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endocrinology Flashcards

0
Q

elevated prolactin levels cause amenorrhea because

A

LH and FSH will decrease

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1
Q

Damage to the pituitary stalk will affect labs how

A

all levels will decrease except prolactin will increase

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2
Q

prolactin has no stimulatory hormone, it has only

A

dopamine

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3
Q

hypothyroidism will also cause increased prolactin due to

A

TRH -thyroid releasing hormone- acts on prolactin and TSH

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4
Q

signs/symptoms of hyperprolactinemia in female

A

galactorrhea
amenorrhea
infertility

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5
Q

signs/symptoms of hyperprolactinemia in male

A

impotence
decreased libido
infertility

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6
Q

causes of hyperprolactinemia

A

hypothalamic dz-sarcoid, pituitary stalk dz,pregnancy, hypothyroid, renal failure, pituitary tumors,cirrhosis, acromegaly, idiopathic, drugs,

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7
Q

drugs assoc with hyperprolactinemia

A

phenothiazine, metoclopramide,reserpine,methyldopa,, estrogen, opiates,cocaine, TCA, MAO inhib., verapamil, H2 blockers, SSRI’s

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8
Q

prolactin level >150 in nonlactating and nonpregnant, think

A

prolactinoma

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9
Q

macroadenoma

A

> 10mm

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10
Q

microadenoma

A

<10mm

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11
Q

rule out secondary causes hyperprolactinema by

A

MRI brain

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12
Q

work up suprasellar macroadenoma, infrasellar macroadenomas

A

visual field testing, eval anterior pituitary function (TSH,ACTH,FSH,LH,IGF1)
infertility or amenorrhea tx with bromocriptine or caberrgoline
if no response to rx, may need surgery

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13
Q

treatment of microadenamas

A

regular menses-no tx
infertility-bromocriptine
amenorrhea- bromo/cabergoline, OR estrogen/progesterone

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14
Q

most common cause of acromegaly

A

GH producing tumor of the pituitary

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15
Q

unique sign of acromegaly

A

enlarging glove and shoe size

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16
Q

S/S acromegaly

A

enlarging shoe and glove size, widened teeth spacing, incr. soft tissue mass palms/soles, macroglossia, hyperhydrosis, prominent jaw, deep voice, hyperglycemia, arthritis

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17
Q

best screening lab for acromegaly

A

IGF-1

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18
Q

confirmation of acromegaly diagnosis

A

failure of growth hormone to suppress <1ug/L within 1-2 hours of 75G oral glucose load

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19
Q

tx of acromegaly

A

surgery for pituitary adenoma, if no remission after surgery, add somatostatin (octreotide) +/- GH receptor antagonist pegvisomant +/- pituitary irradiation

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20
Q

complications of acromegaly

A

sleep apnea, carpal tunnel, CHF, LVH, HTN, cardiomegaly, OA, DM, hyperprolactinemia, hypogonadism, visual field defects , giantism

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21
Q

giantism in acromegaly occurs when

A

GH hyper secretion occurs prior to long bone epiphyseal closure

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22
Q

**Surgery indicated in acromegaly for

A

pituitary adenomas secreting : ACTH,TSH,GH
adenomas assoc with mass effect, vision field defects or hypopituitarism
prolactinomas unresponsive to dopamine agonists

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23
Q

20 year old presents with impotence, decreased libido, infertility, and anosmia. Lab: decreased testosterone, LH, FSH
Dx & Tx

A

Kallman’s syndrome-GnRH deficiency

Tx-testosterone

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24
Q

causes of GnRH deficiency

A

Kallman syndrome, mutation in GnRH receptor gene, hyperprolactinemia
acquired deficiency: long distance runners, anorexia nervosa, starvation, stress

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25
Q

Prolactin levels must be measured in all patients with….

