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Endocrine > TEST 1 > Flashcards

TEST 1 Flashcards

1
Q

hypopituitarism

A

-partial/complete loss of anterior pituitary
-dx- MRI*, CT, pituitary hormone levels
-primary- tumor (MC), infarction (apoplexy, sheehan’s), inflammatory (meningitis, abscess, sarcoidosis), infiltrative (langerhan’s cell histiocytosis, hemochromatosis), iatrogenic, autoimmune
-secondary- hypothalamic
-insidious onset is MC but sudden is more deadly
-congenital is deadly (GH only affects kids)
-ACTH with adrenal crisis and TSH with myxedema -> deadly
-GH is lost first -> GnRH, TSH, ACTH
-ADH rarely lost unless secondary issue -> if pt has polydipsia or SIADH -> suspect hypothalamus

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2
Q

hypopituitarism tx: urgent cute adrenal insufficiency, visual field loss, prolactinoma, pituitary apoplexy

A

-urgent acute adrenal insufficiency -> ASAP glucocorticoids -> 100mg hydrocortisone IV, then 5-100 every 6 hrs and fluid replacement
-visual field loss/tumor -> ASAP referral -> transsphenoidal removal or irradiation
-hormone replacement
-dopamine agonist- prolactinoma
-pituitary apoplexy- ASAP surgery if visual issues or coma

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3
Q

ddx of generalized hypopituitarism

A

-anorexia nervosa- maintenance of secondary sexual characteristics! (this differentiates it) despite amenorrhea -> increased GH (low IGF) and high cortisol
-alcohol liver disease of hemochromatosis- evidence of liver disease -> lab testing
-myotonia dystrophica- progressive weakness, premature balding, cataracts, facial features of accelerated aging -> lab testing
-polyglandular autoimmune disease

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4
Q

hypopituitarism in children

A

-pituitary tumor- craniopahrngioma
-langerhan’s cell histiocytosis
-cleft palate
-idiopathic, hereditary (5%)
-ht below 3rd precentile
-skeletal maturation > 2yrs behind -> left hand x-ray
-late puberty
-CT or MRI
-mid to late childhood -> IGF-1 measured
-tx- surgery, GH therapy, other hormone therapy

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5
Q

ACTH deficiency

A

-fatigue, weak
-wt loss
-hypotension
-hypoglycemia
-intolerance to stress and infection
-decreased axillary and pubic hair
-NO hyperpigmentation
-plasma and urine steroid levels are low

-dx-ACTH stimulation test- synthetic ACTH (cosyntropin) -> cortisol should rise >21 and aldosterone >4 from baseline after 30-60 mins
-insulin tolerance test- hazardous in panhypopituitarism, DM, old -> CI in CAD and epilepsy

-tx- cortisol replacement

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6
Q

Kallmans syndrome

A

-lack of GnRH
-midline facial defect- cleft
-anosmia, sensorineural deafness
-color blind
-hypogonadism
-unilateral renal agenesis (missing 1 kidney)- 50%
-cryptochidism (testes dont descend), micropenis
-bimanual synkinesis (mirror)
-ataxia, cognitive problems
-menarache with secondary amenorrhea

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7
Q

panhypopituitarism

A

-simmond’s syndrome- involves all hormones -> embolic infarction, tumor, syphilis, tuberculosis, metastatic abscess
-sheehan’s syndrome- placenta not delivered right away -> no contraction -> blood loss -> pituitary necrosis from hypovolemia and SHOCK
-no lactation after birth, fatigue
-loss of secondary sexual characteristics (pubic and axillary hair)

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8
Q

pituitary apoplexy

A

-adrenal crisis
-sudden
-pituitary outgrows blood supply
-hemorrhagic infarction of normal or tumor pituitary
-headache, neck stiff, fever, visual field defects*, oculomotor palsies
-compression on hypothalamus -> coma
-hypopituitarism results suddenly -> vascular collapse due to low ATCH and cortisol
-CSF +/- blood
-MRI- hemorrhage

