Endocrine Flashcards
(210 cards)
1
Q
Calcium levels during prolonged immobilization
A
Elevated
(due to increased osteoclastic bone resorption)
2
Q
Immobilization can cause ____ due to increased osteoclastic bone resorption
A
Hypercalcemia
(Tx: Bisphosphonates)
3
Q
Inhibit osteoclastic resorption, reducing bone loss
A
Bisphosphonates
4
Q
Proximal myopathy in Cushing syndrome (hypercortisolism) is due to
A
Muscle atrophy
(from direct catabolic effects of cortisol on skeletal muscle)
5
Q
___ in transfused blood binds ionized calcium
A
Citrate
(causes symptomatic hypocalcemia by affecting ionized calcium only)
6
Q
Calcium after high-volume blood transfusion
A
Hypocalcemia
due to citrate-chelation of ionized calcium
7
Q
Magnesium abnormality in hyperreflexia
A
Hypomagnesemia
8
Q
Young woman with new-onset absence of menses, next step
A
Secondary amenorrhea w/u:
- Pregnancy Test (beta-hCG)
- Prolactin, TSH, FSH to test for most common causes of secondary amenorrhea
- Hyperprolactinemia
- Thyroid dysfunction
- Premature ovarian failure (early menopause)
9
Q
Hyperandrogenism presenting in non-obese adolescent
A
CAH: 21-hydroxylase deficiency
(elevated 17-hydroxyprogesterone)
10
Q
Estrogen/Pregnancy & Thyroid Function
A
Estrogen increases TBG, necessitating increased endogenous thyroid production or increased levothyroxine dosing requirements in hypothyroid pts to achieve same level of free T4.
11
Q
Prolonged glucocorticoid therapy can lead to
A
Central adrenal insufficiency (low [suppressed] ACTH secretion, low cortisol, normal aldosterone due to regulation by RAAS, not HPA axis)
12
Q
Best markers to track resolution of DKA
A
Serum anion gap or beta-hydroxybutyrate levels
AG estimates unmeasured anion concentration in blood & returns to nml w/ disappearance of ketoacid anions
13
Q
Enlarged hands and feet
A
Acromegaly
(excessive GH secretion from pituitary somatotroph adenoma)
- +Coarsening facial features
- +OSA
- +Concentric LVH
14
Q
Leading cause of death in acromegaly pts
A
Cardiovascular disease
15
Q
Ease of bruising + hyperglycemia
A
Think Cushing syndrome
(hypercortisolism)
16
Q
HTN + Hypokalemia vs. Hypotension + Hyperkalemia
A
Primary Hyperaldosteronism vs. Primary Adrenal Insufficiency (Addison Disease) respectively
- Hyperaldo → HTN, Na+ reabsorption, K+ loss
- PAI → Low aldosterone: Decreased Na+ reabsorption, increased K+
17
Q
Hyperglycemia in Cushing is due to
A
Hypercortisolism-induced gluconeogenesis (physiological stress response)
18
Q
Hypernatremia + increased serum Osm
A
Diabetes Insipidus
(central vs. nephrogenic): Too low ADH
19
Q
Necrotic migratory erythema rash (w/ central clearing in thighs)
A
Glucagonoma
(+ hyperglycemia)
20
Q
Predisposition in pts with Hashimoto
A
Thyroid lymphoma
(presents w/ rapidly progressive thyroid enlargement)
21
Q
Wt gain, psychiatric sx, hirsutism, HTN, hyperglycemia
A
Hypercortisolism
(Cushing syndrome)
- Dx: Low THen High
22
Q
Most common cause of primary adrenal insufficiency in developed countries
A
Autoimmune adrenalitis
(Addison disease)
- Associated w/ other autoimmune diseases, e.g. Hashimoto Thyroiditis
23
Q
Plaques w/ central clearing & blistering; crusting & scaling at borders
A
Necrolytic migratory erythema
(Glucagonoma)
- Usually in the thighs
24
Q
Pancreatic tumor w/ elevated glucagon levels (>500)
A
Glucagonoma
25
5-HIAA
**Carcinoid syndrome diagnosis**
26
Anti-Glutamic Acid Decarboxylase Antibody
(**Anti-GAD65)**
**Serum marker** for T1DM predisposition
| (pancreatic islet autoantibodies)
27
Palliation of anorexia to improve appetite & wt gain in cancer-related anorexia/cachexia syndrome
Progesterone analogs
(**Megestrol acetate** or **Medroxyprogesterone acetate**)
28
Diabetic w/ low blood sugars after meals
**Diabetic Gastroparesis**
| (give metoclopramide)
29
Diabetic w/ early satiety
**Gastroparesis**
(2/2 diabetic autonomic neuropathy of the GI tract)
* Tx: Metoclopramide
