Endo Block 1 Flashcards
1
Q
For endocrine homones what are the biological active fraction, bound or unbound
A
Unbound (free)
2
Q
What are the two basic classes of hormones
A
polypeptides (proteins) and steroids (thyronines)
3
Q
How are steroids chaparoned thoughout the body
A
By binding to a protein
4
Q
High levels of circulating hormone produces what in negative feedback
A
Decreases hormone synthesis and secretion
5
Q
Low levels of circulating hormone has what response in negative feedback loops
A
Increase hormone synthesis
6
Q
In hyperfunction of endocrine tissue what is primary disfunction
A
Alteration of the hormone secreting gland
7
Q
In hyperfunction in endocrine tissue what is secondary disfunction
A
Alteration in pituitary or hypothalumus
8
Q
What is ectopic endocrine tissue disfunction
A
Hormone secreted from tissue other tahn usual sourse
9
Q
What is resistnce endocrice disfunction
A
Inability of target tissue to recognize the hormone
10
Q
What is an adenoma
A
Adenoma—benign enlargement of a cluster of glandular (secreting) cells
Can become malignant (i.e. adenocarcinoma)
11
Q
What is a neoplasm
A
Neoplasm—abnormal new growth of tissue
Generally considered malignant
12
Q
What is hyperplasia
A
Hyperplasia—benign enlargement of entire gland
13
Q
What is the differnce between atrophy and hypoplasia
A
Atrophy – the wasting away of existing cells
Hypoplasia – underdevelopment or incomplete development (congenital)
14
Q
What is the single best screening lab for someone with hypothyroidism
A
Screen the pituitary ( TSH)
15
Q
What are the two hormones secreted from the posterior pituitary gland
A
Oxytocin and ADH
16
Q
Is the post pituitary a gland
A
Not a gland but is the distal axon terminals of the hypothalamic neurons
17
Q
What are the two receptors for ADH
A
V1 and V2
V1 receptors are found in blood vessels, constricts vascular smooth muscle (however it is a weak pressor)
V2 receptors are found in the collecting duct of the kidney, and they cause water to be retained in the body
The major function of ADH is to retain water in the body
18
Q
What is the major function of ADH
A
NO PEEING, to retain water in the body
19
Q
What is the response of ADH to osmolarity increases
A
ADH is released
20
Q
Where are the V2 receptos for ADH
A
Works in the collecting tubel and increases aquaporins to increase water absorption
21
Q
What are the two regulators for ADH secterion
A
#1 - Osmoreceptors in hypothalamus -1% INCREASE in plasma osmolality releases ADH
#2 - Baroreceptors in arteries and atria -10% or greater DECREASE in plasma volume or pressure, releases ADH
22
Q
What effect does alcohol have on ADH secretion
A
Inhibits ADH and increase urine output
23
Q
What is SIADH
A
Too much ADH, SI makes you SWELL! Retain fluid
24
Q
What is Diabetes insipidus
A
Not enough ADH, DI makes you DRY, PEE OUT ALL YOUR FLUID
25
What are the initial clues of SIADH
normal or expanded plasma volume, but NOT low plasma volume
low serum sodium (hyponatremia)
high urine specific gravity (SG)
high urine sodium
26
What are the top three causes of SIADH
Central nervous system or lung disorders
Malignancy - tumors which secrete ectopic ADH
Prescription and recreational drugs
27
80 percent of lung tumors associated with SIADH are..
Small cell lung cancer
28
A pt presents with unexplained hyponatremia and oliguria/ anuria…
What should you order
Chest Ct or MRI r/o malignancy
29
What effect does antineoplastic medication have on ADH
Increased secretion (SIADH) due to nausea mechanism
30
What effects for NSAIDs have on ADH
Increase ADH by inhibiting prostaglandins
31
What medications induce SAIDH
Antidepressants ( SSRI, TCA, MAOI)
Anti neoplastic agents ( that cause nausea)
MDMA- Exctasy
NSAIDs
Opiates
32
Low Na+ in the setting of SIADH is due to…
Excess water, not lack of sodium
33
What are the early S/s of low serum Na+
Fatigue
HA
Nausea
34
What are late signs of Low serum Na+
Letharfy, confusion, stupro, and coma
Neuromuscular excitabilty, muscle twitching a SZR, from electrolyte abnomrl
Vomiting and abdominal cramps
35
What are the labs values in SIADH
Low plasma osmololity
W/ normal plama volume
HypoNa+ (<135)
High urine osmololity compared to plasma (>20mEq/dL)
```
Low BUN (<10 mg/dL)
Hypouricemia
```
36
What is the Tx approach to euvolemic, aS/s or mild S/s of SIADH
Water restriction
Demeclocycline ( if the pt cant adhere to water restriction)
Ensure adequate dietary Na+ intake
37
What is the Tx appraoch to S/s and severe hyponatremia
Raise serum Na+ by o.5-1 mEq/ hr to a max 125-130 (avoid locked in syndorme) No more than 8-10 mmol in a 24 hour period
3% hypertonic saline-- for emergencies only (CNS symptoms present)
-Seizures, confusion, etc.
