido and menstruation, fatigue, vague sxs
-insulin stim test (induce hypoglycemia, does GH increase?)
-MRI to confirm, replace hormones
-what 2 dx to know, how present?
1. sheehans--ischemic pituitary post-partum
-reduced lactation post-partum is 1st sign
2. apoplexy--pit tumor outgrows blood supply, bleeds
-rapid decompensation--Think sudden HA with vision change and N/V, followed by adrenal insuff, lethargy, coma. Catastrophic.
Tx: replace hormones! (esp cortisol, T4)
MRI shows no pituitary. what is going on
Empty Sella syndrome.
pituitary is located somehwere else.
Male pt presenting with low libido and vision change. think what
Diabetes insipidus tx:
-gentle diuretics (HCTZ +/- amiloride)
-think what 3 categories
1. brain--tumor, infxn, trauma
2. lung--small cell CA, COPD, TB
3. hypothyroid (high TSH can stim ADH)
tx underlying cause (eg head trauma, etc)
-Demeclocyline to induce nephrogenic DI to get rid of free water
Sick euthyroid syndrome
TSH normal, but T4 wacky.
Pt in ICU can get this. Disregard the T4 if TSH is normal!
This is only time to get a rT3 level. (in sick euthyroid rT3 is elevated, confirming sick euthyroid)
When to get free T3 level
Only get if you suspect hyperthyroid (low TSH), but T4 is normal/low
What things affect total T4 level? (2 to remember)
1. estrogen (pregnancy) increases proteins (thyroid binding globulin). So, increased total T4
2. Cirrhosis is low protein. So, low total T4
Female pt with hyperthyroidism sxs. TSH low, T4 high, cold RAIU.
-DDx, and what is next step
1. factitious hyperT
2. struma ovarii
3. thyroiditis (acute stage)
Get thyroglobulin levels. Elevated with T4 production, so struma ovarri and thyroiditis have elevated thyroglobulin.
If low, then factitious!b Can also do Sestamibi scan of ovaries.
Pt with hyperthyroid sxs. You confirm labs--low TSH, high T4.
What is next step, and what results possible?
Do RAIU test
-diffuse nodules--nodular goiter
If thyroid NOT hot, then:
-Thyroiditis (wait for thyroid to calm down, might be temp hypothyroid)
-how to dx
1. anti-TPO (thyroid peroxidase),
2. anti-TG (thyroglobulin).
(these 2 are 90% spec) Definitive is Bx.
Can present with transient hyper and hypothyroidism
Grave's unique sxs (2) among all hyperT
-how to tx
1. exophthalmos--tx with steroids
2. pretibial edema
Thyroid storm tx in what order, mechs
First, IVF and cooling blankets. Then 3 P's
1. Propranolol--reduce HR to increase BP
2. PTU/methimazole--reduce T4 production
3. Prednisone (more likely IV methyprednisolone)--reduce T4-T3 conversion
Iodide can also be used (Wolff-Chaikoff). Thyroid preferential picks up iodide instead of making T4, so temporizing measure. However, if thyroid storm not fixed, that iodide will be used to make more T4! (Wolff-Chaikoff escape)
Thyroid storm, what alarm sxs?
Pt with hyperthyroidism. TSH low, T4 high.
How to know if this is Graves or early Hashi's?
ESR/CRP is elevated in Hashi's only
-how to workup
Get TSH first, even if asx. If euthyroid, then get FNA.
If obvious dx is CA (hx of neck CA), then go straight to excision.
what to remember about each
Papillary--MCC. orphan annie, psammoma, resection with good prognosis
Follicular--"sneaky." FNA cannot dx, spreads hemotogenously. However, full resection and iodine ablation will find and kill all mets.
Anaplasic--bad, chokes esophagus and trachea. Death 1 yr
Medullary--MEN 2a/b, Calcitonin producing (so HypoCa)
diamond, square, triangle with tip
MEN 1--pit, parathyroid, panc
MEN 2a--parathyroid, thyroid medullary, pheo
MEN 2b (lincoln--tall)--mucosal, thyroid medullary, pheo
Only get if suspect sick euthyroid. will be increased, confirming sick euthyroid
-how does this correlate with other thyroid labs
Thyroglobulin is increased when T4 production is increased. So, you can use to see factitious hyperT
-name types and differences
All can present with transient hyperT (can be months), then transient hypoT.
1. Hashi's--stays hypothyroid
2. de Quervain (tender thyroid)
3. silent lymphocytic--eventually recovers.(in hypothyroid state, distinguish from Hashi's with Ab tests)
New Grave's dx
Propranolol first, PTU/methimazole takes time for effect
Prednisone for exophtalmos