A

hypogonadism and low LH/FSH

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26
Q

hypopituitarism leads to deficiency of

A

multiple hormones

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27
Q

hypopituitarism in young children see

A

growth retardation ( decreased growth hormone)

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28
Q

hypopituitarism in older children see

A

delayed puberty (decreased LH/FSH)

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29
Q

hypopituitarism in premeopausal see

A

amenorrhea (decr LH/FSH)

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30
Q

hypopituitarism in men see

A

hypogonadism (decr libido, infertility, impotence)
hypothyroidism
secondary hypocortisolism

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31
Q

growth hormone deficiency causes

A

increased fat mass
decreased lean body mass
decreased bone density
decreased quality of life

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32
Q

prolactin deficiency causes

A

inability to lactate following pregnancy

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33
Q

ACTH deficiency causes

A

secondary hypocortisolism: hypoglycemis, fatigue, anorexia

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34
Q

thyrotropin deficiency -TSH

A

wt gain, dry brittle hair, hair loss, dry skin, constipation, fatigue, cold intolerance, cognitive complaints

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35
Q

dx of hypopituitarism

A

low or inappropriately normal levels of pituitary hormones in the setting of low target hormone ie: low free T4 and normal TSH

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36
Q

initial tests for eval of hypopituitarism

A

MRI of pituitary
IGF-1,free t4, TSH, am cortisol, ACTH, testosterone, LH, FSH, prolactin
(TSH,LH,FSH may be normal or low in hypopituitarism)

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37
Q

common etiology of hypopituitarism

A

tumors, brain radiation
hemochromatosis, amyloidosis
sheehan syndrome, empty sella symdrome
lymphocytic hypophysitis

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38
Q

sheehan syndrome

A

seen after delivery baby, hypotension during labor causes pituitary necrosis
see: failure of lactation, failure to resume regular menses, and fatigue

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39
Q

Empty sell syndrome

A

decreased pituitary gland volume

10% may have hypopituitarism or increased prolactin

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40
Q

lymphocytic hypophysitis

A

symmetric and homogeneous sellar mass
usually occurs during or after pregnancy
adrenal insufficiency is common

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41
Q

treatment of hypopituitarism

A

** cortisol replacement before thyroid replacement
remember stress cortisol dose if ill, stress, surgery
testosterone replacement in males
estrogen/progesterone in females
GH replacement

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42
Q

polyuria, think

A

central diabetes insipidus
nephrogenic diabetes insipidus
psychogenic polydipsia

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43
Q

with central diabetes insipidus see

A

> 50% urine osmolality after vasopressin or desmopressin

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44
Q

with psychogenic polydipsia see

A

hyponatremia

increases urine osmolality after water deprivation

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45
Q

50 y/o male with headache, decreased libido, sparse facial hair, lab:decreased testosterone,LH, and FSH. prolactin 2000. MRI large pituitary adenoma with suprasellar extension. visual exam-bitemporal heminopsia. Dx and Tx

A

macroadenoma

bromocriptine

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46
Q

in prior pt, if all same except prolactin 50, what dx and tx?

A

nonsecreting macroadenoma

TX*** nonsecreting large tumors need surgery!!!

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47
Q

same patient but free T4,TSH,am cortisol all decreased, prolactin 2000. Dx & Tx

A

hypopituitarism

tx: cortisol, thyroid, testosterone if male, bromocriptine

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48
Q

30 y/o female,2mm pituitary adenoma on routine MRI. asymptomatic and menses and prolactin levels are normal. what to do next?

A

Dx: incidentiloma
Tx: measure IGF-1 and prolactin, if normal, recheck lab and MRI in 6 months

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49
Q

54 y/o male severe headache,nausea, vomiting, hypotension, altered consciousness. MRI show a hemorrhagic mass in the sella.
Dx & Tx

A

Pituitary Apoplexy (hemorrhage into tumor)

Tx hydrocortisone and surgery

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50
Q

patient to ER after head injury. he is polyuric, elevated BUN, Na 150, urine osmolality of 40.
Dx and how to confirm

A

central diabetes insipitis

IV desmopressine- should decrease urine volume

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51
Q

38 y/o female with diabetes, amenorrhea, and bronze pigmentation of skin. Lab: neg pregnancy, decreased FT4,TSH,FSH,LH.
Dx and what to do next

A

dx: hemochromatosis
do iron studies
replace her hormones and thyroid

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52
Q

24 y/o female with polyuria and polydipsia, urine osm is 60 and does NOT change with water deprivation. after vasopressin, osmolality increases to 100. Dx?

A

central diabetes insipidus

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53
Q

19 y/o female with syncope and has K+ 2.5, HCO3 34, urine K 8
Dx?