30
Severe hyperglycemia (\>1000) without acidosis
**HHS**
(Hyperosmolar Hyperglycemic State)
* Tx: IVF (Normal Saline) + slow IV Insulin
31
Hypercalcemia + Lymphoma
Due to **increased 1,25-VitD** from extrarenal production
(also seen in **sarcoidosis**)
32
Parathyroid Hormone-related Protein
Think **Cancer-related hypercalcemia**
(mimics PTH):
* SCC of lung, renal/bladder, or breast/ovarian cancer
* Released by SCC of lung, causing Humoral Hypercalcemia of Malignancy
33
Severe, rapid-onset hypercalcemia + hypophosphatemia + smoker
**Humoral Hypercalcemia of Malignancy**
(SCC of the lung) due to release of parathyroid hormone-related protein (PTHrP) by tumor cells
34
Low T3, Normal T4, Normal TSH
**Euthyroid sick syndrome**
(usually in setting of acute, severe illness)
35
Riedel’s Thyroiditis
**Fibrous thyroiditis**
(Fibrosclerosis of thyroid causing hard goiter + hypothyroidism)
36
Euthyroid sick syndrome
**“Low T3 syndrome”:**
Decreased peripheral 5’-deiodination of T4 due to caloric deprivation in setting of acute, severe illness
37
Pt w/ fever + sore throat within 90d of starting antithyroid drugs (propylthiouracil or methimazole)
**DISCONTINUE PTU** or **MMI** and check **WBCs** (agranulocytosis is a feared but uncommon side effect)
38
Does primary hyperaldosterone cause peripheral edema?
Not significantly, due to **aldosterone escape**
39
Tx for BL adrenal hyperplasia
**MRAs**
(aldosterone antagonists): Spironolactone, Eplerenone
40
Recurrent pregnancy loss + thyroid disease
**Antithyroid peroxidase antibodies**
| (**Hashimoto Thyroiditis**; Anti-TPO Abs)
41
Hyperpigmentation
think high **ACTH**
(Cushing vs. ectopic ACTH-producing tumor)
42
Easy bruising, myopathy, virilization, lanugo hair
**Cushing syndrome**
43
Dx of Primary Adrenal Insufficiency
**ACTH** Stimulation Test
(then cortisol and aldosterone measured)
44
Tx of Primary Adrenal Insufficiency
| (Addison’s disease)
**Cortisol, Aldosterone, and Testosterone**
45
Cravings for salty foods, N/V, fatigue, dizziness, syncopal episodes, hypovolemia
**Primary adrenal insufficiency**
* Low aldosterone - hyponatremia, hypovolemia, hyperkalemia
* Low cortisol - Elevated ACTH, hyperpigmentation
* Low adrenal-produced testosterone - decreased sex drive in women
46
Hyperpigmentation + fatigue + dizziness
**Primary adrenal insufficiency**
(elevated ACTH due to low adrenal production of cortisol)
47
**Addisonian Crisis**
**Acute primary adrenal insufficiency**
(injury, surgery, infection)
* Sudden pain in back, abd, or legs
* Dehydration from Vomiting, Diarrhea
* Syncope from Low BP
* Can be fatal
48
**Waterhouse-Friderichsen Syndrome**
Acute adrenal insufficiency when sudden increase in BP causes blood vessels in adrenal cortex to rupture —\> ischemia, adrenal gland failure
49
Multiple gastric ulcers + dyspepsia
**Gastrinoma**
| (ZES)
50
VIPoma
(pancreatic tail tumor) Tx
* **IVF** (volume repletion)
* **Octreotide** (for diarrhea)
* **Surgical resection**
51
Watery diarrhea, hypokalemia, achlorhydria, facial flushing & pancreatic tail tumor
**VIPoma**
(Tx: Surgical)
*
52
**HTN**, hyperglycemia, weight gain, proximal muscle weakness
Cushing syndrome
(Hypercortisolism)
* Exogenous glucocorticoid intake
* SCLC (ectopic ACTH)
* Pituitary adenoma (Cushing disease [ACTH-producing])
53
Galactorrhea + amenorrhea + vaginal dryness
**Prolactinoma**
(dryness due to prolactin inhibition of LH secretion)
54
Basal ganglia lesion
**Parkinson disease**
55
Difficulty combing hair
Proximal muscle weakness
* Polymyositis/Dermatomyositis (normal DTRs)
* Glucocorticoid use/Cushing disease
* Hypothyroidism/Hyperthyroidism
56
MG/Lambert-Eaton syndrome Basal ganglia lesion
**Parkinson disease**
57
Effects of CKD on Ca, Phos, VitD
Inadequate phosphate excretion, decreased conversion to 1,25-hydroxyvitamin D
(Elevated Phos, Low Ca, Elevated PTH, Low active VitD)
58
Positive sx in diabetic neuropathy