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9
Q

gigantism

A

-little bony deformity
-delayed puberty
-hypogonadotropic -> eunuchoid habitus

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10
Q

acromegaly

A

-1st symptoms- coarsening of face, soft tissue swelling of hands and feet
-naso-sinus abnormality -> snoring, sinusitis, sleep apnea
-diplopia
-arthralgias - TMJ- prognathism
-gums grow -> teeth gaps
-dorsal kyphosis
-deepening of voice
-increase soft tissue- macroglossia, heel thickness (>22mm), sausage fingers
-barrel chest
-insulin resistance, glucose intolerance -> hyperglycemia
-hypertriglyceridemia
-HTN, cardiovascular abnormal
-pulmonary issues from soft tissue growth
-colonic polyposis
-hyperprolactenemia- galactorrhea
-decrease libido and impotence

-tumor- headache, visual issues -> hypopituitarism due to compression
-mortality- stress on body, prone to malignancy
-oily, doughy moist handshake, sweaty
-carpal tunnel, weakness in arms and legs
-skin tags*
-frontal bossing

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11
Q

non-pituitary tumor secretion of GH

A

-RARE
-Pancreatic cancer
-Small cell lung cancer
-Tumors of the adrenal gland
-Carcinoid syndrome
-Carcinoma of the thyroid
-Hypothalamic tumors - extremely rare -> Hamartoma, glioma, or gangliocytoma

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12
Q

acromegaly/gigantism dx

A

-symptoms lead to suspicion
-IGF-1*
-GOLD STANDARD- OGGT - confirms dx
-if GH fails to decrease to <1 after ingestion of glucose -> +
-give glucose- GH and IGF should decrease BUT with acromegaly it will not decrease
-MRI- pituitary adenoma
-CT*
-whole body scan, SPECT, somatostatin receptor scintigraphy - ectopic tumor

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13
Q

gigantism/acromegaly tx

A

-surgery- 1st line
-microadenomas (<10mm), macro (>10mm) -> most are macro (50% curable with resection)
-usually do med or radiation therapy with resection

-Pharmacotherapy- 2nd line
-somatostatin analogs- octreotide -> can also be give before surgery to shrink the tumor down
-dopamine agonist- cabergoline or bromocriptine
-GH receptor antagonist- pegvisomant

-radiation- adjunct or 3rd line
-used for non-resectable, pharm therapy fail, or adjunct
-usually used on its own
-risk of hypopituitarism within 10 years
-stereotactic (gamma knife) radio surgery

-decline in sweating/oily skin -> hallmark of surgical success
-soft tissue symptoms resolve with tx
-bone changes do not resolve
-if colonic polyps were an issue -> continued to be high risk
-if tx before articular cartilage damage -> joint symptoms are reversible

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14
Q

hypothalamic pituitary lesions

A

-MC tumor- hypo (compression) or hypersecretion
-headache, visual field defects
-thirst, altered appetite
-MRI
-can cause enlarged sella

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15
Q

pituitary adenoma

A

-macroadenoma- >10mm -> mass effect
-macro -> look for signs of hypopituitarism!!!!!!!!! (big enough to compress) -> pallor, hypotension
-microadenoma- <10mm -> hormones effect
-secretory- prolactinoma, GH secreting, corticotroponin secreting, thyrotropin secretion
-non-secretory- MC gonadotropin -> usually present with visual defects bc no hormone symptoms

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16
Q

secretion pituitary adenomas

A

-GH-secreting tumors: Signs of acromegaly

-Thyrotropin-secreting pituitary adenoma:
-Thyrotoxicosis
-Goiter
-Visual impairment

-Corticotropin -secreting pituitary adenoma:
-Truncal obesity
-Round face
-Dorsocervical fat pad (buffalo hump)
-Hirsutism
-Acne
-Menstrual disorders
-Hypertension
-Striae
-Bruising
-Thin skin