A

dx-bulemia

** #1 cause of metabolic alkalosis in young female- vomiting caues lose of acid from the GI tract

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54
Q

same 19 y/o patient but HCO3 of 20

whats dx now/

A

laxative abuse, mild acidosis

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55
Q

same 19 y/o but K+ 2.5 and urine K 50

whats diagnosis

A

diuretic abuse or Barter syndrome (lose K in urine)

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56
Q

most common cause of diabetes insipidus

A

autoimmune

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57
Q

patient with polyuria and sodium 128, likely cause

A

psychogenic polydipsia

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58
Q

a few days post op a patient develops Na+ 120. why

A

pain increases ADH

also use of hypotonic fluids

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59
Q

patient on lithium presents with polyuria
urine osm 50, Na+145
Dx & Tx

A

lithium induced DI
tx-thiazide or amiloride
** do not stop lithium

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60
Q

patient with thyrotoxicosis and enlarged thyroid
increased: FT4, T3,TSH,RAI
what next

A

pituitary tumor-do MRI

TSH should be decreased with thyrotoxicosis but since it is increased pituitary is the problem

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61
Q

pt w hashimoto for many yrs now has rapidly enlarging neck mass, engorged neck veins,, hoarseness, dysphagia. ultrasound shows enlarged thyroid and cervical glands. Dx

A

Primary thyroid lymphoma

high incidence with hashimoto’s

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62
Q

disorders associated with increased risk of thrombosis

A 
prothrombin 20210 mutation
ATIII deficiency
Protein C deficiency
antiphospholipid syndrome
resistance to activated protein C
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63
Q

T3 produced by

A

TSH in pituitary or conversion of T4->T3

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64
Q

conditions that impair peripheral conversion of T4 to T3

A

systemic illness
malnutrition
old age
drugs:propranolol, PTU, iodine contrast

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65
Q

with impaired conversion of T4 to T3, see

A

increased rT3

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66
Q

low T3

A

not used in dx hypothyroidism

low T3 doe not always indicate hypothyroidism
no role in eval of hypothyroidism, so dont measure total T3

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67
Q

only time free T3 us ckecked is eval for

A

thyroitoxicosis

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68
Q

labs with thyrotoxicosis (hyperthyroid)

A

^Total T3 &T4, ^ free T3 & T4
decreased TSH
RAI uptake >30%
^except on thyrotoxicosis factitia

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69
Q

hypothyroidism lab

A

decreased T4 & T3, total and free levels, increased TSH

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70
Q

TPO Ab -thyroid peroxidase antibodies and thyroglobulin antibodies seen in

A

hashimoto thyroiditis

*presence in euthyroid or subclinical hypothyroidism confer an increased risk of developing overt hypothyroidism

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71
Q

thyroid stimulating immunoglobulin (TSI) seen in

A

Graves’ disease

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72
Q

TSH binding inhibitor immunoglobulin (TBII)

A

Graves’ disease or Hashimoto’s thyroiditis

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73
Q

a patient with thyrotoxicosis with enlarged thyroid, incr free T4 and free T3, ^TSH, ^RAI. what test to do next?

A

do pituitary MRI-pituitary tumor

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74
Q

pt with hashimoto thyroiditis for years presents with rapidly enlg neck mass, engorged neck veins, hoarse, dysphagia.Likely dx

A

primary thyroid lymphoma-high incident with hashimotos

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75
Q

thyroid binding globulin increased in

A

pregnancy
estrogen,tamoxifen,methadone
genetic
hepatitis, biliary cirrhosis

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76
Q

thyroid binding globulin decreased in

A 
androgens, glucocorticoids
nephrotic syndr, chronic liver disease
severe systemic illness
acromegaly
genetic
77
Q

if suspect thyroid dx, measure

A

TSH , Free T4

78
Q

high FT4

A

hyperthyroidism

79
Q

high FT4 and TSH low

A

primary hyperthyroidism

test RAI uptake

80
Q

RAI uptake with diffuse increase

A

Graves’ disease

81
Q

RAI uptake with focal increase

A

toxic adenoma

82
Q

RAI uptake with decreased uptake

A

subacute or lymphocytic thyroiditis
factitious thyrotoxicosis
iodine excess
struma ovarii-teratoma produces thyroid hormone