| (pain, paresthesias)
**Small nerve fiber neuropathy**
| (early)
59
Negative sx in diabetic neuropathy
| (sensory loss)
**Large nerve fiber neuropathy**
| (late; leads to foot ulcers)
60
Anti-thyroid peroxidase antibodies
**Hashimoto thyroiditis vs. Painless**
**(silent) thyroiditis**
61
Tx for painless
(silent) thyroiditis
Self-limited
| (**BBs** for symptoms)
62
RET proto-oncogene mutation
**MEN2**A or 2B
| (MPP, MPM)
63
Neuroendocrine parafollicular C cell malignancy
**Medullary thyroid cancer**
| (Calcitonin-producing tumor)
64
**MEN1**
* Primary hyperParathyroidism
* Pituitary tumors
* Pancreatic tumors (or gastrinomas)
65
**MEN2A**
* **Medullary Thyroid Cancer** (calcitonin)
* **Parathyroid hyperplasia**
* **Pheochromocytoma**
66
**MEN2B**
* **Medullary Thyroid Cancer** (calcitonin)
* **Pheochromocytoma**
* **Mucosal neuromas/Marfanoid habitus**
67
Diuretics that increase calcium resorption
**Thiazides**
68
Polyuria, polydipsia, shortening of QT interval
**Hypercalcemia**
**(**symptomatic)
69
Symptomatic hypercalcemia and AKI from excessive calcium intake
**Milk-Alkali Syndrome**
(often seen in OTC-treated osteoporosis)
70
Thyroid storm is often triggered by
* **Surgery**
* **Trauma**
* **Infection**
* **Iodine Contrast**
* **Childbirth**
71
Lid lag + normal reflexes
**Hyperthyroidism**
72
Lid lag + absent reflexes
**Hypothyroidism**
73
Malignant hyperthermia tx
**Dantrolene**
74
T cell activation and stimulation of orbital fibroblasts
**Graves Ophthalmopathy**
**(**TRAB-induced)
75
Autoantibodies against ACh receptors
**Myasthenia Gravis**
| (on the motor endplate)
76
Increases sensitivity to catecholamines
**Thyroid hormone**
77
Acid/Base in hyperaldosteronism
**Metabolic alkalosis**
| (due to aldosterone-induced H+ loss)
78
Increased aldosterone, decreased renin
**Primary Hyperaldosteronism**
(Presents w/ HTN + hypokalemia)
* **Aldosterone-producing tumor, or**
* **BL adrenal hyperplasia**
79
PCOS increases risk for
**Metabolic syndrome**
* **T2DM**
* **HTN**
* **Dyslipidem**ia
80
Dx of Carcinoid Syndrome
**Elevated 24hr urinary 5-HIAA**
81
Tx for Carcinoid Syndrome
**Octreotide**
82
Carcinoid cells cause increased production of serotonin from tryptophan, resulting in ____ deficiency
**Niacin**
(tryptophan is required for niacin synthesis) —\> Pellagra (dermatitis, diarrhea, dementia)
83
At risk for autoimmune thyroid disease
| (e.g. Graves)
**T1DM**
84
Marfanoid habitus + thyroid cancer
**MEN2B**
85
Defective formation of type 1 collagen
**Osteogenesis imperfecta**
86
Low bone mass w/ normal mineralization
**Osteoporosis**
87
Marker of bone formation
**Alkaline phosphatase**
88
Symmetric pseudofractures (looser zones) on x-ray
**Osteomalacia**
| (VitD deficiency)
89
Hypophosphatemia \> Hypocalcemia; Elevated PTH & alk phos
**Vitamin D Deficiency**
**(**Osteomalacia / Rickets)
90
Follicular thyroid carcinoma vs. benign follicular adenomas
**Invasion of tumor capsule and/or blood vessels**
91
Thyroid carcinoma that metastasizes via hematogenous spread to distant tissues (e.g. bone, lung)
**Follicular thyroid carcinoma**
| (FTC)
92
Thyroid tumor + elevated calcitonin
**Medullary thyroid carcinoma**
| (secreted by parafollicular cells)
93
Slow spreading thyroid cells with large cells w/ ground glass cytoplasm, pale nuclei w/ inclusion bodies and central grooving, and lamellated calcifications
**Papillary thyroid cancer**
94
Psammoma bodies
**Papillary thyroid cancer vs. Papillary breast carcinoma**
95
HTN + hypokalemia
**Think hyperaldosteronism**
(check Plasma aldosterone/renin ratio to differentiate primary vs. secondary vs. non-aldosterone causes)
96
Progressively worsening proximal muscle weakness, ptosis, dry mouth
**Lambert-Eaton syndrome**
97
Proximal muscle wasting
**Cushing syndrome**
**(**Dexamethasone suppression test)
98
Episodic HA, sweating, palpitations + tachycardia
**Pheochromocytoma**
99
Elevated IGF-1, next step?