Furosemide—increases free H2O excretion
Tolvaptan (V2 receptor antagonist) – mediates the diuretic effect of ADH
These medications would be used in consultation with a nephrologist
Monitor serum sodium levels frequently (q 1-2 hours)
38
What is the referral criteria for SIADH
Nephrology or Endocrinology referral for SEVERE, uncertain, refractory, or complicated cases
If AGGRESIVE therapies are needed, such as with hypertonic saline, demeclocycline, V2 receptor antagonists, or dialysis
In patients with end liver or heart disease
39
A pt presents with 2-20 L of urine production in 24 hours think
Diabetes insipidus
40
What is a normal urine osmolality
300 mOsm/kg
41
What are the 4 main types of DI
Central (important)
Nephrogenic (important)
Primary Polydipsia
Gestational
42
What causes nephrogenic DI
Decreased ability to concentrate the urine due to resestance to ADH in the kidney
43
What is sheehan syndrome
Massive blood loss post parturm, leading to hypovolemic shock and pituitary infarction ( may cause DI)
44
What are the common causes of Nephrogenic DI
Medications like LITHIUM, demeclocycline, ETOH, CAFFINE, Wt loss medicaions
Hypokalemia and hypercalcemia
Renal Dz
45
A pt presents with polydispsia, polyuria with a normal serum sodium, (with possible nocturia)
Think ?
Classic presentation of DI
46
How does an unconscious pt present with DI
HOTN, vascular collapse, Hypernatremia
47
What is a urine output volume that would r/o DI
Less than 2L in 24 hrs
48
What is a vasopressin challange test
A w/u for central DI Dx
Patient is admitted to hospital
-Give desmopressin acetate (0.05-0.1 mL/1mcg)*intranasally, subcutaneously or intravenously
Measure urine volume before for 12 hrs, then after DDAVP
Measure serum sodium at baseline, 12 hours after DDAVP
If pt has Central DI, they will have decreased thirst, decreased urine output, increased urine osmolality
49
A pt with an elevated ADH during fluid restriction
Think
DI
50
What is the Tx approach to Central DI
DDAVP, lowest effective dose 2-3 x a day
Monitor elecrtrolytes
Avoid dehydration ( V/D)
51
What is the tx appraoch to Nephrogenic DI
Indomethacin 50 mg q 8hrs
52
What is the adenohypophysis
The anterior pituitary
53
What is the relationship with ACTH and MSH
ACTH stimulates alpha-MSH in the Ant. Pituitary
54
What is the effect of pregnancy on the Ant. Pituitary
Doubles in size
55
What is the diff between clinically functioning and non functioning pit. Adenomas
Functioning is secreting at least 1 hormone, non functioning is not and typically found on accident
56
What is the diff between macro and micro adenomas
Macro : >1 cm and micros are less
57
What is the procedure of choice to investigate a pituitary problem
MRI!
58
What effect does dopamine agonists and somatostatin have on Prolactin secrtion
Decrease/ Block the secretion
59
What is bromocriptine
A dopamine agonist that can suppress the secretioin of Prolactin
60
What is a normal prolactin level
Less than 20mg/dl is normal
61
What effect does glucose have on Growth Hormone
Hyper glycemia suppresses Growth Hormon secretioin, Hypoglycemia stimulates Growth Hormone production
62
What is the Tx of choice for Acromegaly
Transsphenoidal resection (SRGRY)
63
What cardiac conditions are assoc. with acromegaly
Valvular regurgitation and persistant HTN
64
What is cushings “disease”
A cortisol hormone d/o that comes from the brain ( secondary)
65
What is cushings “syndrome”
Primary adrenal problem with cortisol
66
What is the most common cause of cushings syndrome
Taking too much corticosteroids
67
A pt presents with central obesity, facial plethora, thin skin with easy bruising, proximal muscle weakness, HTN and DM
Think?