83
Q

High FT4 and TSH normal or elevated

A

secondary hypothyroidism-rare-can be due to:
TSH producing tumor
thyroid hormone resistance syndrome

84
Q

Low FT4

A

hypothyroidism

85
Q

low FT4 and TSH elevated

A

primary hypothyroidism, check TPO Ab:
(+) Hashimoto
(-) other causes

86
Q

FT4 low and TSH normal or low

A

secondary hypothyroidism.

get CT,MRI, measure other hormones

87
Q

sick euthyroid syndrome

A

acute systemic illness can affect thyroid function

88
Q

apathetic thyrotoxicosis

A

FT4 normal TSH decreased: see apathy rather than hyperacitvity:
lethargy, depression, wt gain, droopy eyelids, constipation . A fib, CHF

89
Q

types of thyroiditis

A 
Hashimoto
painless postpartum, sporadic, subacute
suppurative
drug induced
Riedels
90
Q

hashimoto thyroiditis

A

1 cause of hypothyroidism

thyroid firm, lumpy, painless
+ TPO or thyroglobulin antibodies

91
Q

Painless postpartum (lymphocytic) thyroiditis

A

thyroid enlarged and nontender
thyrotoxicosis at first then hypothyroid, lasts 4-6 months
Tx thyrotoxicosis with beta blockers, hypothyroid with synthroid

92
Q

painful subacute thyroiditis

A

follows URI,tender and enlarged thyroid, incr sed rate
thyrotoxicosis early->transient hypothyroid->recovery 6-12 month
Tx NSAIDS,steroids if severe pain
B blockers for toxicosis, synthroid for hypothyroid

93
Q

suppurative thyroiditis

A

fever, chills, tender nodule

tx-drainage and anibiotics

94
Q

drug-induced thyroiditis

A

amiodarone, lithium, interferon alpha, interleukin 2

95
Q

riedels thyroiditis

A

rock hard, fixed, painless goiter
negative antibodies
may cause esophageal or tracheal compression

96
Q

indications for RAI (radioactive iodine)

A

severe hyperthyroidism
very large goiter (>4 x normal)
T3:T4 ratio >20
elevated antithyrotropin antibody

97
Q

contraindications of RAI

A

pregnant, lactating
unable to comply with safety regulations:
no contact children or pregnant for 1 week
avoid close contact >2 hours at 6 feet or closer for 5 days

98
Q

RAI pretreatment

A

Bblocker for symptoms
High risk patient tx with antithyroid meds for several weeks prior, stop them 2-3 days before and resume 3-7 days after tx:
elderly, underlying CV dz, severe hyper symptoms,or hormone >2-3 times normal

99
Q

indications for antithyroid drug therapy (PTU,methimazole)

A

children, preg/lactating
initial tx in adult with severe eye dz, mild-mod hyperthyrodism, small goiter,T3:T4 <20, (-)antithyrotropin antibody
PTU not used as first line except in first trimester pregnancy, and thyroid storm tx

100
Q

antithyroid drug tx for 12-18 months and

A

if adult relapses->tx with RAI

if child, give second round of antithyroid meds

101
Q

side effects of anti thyroid drugs

A

agranulocytosis-stop if neutrophil count <1000
arthralgias, polyarthritis
ANCA + vasculitis, immunoallergic hepatitis (PTU)
severe hepatic necrosis)PTU),cholestasis (methimazole)
hypoglycemia-insulin autoimmune syndr (methimazole)

102
Q

Thyroid storm

A

rare, life threatening condition with severe clinical manifestations of thyrotoxicosis
mortality 15-20%

103
Q

clinical features of thyroid storm

A

hyperpyrexia
CNS:agitation, delirium,confusion, psychosis, sz, stupor, coma
GI: N/V, diarrhea, abd pain, jaundice
CVS: tachycardia, heart failure, atrial fib

104
Q

causes of thyroid storm

A

graves dz #1
toxic adenoma
multinodular goiter

105
Q

precipitating factors of thyroid storm

A

surgery, infection, trauma, parturition, acute iodine exposure, RAI therapy, ingestion of salicylates and pseudoephedrine