**Oral Glucose Suppression Test**
| (glucose should suppress GH secretion)
100
Coarse facial features, arthralgias, uncontrolled HTN, hyperhidrosis, digit enlargement, carpal tunnel syndrome
**Acromegaly**
(excessive GH secretion 2/2 pituitary somatotroph adenoma) —\> **Check IGF-1 levels**
101
Acromegaly Dx
**Elevated IGF-1 levels**
(GH-stimulated hepatic secretion)
* **GH** varies widely throughout day and is not reliable
102
Acute-onset hirsutism
**Androgen-secreting neoplasm of ovary or adrenal glands**:
* Ovarian tumor (**Elevated Testosterone,** Normal DHEAS)
* Adrenal tumor (Normal Testosterone, **Elevated DHEAS)**
103
Prolactinoma therapy
**Dopaminergic agonists**
| (cabergoline, bromocriptine)
104
Radioactive iodine uptake in Graves disease
**Increased**
| (hormone overproduction)
105
Radioactive iodine uptake in painless thyroiditis
**Decreased**
| (release of preformed hormone)
106
Radioactive iodine uptake in subacute thyroiditis
**Increased**
(post-viral & painful; hormone overproduction)
107
Decreased RAIU (radioactive iodine uptake)
**Release of preformed hormone**
* Painless thyroiditis
* Subacute thyroiditis (post-viral)
108
Myalgias, proximal muscle weakness, elevated CK, delayed reflexes
**Hypothyroid myopathy**
| (Polymyositis has nml DTRs)
109
**Chromaffin cells** of the adrenal medulla
**Pheochromocytoma**
110
Catecholamine surge due to anesthesia
**Pheochromocytoma**
111
Despite normal to elevated serum potassium levels in **DKA** or **HHS,** pts have
**total body potassium deficit due to excessive urinary loss caused by hyperglycemia-induced osmotic diuresis.**
* Provide potassium after IV insulin/fluids administration
112
Fetal hyperthyroidism
Graves disease
| (**TSHR antibodies** cross placenta)
113
Untreated hyperthyroid pts are at greatest risk for
* **Bon**e loss from chronically increased osteoclastic activity
* **AFib** or other cardiac arrhythmias
114
Stones, Bones, Abd Moans, Psychiatric Overtones
**Primary Hyperparathyroidism**
(elevated calcium & **PTH)**
115
Tx of hypoparathyroidism
* **IV Calcium Gluconate** (severe)
* **PO Calcium** (mild-moderate)
116
Tx of primary hyperparathyroidism
* **Surgery** (parathyroidectomy) - first line
* **Diuretics** (except thiazide!!)