Hypercortisolism ( adrenal, ACTH problems)
68
What is the test to assess corticotropic adenomas
A dexamethasone supression challange
and a 24 hour urine
69
What is the Tx of choice for a Cushings Disease
Surgical removal of the tumor
70
A pt presents with sudden severe headache, AMS, Vomitting, Ocular defects, with HOTN
Think
Pituitary D/o likely hypo
71
In hypopituitary d/o what are the order of loss hormones
GH is lost first
72
What are the common S/s of hypothroidism
Fatigue, letharfy, constipation , depression, wt gain, cold intolerance, dyspnea on execrtion, menorraghia, arthlagias, parasethisias
(Metabolism is down)
73
How with DTRs present with hypothyroidism
Delayed relaxation
74
What is the single best test to evaluate hypothyroidism
TSH
May be increased/ elevated in primary
And may be low in secondary
75
What is a normal TSH level
0.4-4.0 mL/L
76
When should TSH be checked after starting levothyroxine tx
Not until after 6 weeks!
77
How should levothyroxine for hypothyroidism be taken
Must take in the AM, without other food or drugs,
At least 4 hours before other drugs
LONG TERM!
78
What is the dosing regiment for levothyroxine
Start at 50 mcg/ day then increase q 6 weeks by 25-50 mcgs until target dose is reached
(1.6 mcg/kg/day)
79
What is the TSH goal for hypothyroidism Tx
A TSH between 04.-2.0 mL/L
80
What effect does pregnancy have on Levothyroxine Tx
Dosage requires in the 5th week of pregnancy a 20-30% increase
81
A pt with hypothyrdoidism + hypercapnia, + myxedema coma… what do you do
ADMIT!
82
What is cretinism
Congenital hypothyroidism
Hypoplastic or failure of the thyroid to migrate to its appropriate location
Usually heriditary from hashimotos
S/s: slow mentation, slow bone development, decreased longitudinal growth, Thick dry scalp, with delayed sexual maturation
Tx: levothyroxine
83
Resting tremor is a sign and symptom of what D/o
Hyperthyroidism
84
How does Graves Dz present
High Thyroid s/s
Bruit + enlarged thyroid
Non pitting edema
SubQ infitrates
Exopthalmos
85
What is thyroid acopathy
Swelling/ clubbing of the fingers seen in graves dz
86
A pt presents with LOW TSH and High T3 T4 think
Hyperthyroidism, Graves Dz
87
What are the Tx approachs to Hyperthyroidism
Methimazole
Proprothyuricil ( pregnant seeking pts)
Surgery
S/s control with b blockers
radioactive therpay
88
What are the ADE of Tx of hyperthyroidism
Rash, agranulocytosis, N/ dyspepsia, Liver failure with PTU 1:1000
89
What are Orargrafin and telepaque
Bridge therapy to surgery for hyperthyroidism
Used for severe S/s
90
What is the Tx of Choice for Graves Dz (Hyperthyroidism)
Ablation of the thyroid with radiation
91
What is the Tx appraoch to exopthalmos
Corticosteroids (treat during the ablation of the thyroid)
92
What are the three indications for surgery of the thyroid in hyperthyroidism
Large obstructive gland, risk of malignancy, or pregnant women with uncontrolled S/s
93
What is the most common type of thyroid cancer
Papillary
94
What is the most aggresive form of thyroid cancer
Anaplastic
Which is also the least common
95
What is the most sig RSK fx for development of papillary thyroid cancer
Exposure to radiation
96
What is the Tx of choice for Thyroid Cancer
SURGERY
97
Post surgical RAI is only effective on what two types of thyroid cancer
Papillary and follicular
98
What is the tx approach to thyroid storm
Admit to ICU
+propranolol
+ Proprylthiuricil
+ Corticosteroids
B Blockers can be used for cardiac S/s
99
What is the Tx approach to myxedma coma
IV levothyroxime
Supportive care, passive warming, electrolyte correction
100
Where does ACTH have its action in the adrenal gland
Reticularis and Fasciculata
101
What is ACTH made from
Pituitary corticotropes
102
What is the pattern of secretion with ACTH
Diurnal rhythm
Earlest at 0400
Lowest at night
103
What is the most common ACTH producing tumor
Small cell lung tumor
104
What is the testing approach to Cushing syndrome Dx
1. Dexamethasone Test (Tests ACTH)
(If elevated in the AM then think Cushing syndrome)
2. 24 hours urinary free cortisol test
(Confirms if cortisol is high or not)
3. Check a baseline ACTH
(If NML or elevated= get an MRI) (Cushing Dz)
(If VERY VERY elevated= get a Chest CT )
(Ectopic ACTH Secretion)
105
What is the most common cause of adrenal insufficiency
Autoimmune adrenalitis
Also TB
106
What is the Test approach to Addisons Dz
1st: check serum cortisol
2: sythetic ACTH test
3: no response= Primary
Responce= secondary
107
TRH stimulates what two hormones
TSH and PRL
108
PRL inhibits what hormone
LH
109