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17
Q

MEN

A

-autosomal dominant
-genetic testing
-MEN1- pituitary, parathyroid, pancreas
-MC prolactinoma
-Carney syndrome- spotty skin, myxomas, endocrine tumors (testicular, adrenal, pituitary)
-McCune-Albright syndrome- polyostotic fibrous dysplasia, pigmented skin patches, endocrine disorders (GH pituitary tumors, adrenal adenomas, autonomous ovarian function
-familial acromegaly

-MEN2- medullary thyroid cancers, pheochromocytoma, hirschspring disease

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18
Q

pituitary metastases

A

-rare
-POSTERIOR PUTIATRY (almost exclusively)
-diabetes insipidus!
-lung, GI, BREAST*
-MRI- hard to distinguish from pituitary adenoma
-primary or metastatic lymphoma, leukemias, plasmacytomas can occur within sella

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19
Q

prolactinoma S&S

A

-MC tumor
-usually microadenoma in women
-women - galactorrhea, amenorrhea, infertility, low libido, osteoporosis, painful sex, increase body hair, atrophic vaginitis, loss of labial fat pads, decrease breast size

-men- visual disturbances!
-usually macroadenoma- hypopituitarism
-hypogonadism, low libido, ED, infertility, decrease body hair, gynecomastia, galactorrhea (1/3), osteoporosis, decrease body hair

-apathy in women and men- ddx depression
-pharmacologic causes- amphetamines, nicotine, TCA, verapamil, estrogens*
-other causes: chronic renal failure, liver disease, ectopic production of prolactin- bronchogenic carcinoma (mostly small cell undifferentiated)*, hypernephroma

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20
Q

prolactinoma dx and tx

A

-are medications causing it?
-TSH*
-serum prolactin levels
-prolactin is episodic- stress can increase
-repeat sample should be taken if borderline
-NORMAL- <20
-if single draw is > 200 -> dx prolactinoma
-MRI*!

-tx- INDICATION- infertility or macroadenoma
-dopamine agonist- 1st line -> cabergoline, bromocriptine
-if visual issues -> transsphenoidal surgery
-radiotherapy- prior to surgery or after
-reoccurance is high after tx stops

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21
Q

macroadenoma

A

-seizures if extends into temporal lobe- rare
-lateral extension into cavernous sinus- impaired oculomotor function - CN 3, 4, 6, 5
-ophthalmoplegia- squint
-double vision
-bitemporal hemianopsia -MC
-hemifield slide- drift apart

22
Q

empty sella

A

-appear empty due to CSF compressing pituitary
-congenital, primary, secondary to injury (childbirth, surgery, trauma, radiation)
-MC- obese female with HTN
-idiopathic intracranial HTN
-spinal fluid rhinorrhea
-usually normal functioning -> hypopituitarism can occur
-can occur with tumors
-CT or MRI dx
-no tx if asymptomatic

23
Q

ADH

A

-increases permeability of distal tubular epithelium -> increase reabsorption of water
-can cause vasoconstriction at high levels
-MAIN STIMULUS- high osmotic pressure
-other stimulus- volume depletion (baroreceptors in LA, PV, carotid sinus, aortic arch via vagus and glossopharyngeal), pain, stress, emesis, hypoxia, exercise, hypoglycemia, B-blockers, angiotensin, prostaglandins
-inhibitory- alcohol, alpha-blockers, glucocorticoids
-removal of pituitary does NOT result in DI -> remaining hypothalamic neurons produce ADH

-a lack of is caused by primary (hypothalamic/stalk) or secondary (hypophysectomy, injury, tumor, infection, granulomas, vascular)

24
Q

DI sx

A

-CDI
-acute or insidious, any age
-primary- polydipsia, polyuria
-secondary- can also have secondary sx depending on cause
-3-30 L/day urine
-Sp.gr < 1.005
-urine osmolality <200
-nocturia
-ADH < 1