106
Q

treatment of thyroid storm

A

large doses of PTU and SSKI (start 1 hour after PTU) plus propranolol to control heartrate, plus IV hydrocortisone

107
Q

features of Graves opthalmopathy, moderate to severe

A

spont. retrobulbar pain, pain w eye movement, redness of eyelids, conjuncitva, swelling of eyelids, caruncle and conjunctival edema
eyelid retraction >2mm,exopth>3mm, mod to severe soft tissue involvement, extraocular muscle involvement (diplopia), moderate corneal involvement

108
Q

tx of mod-severe graves opthalmopathy

A

weekly infusion methylprednisone 500mg X 6 weeks then 250mg weekly for 6 weeks. if no improvement in 3-4 months, give 2nd course of IV steroids with orbital radiation

109
Q

rare manifestations of hypothyroidism

A 
pericardial effusion, CHF, sinus brady, prolong QT, torsades
hypoventilation
increased CPK and +MB fraction
hyperprolactinemia
diffuse pituitary enlargement
110
Q

clinical features of myxedema coma

A

decr LOC,psychosis, seizures
Hypothermia, hypoventilation leading to hypoxia and incr PCO2
hyponatremia, hypotension, hypoglycemia
sinus bradycardia

111
Q

must rule this out in any patient with coma and has low heartrate

A

myxedema coma

112
Q

precipitating factors in myxedema coma

A

cold weather
sedatives
infections

113
Q

tx of myxedema coma

A

high doses of both levothyroxine and glucocorticoid

114
Q

multinodular goiter with normal FT4,normal TSH

A

observe

115
Q

multinodular goiter with normal FT4 and low TSH, treatment

A

symptomatic-RAI

asymptomatic-observe

116
Q

multinodular goiter with increased FT4 and Low TSH Tx

A

RAI

117
Q

Jod-Basedow phenomenon

A

patient with multinodular goiter that develop thyrotoxicosis on exposure to iodine containing contrast agents

118
Q

tx of papillary and follicular thyroid carcinoma

A

near total thyroidectomy
RAI after 6 weeks when TSh >50-ablates thyroid remnants/mets
thyroid hormone replacement
repeat scan 6-12 month
follow serial thyroglobulin levels, repeat scan if increase levels

119
Q

indications of RAI tx after thyroidectomy for cancer

A

all with distant mets
extrathyroidal extension of tumor regardless of size
primary tumor >4cm even with no high risk features
1-4cm w lymph node mets or high risk features

120
Q

thyroid nodules with high suspicion of thyroid cancer

A 
nodule firm/hard/fixed to adjacent structures
rapid growth
regional or distant lymphadenopathy
paralysis of vocal cords
family Hx medullary ca or MEN syndrome
121
Q

thyroid nodules with moderate suspicion of thyroid Cancer

A

male, age 70
hx of head and neck radiation
dysphagia, hoarse, dyspnea, cough
U/S: >3cm, speckled calcification w/in nodule, high vasc flow in center, hypoechogenicity,irreg border, taller than wide

122
Q

thyroid nodules indications for biopsy

A

nodule >1cm or smaller if risk factors

if nodule >3cm and FNA is (-), consider repeat

123
Q

effects of amiodarone on thyroid functions

A

hypothyroidism–dont stop drug, tx with synthroid
hyperthyroid in pt w prior graves or multinodular goiter-discontinue amiodarone, may need antithyroid meds
impaired T4 to T3 conversion

124
Q

intensive therapy to achieve near-normal glucose delays onset and slows the progression of

A

microvascular complications of diabetes (retinopathy,nephropathy,neuropathy). but NOT the macrovascular complications (MI, CVA)

125
Q

microalbuminuria - 30-300mg/gm of cr on random urine sample

A

risks: increase risk of overt renal failure and CAD

Tx: control BP <130/80, ACE/ARB
intense bs control

126
Q

types of diabetes

A

Type I
Type II
genetic defects
secondary causes

127
Q

type I diabetes is

A

autoimmune destruction of pancreatic beta cells, insulin deficiency, ketosis prone, positive islet cell or glutamic acid decarboxylate antibody

128
Q

type II diabetes is

A

impaired insulin secretion
increased insulin resistance
excessive hepatic glucose production