GHinhibiting Hormone inhibits what two hormones
TSH and GH
110
What is another name for dopamine
Prolactin inhibiting hormone
111
What effect does cabergoline, bromocriptine, and pergolide have on PRL
Decreased secretion of PRL
112
What effect does hypothyroidism have on PRL
Increased secretion of TRSH which increases TSH and PRL
113
What is the Tx of choice for prolactinomas
Levothyroxine if hypothyroidism
Dopamine agonists: Cabergoline (pregnant pts)
or bromocriptine
Can D/c Tx after 24 months
114
What inhibits GH
GHIH, Hyper glycemia, Hypothyroid, Glucocorticoids,
| IGF1
115
What is the DDX of gigantism and acromegaly
Gigantism is GH oversecrtion in a child Acromegaly is oversecretion in adults
116
What is the Dx approach to acromegaly
Random IGF1 level, If abnormal then obtain a fasting IGF1 level, then give 100 mg glucoes, then measure IGF1 again, if GH is greater than 1mcg/L then confrimed
117
Prolactin level high? Investigate…
Prolactinoma OR GH tumor
118
What is the FU criteria for acroegaly
At least annual IGF1
Cardiac followup for valvular dz
Or HTN
119
A pt presents with sudden severe HA, altered LOC +wkness, Vomiting and ocular defects +HOTN
Suspect
Infarction/ pituitary apoplexy
TX w/ glucocorticoids follwed by surgery
120
What is the most commonly affected endocrine structure in head truama
Ant pit
121
What are the recommended screening labs in head truama
Recommended screening labs include: 0800 cortisol, TSH, T4, LH, FSH, IGF-1, testosterone (males), estradiol (females)
122
What is the order of loss in pituitary failure
Gradual loss of normal pituitary function.
In order of loss: GH, gonadotropins, TSH, ACTH
PRL deficiency is rare
123
A pt presents with increased abdominal adipose tissue, decreases streghnt and excercise capacity, decrease in total lean body mass, elevated SBP, increased LDLs
Think what hormone deficiency
GH
124
A pt presents
Girls: delayed breast development, scant pubic/axillary hair, primary amenorrhea
Boys: small phallus & testes, sparse body hair
Adult females: breast atrophy, loss of pubic/axillary hair, secondary amenorrhea, infertility
Adult males: testicular atrophy, decreased libido, loss of body/facial hair, ED, infertility
Think what hormone deficiency
LH/FSH
125
A pt presents with weakness, fatigue, wt gain, constipation, cold intolerance, and a slow HR
Think what hormone deficiency
TSH
126
How will labs present in hypopituiary
Both pituitary and targert hormones will be low
127
What two mechanisms increase aldosterone secretion
Angiotensis II and Hyper K
128
What is the main cause of refractory HTN
Hyperaldosteronism
129
What is conn syndrome
Unlilateral aldosterone secreting adrenal adenoma
Mc in women
130
Bilateral adrenal hyperplasia is most common in men or women?
Men
131
What are the three main causes of hyperaldosteronism
Unilateral aldosterone-producing adrenal adenoma (Conn syndrome)
Women MC
Bilateral adrenal hyperplasia
Men MC
Aldosterone producing adrenocortical carcinomas
132
What is the most common cause of excess renin production
Renal artery stenosis
133
What is the most common cause of adrenal insufficiency
Abrupt stop of steroid use
| WE CAUSE THIS
134
A pt with diastolic hypertension is a key finding of what D/o
Hyperaldosteronism
135
What is the Dx criteria for hyperaldosteronism
Sustained HTN 150/100
(3 diff days)
HTN resistant to 3 anti-HTN drugs
Controlled BP needing 4+ drugs
Hypokalemia
Personal/family hx of early-onset HTN or CVA aged <40
1 degree relative with primary aldosteronism
Presence of an adrenal mass
Low plasmin renin activity (PRA)
136
A pt that has HTN and hypokaleia
Think
Hyperaldosteronism
137
What are the steps to ordering a plasma renin activity
1st correct the hypokalemia
Next eat a ton of salt
(more tha 6g)
Stop diuretics, ace, Arbs , BB, Nsaids, and OCPS
Then draw when pt OOB x 2hrs between 8-10 am
Also order a K+ level and an aldosterone level
138
When ordering a PRA (renin), a suppressed PRA means…
Primary hyperaldosteronism
139
When ordering a PRA (renin), what does an increased PRA mean…
Secondary hyperaldosteronism
Due to renal artery stenosis
Leading to increasaed aldosteronism
140
What is the DX approach to hyperaldosteronism
24 hr aldosterone level,
(Primary presents with elevated aldosterone)
Then order a CT or MRI to r/o adrenocortical carcinoma (MC in women) or a adrenal hyperplasia (MC in Men)
141
What is the Tx apprach to Conn Dz
Conn Syndrome is an adenoma
Tx: surgery
142
What is the Tx approach to bilateral adrenal hyperplasia
TX: Spironolactone (Aldactone) - K+ sparing diuretic and aldosterone antagonist