-NDI
-inherited or secondary to renal impairment
-ADH >1

25
Q

DI dx

A

-water deprivation test*
-weight pt before, draw electrolytes and urine osmolality
-urine collected hourly for- osmolality OR Sp.gr measurement
-administer 5u ADH -> urine collected 60 mins after
-D/C if: orthostatic hypotension, >5% wt loss, postural tachycardia, urine concentration doesnt increase by > .001 sp gr OR >30 osmolality

-NORMAL- increase > 1.02 sp gr OR > 700 (exceeding plasma)
-CDI- urine osmolality increase > 50% (not higher than plasma)
-NDI- no response
-partial CDI- osmolality increases above plasma

-ADH measurement- not necessary
-if you do it, you measure after water deprivation and before ADH administration OR after infusion o hypertonic saline

26
Q

psychogenic polydipsia

A

-ingest up to 6L fluid/day
-nocturia is ABSENT
-acute- can concentration urine during water deprivation
-chronic- unable to concentrate urine during water deprivation
-NO response to ADH after water deprivation
-after prolonged restriction to < 2 L/day -> normal concentration ability is restored within several weeks

27
Q

DI tx

A

-desomopressin- synthetic ADH, many routes
-S/E- fluid retention, headache, increase BP, URI or allergic rhinitis

-diuretics- thiazides

-ADH releasing drugs:
-chloropropamide (hypoglycemia)
-carbamazepine
-clofibrate

-prostaglandin inhibitors:
-reduce GFR and renal blood flow

-NDI- thiazide, low salt, low protein

28
Q

SIADH criteria, causes

A

-max dilute urine with hyponatremia/osmolality WITHOUT:
-volume depletion or overload
-stress
-pain
-diuretics or other meds that stim ADH
-no cardiac, hepatic, renal, adrenal, thyroid impairment
-dx of exclusion

-CAUSES:
-drugs
-post op stress, mechanical ventilator, anesthetics
-hormones- ADH, desmopressin, oxytocin
-CNS infection, trauma, neurosurgery*
-pulmonary!- pneumonia, TB, emphysema, SCLC*
-head trauma

29
Q

SIADH signs and symptoms

A

-asymptomatic
-confusion
-lethargy
-vomiting
-seizures
-hypoosmolality plasma- <275
-euvolemic- normal volume
-hyperosmolality urine- >100 often >300
-serum uric acid < 4
-normal K, Cr, acid base
-normal adrenal and thyroid

30
Q

SIADH diff dx

A

-hypervolemic hypotonic hyponatremia:
-edema
-CHF, liver cirrhosis with ascites, nephrotic syndrome, protein losing enteropathy

-hypovolemic hypotonic hyponatremia:
-diuretics, burns, diarrhea, vomiting
-interstitial nephritis, obstructive nephropathy
-mineralocorticoid deficiency

31
Q

SIADH tx

A

-fluid restriction- 1st line
-achieve safe plasma Na - > 120
-determine and treat underlying cause
-d/c meds causing

-for refractory cases -> demeclocycline or normal saline infusion
-tetracycline antibiotic- antagonizes effect of ADH

32
Q

diabetic retinopathy

A

-within 20 years all type 1 has it and 60% of type 2
-type 2 presents at dx
-macular edema and PDR are MC cause of vision loss
-type 2- dilated and comprehensive exam @ dx
-cataracts
-glaucoma

33
Q

stages of DR

A

-mild NPDR- increase vascular permeability, microaneurysms, intraretinal hemorrhage, ANNUAL FU
-moderate NPDR- venous caliber changes, IRMAs, 6-12 MO FU, color fundus photography
-severe/very severe NPDR- ischemia, IRMAs, extensive hemorrhage and microaneurysms, 3-4 MO FU, color fundus photography, panretinal photocoagulation
-PDR- ischemia with neovascularization at optic disk and retina, vitreous hemorrhage, retinal traction, tears, and detachment, 2-4 MO FU