129
Q

genetic defect as cause of diabetes

A

MODY-maturity onset diabetes of the young

130
Q

secondary causes of diabetes

A

chronic pancreatitis, CF, hemochromatosis, acromegaly, cushings,pheochromocytoma,hyperthyroidism, gestational
Crugs: niacin, glucocorticoids, thiazides, protease inhibitors, clozapine, cyclosporine

131
Q

diagnosis of DM

A

symptoms + random blood glucose >/= 200
2 hr glucose >/=200 after 75gm glucose tol test
8 hr fasting plasma glucose >/= 126 on 2 occasions
HgbA1c >/= 6.5

132
Q

prediabetes

A

fasting plasma glucose 100-125
2 hour plasma glucose 140-199 after 75gm glucose
HgbA1c 5.7-6.4

133
Q

what is risk of coronary event in pt with diabetes?

A

same as those with KNOWN CAD

134
Q

patient with Type I DM has acute pancreatitis. BS 500, TG 5000. what is best tx of the TG in this patient?

A

IV insulin

135
Q

54y/o with FBS 115, 2 hr glucose TT 130, HgbA1c 6, BMI 36.

DX and TX

A

prediabetes

diet and exercise

136
Q

how to differentiate T.I and T.II diabetes?

A

(+) GAB antibodies in Type I

137
Q

where should you maintain blood glucose in critically ill patient?

A

140-180

138
Q

preferred initial agent in diabetic if no contraindication

A

metformin

139
Q

actions of metformin

A

decrease glucose production in the liverr
increase uptake & util. of glucose by adipose ad muscle
no effect on insulin release
promotes wt loss and lowers lipids
decreases macrovasc. complications (MI,CVA)

140
Q

metformin toxicity

A 
lactic acidosis
metalic taste
nausea
diarrhea
abdominal pain
141
Q

contraindications of metformin

A

renal dz:male cr >1.5, female >1.4, GFR <60
impaired liver function, chronic alcoholism or binge drinking
CHF
severe hypoxia

142
Q

discontinue/hold metformin

A

prior to radiographic contrast material
prior to surgery or in critically ill patients
if pt develops N/V

143
Q

rapid acting insulin

A

humalog-insulin lispro
novolog-aspart
apidra-glulisine
inhaled insulin

144
Q

short acting insulin

A

regular-given 30 min before meal

145
Q

intermediate acting

A

NPH

Lente

146
Q

long acting insulin

A

lantus-once a day-insulin glargine

detemir-given BID

147
Q

premixed insulin

A

NPH/regular- 70/30, 50/50
protamine aspart/aspart 70/30
protamine lispro/lispro 75/25, 50/50

148
Q

management type 2 DM-lifestyle intervention and metformin, if HbA1c > or = 7% do one of below

A

add basal insulin-most effective
add sulfonylurea-least expensive, add below if not controlled
add glitazone-avoid hypoglycemia-add sulfonyl if still not control then basal insulin etc.

149
Q

insulin tx in type 2 DM:hs NPH or daily lantus (10units or 0.2u/kg starting dose)->FBS daily, inc dose by 2units every 3 days (4 units if FBS.180)until target range 70-130. after 3 mo if HbA1c.=or > 7%, FBS ac and hs.

A

if glucose incr still, add rapid acting insulin:
pre lunch bs incr-add insulin before breakfast
pre dinner incr bs- add insulin before lunch
if incr at hs-add insulin before dinner

150
Q

goals for tx of diabetes

A

HbA1c 40 in male, >50 female,TG50,female>60

151
Q

insulin dosing

A

total dose .2-0.4 unit/kg/d one-half dose as basal insulin, other half give rapid acting (humalog, novolog) divided equally before each meal

152
Q

ideally prandial insulin is determinedby amount of carbs about to be consumed ( 1 unit for 10-15gm carb) plus a correction factor predicated on preprandial glucose ( 1 extra unit for every 40-50mg/dl above 100)

A

see above

153
Q

diabetic ketoacidosis

A

insulin deficiency and glucagon excess
incr gluconeogenesis & decr peripheral glucose utilization
release of fatty acids from adipose tissue
accelerated fatty acid oxidation in the liver
incr ketones (beta hydroxybutyrate/acetoacetic acid)