OR
Eplerenone – K+ sparing diuretic favored in pregnancy and for men
(pregnant women cant get spirals)
143
What is the Tx approach to renal artery stenosis
Angioplasty or revasc procedures
| Referral to cards
144
What is congenital adrenal hyperplasia
A subset of primary adrenal insufficiency – due to defective cortisol synthesis
145
What enzyme is required for cortisol synthesis
21-hydroxylase is an enzyme required for cortisol synthesis
146
What are the two main types of Congenital adrenal hyperplasia
Classic Vs non classic
Classic CAH – “salt-wasting”
Severe enzyme deficiency (0%-2%)
Present in utero and at birth
Deficiency in cortisol and aldosterone
Excess androgens (progesterone and 17-hydroxyprogesterone)
Both are aldosterone antagonists and cause hyperkalemia and hyponatremia, dehydration
Non-classic CAH:
Milder enzyme deficiency (20%-50%)
Presents after adrenarche (6-7 yo)
Most frequent autosomal recessive disorder in humans (Yupik Alaskans, Ashkenazi Jews, Natives of La Reunion Island)
147
What are the S/s of classic “salt wasting” Congenital adrenal hyperplasia
S/S of Classic CAH:
- Death of fetus or infant
- Masculinization of external genitalia in female infants
- Precocious sexual development of male infants
- Short stature due to premature closure of bone epiphyses
148
What are the S/s of non classic congenital hyperplasia
```
S/S of Non-Classic CAH:
Late onset (during/after puberty)
Hirsutism and acne are predominant signs in females
HTN
Oligomenorrhea and infertility
```
149
What is the key lab to Dx congenital adrenal hyperplasia
Evaluate 17-hydroxyprogesterone level (precursor to 11-Deoxycortisol; deficiency of 21-hydroxylase leads to excess 17-hydroxyprogesterone)
150
What is the Tx approach to congenital adrenal hyperplasia
Treatment:
-Glucocorticoid to suppress ACTH secretion
—Prednisone, cortisol, or dexamethasone
-Replace mineralocorticoids if needed
—Fludrocortisone (Florinef)
- Spironolactone (Aldactone) may be prescribed – (aldosterone antagonist with anti-androgen activity)
- Salt supplements
151
What is the MOA of spirinolactone
Spironolactone (Aldactone) may be prescribed – (aldosterone antagonist with anti-androgen activity)
152
Where is epi and NE produced
In the adrenal medulla
153
What is a pheochromocytoma
A freaking UNICORN
Tumor of the adrenal medulla
Secrets Epi and NE
154
What is a paraganglioma
Tumor outside the adrenal galnds on a ganglia that either secrets NE or nothing
155
What is the S/s triad of pheochromocytoma
Headache, diaphorsesis, and palpatations
156
What drugs trigger pheochromos paroxysms
Drugs: MAOIs, caffeine, nicotine, decongestants, amphetamines, cocaine, IV contrast, epinephrine, corticosteroids
General anesthesia
157
What can trigger a HTN crisis or fatal arrhythmia in a pt with pheochromocytoma
```
IV contrast dye
Glucagon injection
Needle biopsy of the mass
Anesthesia or surgical procedures
Vaginal delivery
```
158
A pt presents with HTN (either sustained or paroxysmal)
Facial pallor, mottled cyanosis, then flushing, +tachycardia
+/- precordial pain
Can also presetn wtih ARDS, Cardiomyopathy, Liver failure, or Death
Pheochromocytoma
159
What is the DX appraoch to pheochromocytoma
Order DDX labs: Free T4, TSH, CBC, ESR, gl
Then to r/o pheo:
Order a Plasma fractioned free metanephrines
(If normal= no pheo)
Next step:
Urinary fractioned metanephrines and creatine
(24 hr urine)
postive finding is Labs 3x ULN
Once postive finding order a non con CT or the abdomen and adrenals (Can use abd MRI)
(Contrast can trigger a paroxysm or HTN crisis)
160
What is the most senstive imaging for a pheo
68Ga-DOTATOC-PET
161
What is the approach to TX of a pheo
Preop Alpha blockade (Phenooxybenzamie)
Or
CCB ( nifedipine)
DO NOT GIVE BB FIRST
Preop: BP must be controlled for 4-7 days prior with ECG monitoring
Inra op: Monitro BP closely
(Nicardapine for HTN crisis)
Post op: urine catecholamines and BP monitoring
If In OP: Metyrosine
162
What is MEN 1
Hyper Parathyroid, pancreatic, and pituitary invovlmet
Facial angiofibromas
Enteropancreatic tumors
Adrenal adenomas
Hypercalcemia (1st sign)
PHEO (RARE)
AKA wermer sydrome
(MC)
Tx aimed at removing tumors and controlling hypercalcemia
163
What is MEN 2a
Medullary thyroid cancer
PHEOS! BILATERAL
Hyperparathyroidism
HIRSCHSPRING DZ
MEN2a is more rare, and is autosomal dominant
(Siblings and children)
Tx approach is pophylactic thyroidectomy (prevents medually thyroid cancer, but you MUST screen them for a PHEO 1st)
164
What is MEN 3 (2b)
```
Mucosal and GI neuromas
Meduallry thyroid cancer
PHEOs!