-If CSME present: color fundus photography, fluorescein angiography, and photocoagulation

34
Q

neuropathy + dx

A

-caused by high glucose, glycation end products, sorbitol, blood fat levels, ischemia
-type 2- @ dx
-type 1- 5 years after dx
-nerve conduction studies
-electromyographic exam
-US
-foot exam at every visit or more:
-temperature/pinprick
-vibration with 128Hz
-quantitative sensory testing
-monofilament (4/10)

-gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressents, sodium channel blockers
-anticonvulsants, topical cream, moisturizer
-infected ulcer -> antibiotics
-fil calluses with pumice

35
Q

symmetric polyneuropathy

A

-MC
-stocking glove
-vibratory, thermal pain, paresthesia
-ulcers, charcot arthropathy
-PVD

36
Q

autonomic neuropathy

A

-internal organs- GI, GU, cardio, peripheral
-charcot foot
-edema, pruritus, pulsation, tight, aching, sweating
-GU- bladder, retrograde ejaculation, ED, dyspareunia
-GI- gastroparesis, enteropathy
-cardio- exercise intolerance, hypotension

-dx- direct microelectrode recording of postganglionic C fibers
-galvanic skin responses
-measurement of vascular responses

-tx- midodrine, diuretics, d/c aggravating drugs, elevate feet, stockings, screen for CVD
-tx GI- metoclopramide (motility), erythromycin, R/O atherosclerosis/tumor, loperamide (anti-diarrhea), antibiotic, stool softeners, dietary fiber
-aldose reductase inhibitors
-ACE inhibitors- doesnt need to be HTN

37
Q

polyradiculopathy

A

-amyotrophy- thigh pain with muscle weakness and atrophy
-dx- electromyographic studies

38
Q

mononeuropathy

A

-single nerve
-compression / ischemia
-carpal tunnel
-elbow
-foot- unilateral foot drop
-numbness, edema, pain, prickling

-cranial- CN 3, 4, 6 -> diplopia, abn visual fields, unilateral pain, paralysis

39
Q

nephropathy

A

-first evidence - albuminuria (>300)
-by the time Cr is high -> 50% renal lost
-GOALS:
-bp <140/90 and <130/80 in ASCVD
-HmgA1c <7 and <8 for GDM
-preprandial 90-130
-peak postprandial <140

-kidney transplant- blood type, human leukocyte antigens (HLAs), cross matching antigens

-1. high GFR
-2. microalbuminuria with some glomeruli damage
-3. albuminuria (>200), Cr and urea rise, BP may rise
-4. GFR < 75, HTN, proteinuria
-5. GFR <10

-tx- bp, protein restriction, ACE
-end stage- hemodialysis, transplant, peritoneal dialysis
-dialysis- limit potassium and fluid, phosphorus

40
Q

DKA

A

-ketones > 5
-glucose > 250
-pH < 7.2 and gap > 12
-bicarbonate < 15
-high amylase and lipase
-low insulin and high glucagon -> glucagon converts FFA to ketones -> insulin would normally block this -> acetoacetic acid and β-hydroxybutyric acid
-can be caused by infection, cocaine, inadequate insulin use, pregnancy, infarction
-dry membranes, SOB, kussmaul respirations, fever if infection, acute cerebral edema in children (monitor fluids!)
-children with highest BUN and lowest CO2 at presentation -> greatest risk

41
Q

DKA tx

A

-potassium 5.5 and greater -> IV insulin
-4.5- monitor while giving
-<3.3- you cant give insulin
-<5.5 supplement K 10
-<3.5 supplement K 40-80 or if bicarbonate if given
-cont until acidosis and glucose is good

-rapid 2-3L 0.9% saline in first 1-3hrs
-once BP and urine flow stable -> 0.45% saline
-5% glucose and 0.45% saline when glucose reaches 250