154
Q

precipitating factors of diabetic ketoacidosis

A 
inadequate insulin administration
infection,MI,CVA
surgery, trauma
pregnancy
cocaine
155
Q

clinical features of diabetic ketoacidosis:
anorexia, N/V, polyuria, polydipsia
altered mental status,focal deficits, coma , Kussmaul respiraions, acetone odor on breath, diffuse abd pain
tachycardia, hypotension, dehydration

A

Lab: increased WBC,TG,amylase
decreased sodium (1.6 meq decr for each 100 rise in serum glucose) decreased HCO3, decr K+.
+ ketones

156
Q

Tx of DKA
1. severe hypovolemia-normal saline at 1 liter/hour
mild dehydration-correct Na: high-0.45% Nacl 250-500ml/h.when serum glucose

A
  1. insulin-regular 0.1 u/kg IV bolus then 0.1u/kg/hr IV continuous infusion until glucose 200, decrease insulin to 0.05-0.1u/kg/h to maintain glucose 150-200.
  2. potassium-,3.3-hold insulin, give K 40-0meq/hr until K .3.3, if K+ is 3.3-3.5-repl K at 10meq/hr, if K+>5.3 hold K
  3. HCO3-given only if pH ,7.0or HCO3
157
Q

complications during tx of DKA

A

accelerated coagulopathy
cerebral edema- more common kids, progressive neuro deterioration-IV mannitol
hyperchloreic acidosis, hypophosphatemia(rhabdo, cardiomyopathy,hemolytic anemia), hypoglycemia, hypokalemia

158
Q

in noncritical inpatients, goal fasting glucose

A

90-140 and random or postprandial levels 150 (graded scale 1-4 units for each 50 mg/dl

159
Q

autonomic neuropathies in diabetes

A

gastroparesis, alternating diarrhea and constipation, impotence, urinary incontinence or retention, orthostatic hypotension without reflex tachycardia, persistent sinus tachycardia

160
Q

gastroparesis in diabetes symptoms

A

early saiety
N/V
dyspepsia
postprandial abd fullness

161
Q

Dx gastroparesis in diabetes and tx

A

Dx-gastric emptying scan

Tx-metoclopramide or erythromycin

162
Q

risk factors for diabetic foot ulcers

A 
increased formation of keratin
loss of pressure sensation
loss of pain and temperature sensation
weakness of intrinsic muscles
loss of sweating
163
Q

clinical features of hyperglycemic hyperosmolar state

A

profound dehydration, hypotension, incr HR, alt mental status
NO-N/V,abd pain, Kussmauls are NOT present
often precipitated by serious illness:MI,CVA,sepsis, pneumonia

164
Q

labs in hyperglycemic hyperosmolar state

A

marked hyperglycemia (600-1200)
hyperosmolality (330-380)
Na+ normal to mild decr-correct add 1.6 meq to measured Na for every 100mg rise in glucose
small anion gap acidosis due to lactic acidosis, serum ketones +/-

165
Q

Tx hyperglycemic hyperosmolar state

A

NS initially and change to 1/2 NS after hemodyn. stable. water deficit is 9-10 liters and should be replaced over 2-3 days.
insulin bolus 0.1 unit/kg then drip 0.1unit/kg/hr
when glucose 200-300 add D5 and reduce insulinto 0.05-0.1unit/kg

166
Q

manifestations of vit D deficiency

A

osteomalacia, ricketts in children, osteopenia/osteoporosis
muscle weakness and incr risk of falls
incr risk of: cancer(breast,colon,prostate), HTN, CV dz,diabetes, metabolic syndr, MS, schizophrenia, depression

167
Q

Osteomalacia-manifestation of vit D deficiency see

A

bone pains/tenderness, fracture after minimal trauma, pseudofractures
Lab: calcium-normal or decreased
phosphorous-normal to decreased
increased alk phos

168
Q

vitamin D testing

A

measure 25(OH)D2 and D3
normal 30-60
<20 tx 50,000u D2 weekly for 6- weeks then 800u/d of D3
20-30 tx vit D3 800u/d

169
Q

causes of vit D deficiency

A

reduced skin synthesis-decr sun exposure, sunscreens,skin pigmentation,aging
decreased bioavailability-malabsorption, obesity
increased catabolism-anticonvulsants, glucocorticoids, HAART
breastfeeding, pregnancy, lactation