SKELETAL ABNMLS ( MARFANS)
Delayed puberity
```
Tx: early prophylactic thyroid removal ( prevents medullary CA)
165
What is MEN4
Parathyroid adenomas (80%)
Pancreatic neuroendocrine tumors
Pituitary adenoma
Adrenal tumors
Alos prone to renal tumors, test CA, cercival CA, and primary ovarian failure
4 effects the gonads
166
What is the appraoch to finding an incedental adrenal mass
Order
Plasma fractioned free metanephrines (PHEO)
Order ACTH and serum cortisol ( Cushings or addisons)(if abnml order a dexamathasone suppresss test)
Order a PRA (renin) and aldosterone level
Then serial CT scans a 6 and 12 months (determine if its nonfunctional or less than 4 cm)
Then CT every 2-3 years if the mass is static in growth
ALERT-
If the mass is greater than 4 cm, it should be surgically remover and biopsied even if its non functional
167
What are the red flags for secondary HTN in endocrine HTN
Hypokalemia without diuretic Rx
Presentation at an early age without a family history of HTN
New presentation of HTN in patients > 50 years old
Higher degree of severity
Diastolic > 110mmHg
Well controlled HTN that is suddenlt refractry
Increased BP which is paroxysmal (PHEO!)
HTN without obestiy
OR
New S?s suggestive of a endocrice D/o
168
What does a meduallry thyroid cancer secrete
Calcitonin, prostaglandins, serotonin, ACTH, corticotropin-releasing hormone
Think of this in a pt with MEN 2a
169
What are the drugs that specifically stimulate ADH secretion
SSRIs, TCAs, MDMA, NSAIDs, Amioderone, Antipsycotics
170
What is the relationship between TRH and PRL and TSH
Thyroid releasing hormone stimulates not only TSH but also PRL
171
PRL inhibits what hormones
LH
172
GHIH inhibits not only GH but what other hormone
TSH
173
What are the two ost common pituitary adenomas
PRL secreting and GH secreting
174
Any pt that presents with visual field defects,,, you must investigate
R/o a pituitaty/ hypothalamic mass
175
The first line therapy for ademnomas is _______, except for ______ which is med Tx first
Surgery, except for PRL adenomas with are treated with surgery
176
How is prolactin secreted differnetly than other hormones
Secreted continuosly unless inhibited by dopamine
177
What effect does hypothyroidism have on PRL
Hypothyroidism (Thyrotropin releasing hormone (TRH) is the precursor to TSH in the anterior pituitary that can stimulate PRL)
178
GH secreting adenomas often secrete what other hormone
PRL
179
What effect does hypothyroidism have on growth hormone
Inhibtis its secretion
180
What is the manner in which GH is secreted
Pulsatile anner, 8-12 pulses in a 24 hr period
181
What is the major secretory product of the thyroid
T4
182
How will T4 be in hypothyroidism vs hyperthroidism
Will be Low in hypo, High in hyper
183
How will T3 be in thyrotoxicosis
Will be high in thyrotoxicosis
(better test for diagnosis than free T4)
Not accurate for diagnosing hypothyroidism due to increase in relative secretion of T3 in hypothyroidism
184
What test Dx for hashimotos
Anti-TPO
But can also be seen in Graves Dz
185
What tests are specif to Dx graves Dz
Anti-thyrotropin receptor antibodies (i.e. anti-TSH receptor, or TSH receptor stimulating antibody)
186
What imaging study should be ordered for pts with S/s of thyrotoxicosis
RAIU scan
187
What is the indication for a RAIU scan
For patients with s/s of thyrotoxicosis
To determine quantity of radioiodine txt for hyperthyroidism
For evaluation of a suspicious nodule
To evaluate metastatic thyroid cancer
Identify if a mass is ectopic thyroid tissue
188
What is the bst method for differentiating benign from malignant thyroid nodules and diffuse goiters
Fine needle Aspiration BIOPSY
189
What is the Tx approach to painful subacute thyroiditis
ASA, prednisone x 2 wks, BB (propranolol), +levo if hypothyroid
Remember, this usually resolves completely and spontaneously over weeks to months
190
What is the most common type of thyroiditis
Hashimoto
| chronic autoimmune dz
191
What is the hallmark lab in Hashimoto (chronic) thyroiditis
AntiTPO
| FT4 initially high, then low
192
What types of thyroiditis present with pain and which do not
Infectious, riedels, and dequervains present with pain
Chronic/ Hashimoto and post partum do not
193
A pt presents with HX of VRI, painful goiter/ thyroid, low grade fever, and dysphagia…
Think
Dequervains thyroiditis (painful)
194
A pt presetns with a previous strep throat infx, fvr, sever pain and erythamatous thyroid…
Think
Infectious thyroiditis
195
A pt presents with slowly enlarging stony mass within the thyroid
Think..