-IV insulin
-increase 2-10 fold if no response by 2-4hrs
-once 250 glucose you can reduce dose
-cont insulin until anion gap is WNL and blood and urine are neg for ketones

-pH <7 -> bicarbonate
-once tx initiated may need to supplement phosphate and Mg

-ICU- labs every hour
-capillary glucose every 1-2 hrs
-electrolytes and anion gap every 4 hrs
-vitals every 1-4 hrs

FU:
-education (underlying cause)
-if sick or oral intake is compromised:
-check capillary blood glucose often
-if glucose >300 check urinary ketones
-drink water
-continue or increase insulin
-seek medical attention if dehydration, persistent vomiting or uncontrolled hyperglycemia

42
Q

hypoglycemia tx

A

-Mild- carbohydrate 10-15 gram*

-Moderate:
-20-30 gram of carbohydrates*
-Glucagon, 1 mg IM - if unconscious

-Severe:
-50% dextrose 25 g IV
-Glucagon 1 mg IM or IV

43
Q

HHNK

A

-causes- drugs, procedures, chronic illness, acute illness
-K is not urgent bc insulin is present
-hyperglycemia, dehydration, hyperosmolar
-NO/slight ketosis, NO acidosis
-complications- MI, stroke, PE, mesenteric vein thrombosis, disseminated intravascular coagulation
-dehydration

44
Q
A

-postprandial glucose targeted if A1c goals are not met despite reaching pre-prandial glucose

45
Q

monitoring diabetes

A

-prediabetes- yearly
-uncontrolled diabetes or transition- quarterly
-diabetes stable - 6-12 months
-microalbuminuria, lipids, LFTs, Cr, GFR, c-peptide level, TSH- at dx and annual
-type 1- 3-4 times a day SMBG
-type 2- ass needed SMBG

46
Q

metabolic syndrome

A

-waist circumference
-glucose levels (prediabetes/resistance)
-BP
-triglycerides, HDL

47
Q

insulin types

A

-bedtime intermediate or bedtime/morning long acting
-> if A1c is still high -> rapid acting before breakfast, or lunch, or dinner depending on when glucose starts to rise
-basal- long acting, 1-2x a day, rarely cause hypoglycemia
-rapid insulin- regular
-bolus insulin -> rapid, given before food
-NPH- intermediate acting
-mixed- NPH and regular insulin

48
Q

GDM risk factors

A

-Fasting plasma glucose concentration >85 mg/dL or
-2-hour postprandial glucose concentration >140 mg/dL -> Indicates need to perform a 75-g oral glucose tolerance test

49
Q

Graves disease

A

-toxic diffuse goiter
-MC genetic autoimmune
-can be brought on by environment (stress)
-smoking -> ophthalmopathy
-postpartum
-high HLA
-dermopathy - pretibial myxedema
-ophthalmopathy- can happen before and or after event -> sympathetic overactivity
-thyroid acropachy***
-hyperreflexia (brisk), muscle wasting, proximal myopathy
-osteopenia
-hypercalcemia / uria (mc)
-children- high linear growth, eye symptoms
-elderly- CHF, afib

50
Q

other thyroid disease

A

-plummer disease - toxic multinodular goiter
-jodbasedows disease- iodine induced, or amiodarone
-subacute thyroiditis- viral, idiopathic
-nodule >1-2mm -> bx
-confusion- high bilirubin, LFTs, ferritin
-microcytic anemia, thrombocytopenia

-tx- antithyroid (thioureylene, propylthiouracil, methimazole), propanolol
-radioactive iodine- CI in children <10, preg, active orbitopathy
-thyroidectomy- children, preg who cant handle antithyroid, compression, cancer, rapid progression with comorbid
-uni or multinodule goiter -> radiation after stable with antithyroid or surgery

-fu- antithyroid- every 3 months
-iodine radiation- 6 weeks, 3 months, 6 months, 1 year, annual
-postpartum- 6 weeks

Endocrine (26 decks)

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