170
Q

cont causes of vit D deficiency

A

decr synthesis of 25(OH)D-liver disease
incr urinary loss of 25(OH)D-nephrotic syndrome
decr synthesis of 1-25(OH)2-chronic kidney disease
tumor induced osteomalacia-phosphaturia
primary hyperparathyroidism-decr 25(OH)D, incr 25(OH)2D

171
Q

cont causes of vit D deficiency

A

granulomatous diseases-decr 25(OH)D incr 1-25(OH)2D
thyrotoxicosis-incr metabolism of 25(OH)D
heritable disorders-ricketts

172
Q

hypercalcemia with high or normal PTH

A

hyperparathyroidism
lithium
familial hypocalciuric hypercalcemia

173
Q

hypercalcemia with lor or undetected PTH-

A

if chronic:sarcoid,thyrotoxicosis, adrenal insuff., immobilization, drugs(thiazides, vit A&D, calcium carbonate.
if acute:MALIGNANCY-if incr Ca, decr P-humoral
-if incr Ca, P normal-metastatic myeloma

174
Q

Multiple endocrine neoplasia

A

MEN1, MEN IIa, MEN IIb

175
Q

MEN I

A

hyperparathyroidism
pituitary
pancreatic tumors

176
Q

MEN IIa

A

hyperparathyroidism
pheochromocytoma
medullary carcinoma

177
Q

MEN IIb

A

pheochromocytoma
medullary carcinoma
mucosal neuromas
marfanoid habitus

178
Q

familial hypocalciuric hypercalcemia

A

autosomal dominant
decr calcium excretion<0.1
parathyroidectomy DOES NOT correct calcium

179
Q

hyperparathyroidism-indications for surgery

A

age 400,hx life threat hypercalcemia
symptomatic hypercalcemia
renal stones , Ca >1 above normal , decr bone mass (T score<60

180
Q

hyperparathyroidism procedures

A

sestamibi parathyroid scanning (best),neck ultrasound

indicated if minimally invasive surgery is planned

181
Q

hyperparathyroidism-medical treatment

A

avoid thiazides, normal calcium intake, maint 25(OH)D>20
bisphosphonates if low bone mass
Cinacalcet(calcimimetic agent) use in symptomatic pt not surgical candidates
monitor calcium and cratinine annually and bone density 1-2 years

182
Q

hypercalcemia of malignancy

A 
humoral
metastatic
osteoclast activating factors
ectopic PTH secretion (rare)
coexisting primary hyperparathyroidism
183
Q

hypercalcemia of malignancy-humoral

A

PTHrP increased Ca, decreased P
squamous cell ca of the lung and other sites
other tumors:renal, breast, ovary, endometrium

184
Q

hypercalcemia of malignancy-metastatic

A 
breast
prostate
thyroid
lung
kidney
185
Q

hypercalcemia of malignancy-osteoclast activating factors

A

interleukin-1
TNF
1-25(OH)2 vit D

186
Q

tx of hypercalcemia

A

hydrate with NS, loop diuretics, phosphate repletion if P <3.0
Meds: first line-IV bisphosphonates (Pamidronate, Zoledronate)
2nd line-glucocortioids, Mithramycin,calcitonin, gallium nitrate

187
Q

Hypoparathyroidism

A

diseases assoc with: addisons, premature ovarian failure, autoimmune thyroid disease, pernicious anemia, mucocutaneous candidiasis
LAB: decr Ca++.decr PTH, incr P

188
Q

hypocalcemia

A 
PTH absent (decr Ca++,decr PTH, incr P)-hypoparathyroidism, hypomagnesenia (leads to decr Ca++, decr K)
PTH ineffective (decr Ca++,incr P & PTH)-end organ resistance to PTH-short 4th and 5th metacarpals and metatarsals
PTH overwhelmed-severe acute hyperphosphatemia(tumor lysis, rhabdomyolysis, ARF, hungry bone syndrome(after surgery for hyperparathyroidism)
189
Q

tx of hypocalcemia

A

oral calcium and Vit D to keep calcium 8-8.5

IV calcium gluconate for acute symptomatic hypocalcemia

GI (10 decks)

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