IgG4 related (riedel) thyroiditis
196
What is the Tx appraoach for Riedels thyroidittis ( stony mass)
Surgery, +tamoxifen (may cause remession)
| +corticosteroids
197
What is the Tx appraoch to a Bening multinodular goiter that presents with an elevated TSH level
If TSH is elevated, may treat with levothyroxine to suppress TSH level and achieve euthyroid state
198
What is the most common cause of hypothyroidism
Hashimoto thyroiditis
199
What are the cholesterol and prolactin levels in a pt with hypothyroidism
Elevated in both
200
What is myxedmea madness
Orgnanic psychosis with paraboid delusions seen in hypothyroidism
201
A pt with hypothyroidism and signifigant CAD needing levo tx
What do you do
REFER!
202
What is the differnce between cretenism and childhood hypothyroidism
Cretenism is present at birth, child appears normal then does not develop appropriately
Childhood hypothyroidism presents later in development, near puberty, pt does not sexually mature appropriately
203
What are some complications of exopthalmos associated with graves dz
Inflammation of eye muscles due to lymphocyte infiltration
Proptosis
Periorbital edema
Diplopia
Optic nerve compression
Blindness
204
On xray you see periostitis phalanges and metacarpals
Think
Thyroid acropachy in graves dz
205
What is the MOA od methimazole
Inhibits production of T4
Used to treat hyperthyroidism/ Graves
206
What is the MOA of propythiouracil
Inhibits production of T4 and blocks conversion of T4 to T3
Used if the pt wants to get pregnant
207
WHat are the common complications of Graves Dz trreatemnt
Rash (exfoliative dermatitis)
Agranulocytosis (1/1000) - monitor w/ CBC
Nausea/dyspepsia
Liver failure with PTU 1:1000
208
What is a tx option for pts with severe graves dz as a bridge to surgery
Oragrafin or telepaque ( Iodinated contrast agents)
Temoporary tx
Blocks T4 to T3 conversion
209
What is the pt education required for a Thyroid ablation with I131
Contraindicated in pregnant or
lactating mothers
Contraception recommended for
women AND MEN for 6 months following
RAI treatment
210
If a pt has exopthalmos can they get radiation ablation
Ehhhhh its a relative contra
Worse in smoking pts
211
What is apathetic hyperthyroidism
A subtle presentation of graves in an older pt
```
Weight loss
Fatigue
Lethargy
Depression
Consider this in elderly patients with new mood disorder
May also present with angina pectoris
```
212
A older pt presents with new mood d/o and angina pectoris
Think
Apathetic hyperthyroidism
213
A pt with a serum elevated calcitonin … think
Thyroid nodule/ cancer
214
A firm thyroid nodule greated than 4.5 cm think
Cancer
215
Do pure cyctic nodules require FNAB
No
216
What is the Tx approach to thyroid nodules
Benign: serial US, FNA if increasing in size
If TSH is elevated/ Hypothyroidthen Levo
SRGY: suspicious nodules
RAI TX fro pts with hyperthyroid, toxic thyroid, MNG, or Graves
217
Where does follicular thyroid cancer often metz to
Neck lymph nodes, bones and lungs
218
What types of thyroid cancer do not absorb iodine
Medullary and anaplastic
219
What type of thryoid cancer is assoicated with MEN2a and 2b
Medullary
220
Medullary thyroid cancer secretes what hormones
Calcitonin, prostaglandins, serotonin, ACTH, corticotropin-releasing hormone
Useful in symptom recognition and monitoring (flushing, diarrhea*)
221
What does a follicular carcinoma secrete
FT4 can lead to hyperthyroidism
222
What lab can tell you if the pappilalry or follicular carcinoma is metastatic
Thyroglobulin
223
Amioderone is the cause of 20% of what emergent thyroid condition
Thyroid storm
224
What is myxedema
Fluid retention from hypothyroidism
225
A pt presents with severe AMS, convulsions, severe hypothermia, bradypnea, hypo Na+, hypo gl, HOTN
Think
Myxedema crisis
226
What medication must be avoided in myxedmea crisis
OPIODS!
227
ACTH stimualtes what 3 pathways
Cortisol production, aldosterone sectreion, melanin production
228
What are 4 effects of excess cortisol
Inflammation is suppressed
Immune suppresion
Osteoporsis
Weight gain
229
A pt presents with weeakness and fatigue, salt cravings, amenorrhea, otho HOTN, N/V, FEVER, hyperpigmentation, and hyperkalemia, +/- met acidosis
Think
Addisons
Draw a plasma ortisol level (will be low at 8 am) followed by an ACTH level (will be high)
Confirm with a cosyntroprin stimuation test
230
What is the Tx approach to primary addisons
Replace steroids levels with hydrocortisone or prednisone
+/- fludrocortisone for sodium retention
Needs 2x sick day dosing
Emergency steroid kit of 100mg hydrocortisone
Must wear medical bracelet
231
What is the Tx appraoch to secondary adrenal insufficiency
Replace steroid levels with cortisone, dexamethasone, or prednisone
No need to use fludrocortisone
Tx underlying pituitary d/o
Needs sick day dosing and wear of medical bracelet
232
What RSI medication can cause adrenal crisis
Etomidate
233
A pt presents with extreme weakness, HOTN, fever, N/v dehydration, hypoglycemia!,. Headache and AMS
Think
Adrenal crisis
234
What is the hallmark feature of adrenal crisis
Hypoglycemia
235
What is the Tdx approach to adrenal crisis
Immediate cortisol level (low)
Treat with steroids
Next- cosyntropin test ( will be low)
Admin high dose steroids with broad spec abx
236
What is the net electrolye efect of aldosterone
Holds onto sodium in exchange for potassium
237
Renal artery stenosis stimulates the release of what hormone
Aldosterone
238
What is the most common cause o excess renin secretrion
Renal artery stenosis
239
What are the 3 main etiologies of hyperaldosteronism
Unilateral adrenal adenoma (COnns)
Bilateral hyoperplasia (MC men)
Carincomas
240
What are the s/s of hypo K+
Muscle weakness, paresthias with tetany
HA
Polyuria polydipsia
241
How do you order a PRA for hyperaldosteronism
1st correct they hypo K+
Then eat 6g of salt
Stop any diuretic medications
Draw PRA when pt OOB x 2 hrs between 8-10 am
If PRA is suppresed its primary hyperaldosteronism
If PRA is increased or normal its seccondary 2/2 renal artery stenosis
242
A pt with an elevatede PRA after 6g ingestion fo salt is a sign of
Renal artery stenosis (2ndary hyperaldosteronism )
243
WHat is the Dx appraoch to hyperaldosteronism
It will be a pt with a high diasotolic BP and hypokalemia
1) correct hypok+
2) eat 6g of salt
3) stop diuretics
4) draw PRA with pt OOB x 2 hrs between 8-10 am
5) if PRA is suppresed its primary
6) if PRA is NML or elevated its secondary due to renal artery stenosis
7) order 24 hr urine ( primary will have levated aldosterone)
8) order ABD CT or MRI to r/o carcinoma or hyperplasia
244
What is the Tx for unilateral adenomas (Conns)
Surgery removal
245
What is the Tx for bilateral adrenal hyperplasia
Spirnolocatone
| Or eplererone if pregnant or in men
246
What is the tx for renal artery stenosis
Angioplasty or revasc
247
What part of the nervous system do the adrenal gland and the ganglia belong to
Autonomic/ Sympathetic
248
What medications can trigger a paroxyms
MAOis caffine, nicotine, decongestants, cocaine, meth, IV contrast, Epi, steroids, general anesthestia
249
What are the inoperative options for pheos
Metyrosine
250
How long should BP be controlled prior to pheo surgery
4-7 days prior
251
How is BP controlled during a pheo surgery
IV nicardipine for any HTN crisis
252
What is the size determination that a pheo is metz
Bigger than 7 cm