117
Tx of Toxic Adenoma or Toxic Multinodular Goiter (**MNG**)
**BBs** (symptomatic tx)
**Thionamide** (reduce thyroid hormone levels) - propylthiouracil, methimazole
**Surgery** vs. **Radioiodine ablation** (definitive tx)
118
Hypocalcemia, High PTH, Hyperphosphatemia, low urinary cAMP
**Pseudohypoparathyroidism**
| (end-organ resistance to PTH)
119
Hypoparathyroidism is most commonly due to
**Head & Neck surgery**
120
Elevated calcium & elevated PTH
**Primary Hyperparathyroidism**
121
Low renin + elevated aldosterone
**Primary Hyperaldosteronism**
(Conn syndrome: excess aldosterone due to adrenal adenoma vs. **BL** adrenal hyperplasia)
122
Na+, K+, & acid/base in hyperaldosteronism
* **Hypernatremia**
* **Hypokalemia**
* **Metabolic alkalosis** (due to H+ secretion and hypokalemia-induced bicarbonate resorption)
123
Conn syndrome leads to metabolic
**Alkalosis**
124
Elevated aldosterone + adrenal mass
**Conn syndrome**
(too much aldosterone 2/2 adrenal adenoma or **BL** adrenal hyperplasia)
125
Muscle weakness and decreased exercise tolerance
**hypokalemia**
| (severe)
126
Cardiac effects of hyperthyroidism
* **Chronotropic** (tachycardia)
* **Inotropic** (**Systolic HTN** & widened PP) 2/2 increased contractility & cardiac output
127
Prussian blue+ on urine
**G6PD Deficiency**
128
Cause of refractory hypokalemia
**hypomagnesemia**
129
Common cause of hypocalcemia in hospitalized alcoholics
**hypomagnesemia**
(decreases PTH and induces resistance to PTH)
130
Slows progression of diabetic nephropathy
* **ACE-I (**Tight BP control)
* Tight glucose control
131
Low thyroglobulin in hyperthyroid state
**Exogenous** or **factitious thyrotoxicosis**
132
C-peptide is to insulin as ____ is to T3 & T4
**Thyroglobulin**
**(**elevation indicates endogenous release)
133
Synthesized and formed in thyroid follicle cell with iodinated tyrosine (T3 and T4) before breaking down into T3, T4, and amino acids to diffuse out from follicular cells into circulation
**Thyroglobulin**
134
Thyroid cancer order of prognosis
**Papillary \> Follicular \> Medullary \> Anaplastic**
(often fatal)
135
Thyroid suppression drugs
**Thionamides**
| (Propylthiouracil or Methimazole)
136
Post-radiation cancer of thyroid
**Papillary carcinoma**
137
**Hürthle Cell Tumor**
A more aggressive variant of follicular thyroid carcinoma w/ lymphatic spread
138
Elevated ratio of alpha-subunit to TSH
**Pituitary adenoma**
(Beta-subunit is thyroid-specific; alpha-subunit is pituitary specific)
139
Malignancy that produces calcitonin
**Medullary thyroid carcinoma**
(Parafollicular cells [C cells] are the calcitonin-producing cells)
140
If thyroid medullary carcinoma, screen for \_\_\_
**Pheochromocytoma (**MEN2**)**
141
Most common thyroid cancer
**Papillary carcinoma**
**(**70-80%):
* Least aggressive, excellent prognosis
* Hx of radiation to head/neck
* Positive iodine uptake
142
Thyroid cystic masses are not malignant if
**\>4cm diameter**
143
FNA is reliable for all thyroid cancers except \_\_\_
**follicular neoplasms** —\>
Thus surgery is always indicated in follicular FNA results
144
\_\_\_ nodules more likely to be malignant on thyroid scan
**Cold nodules** (20%) —\> Surgery
145
Fever, elevated ESR, **painful** tender thyroid gland
**Subacute** **granulomatous thyroiditis**
(“de Quervain’s thyroiditis”)
* Usually post-viral (HLA-B35)
* Hyperthyroid state —\> Hypothyroid state
* Low RAI uptake (damaged thyroid follicular cells)
* Elevated T4 & T3 (at first), low TSH
146
**Antithyroid peroxidase antibodies**
**Hashimoto thyroiditis**
autoimmune hypothyroidism w/ transient initial hyperthyroid phase)
147
99% of circulating T4 is bound to:
* **TBG**
* **Transthyretin**
* **Albumin**
148
Increases T4-Binding Globulin levels (TBG) [w/ normal free T4, elevated total T4]
* **Estrogen**
* **Hepatitis (acute)**
* **Meds (Tamoxifen)**
149
Decreases T4-Binding Globulin levels (TBG) [w/ normal free T4]
* **Elevated cortisol or glucocorticoid use**
* **Hypoproteinemia**
* **Meds (Niacin, high-dose androgens)**
150
TSH, Free T4 in Graves
**Elevated Free T4**, **Decreased TSH**
151
Calcium, phosphate, PTH in vitD deficiency
* **PTH elevated** (secondary hyperparathyroidism)
* **Normal calcium**
* **Normal to low phosphate**
152
Vitamin D deficiency is diagnosed by measuring:
**25 hydroxyvitamin D**
153
Calcium & PTH in primary hyperparathyroidism
**Elevated**
154
Renal failure leads to phosphate
**Retention**
(hyperphosphatemia)
* Decreases Ca2+
* Increases PTH
155
**Renal failure leads to Phosphate Retention** (hyperphosphatemia from decreased GFR, decreased renal phosphate excretion). Effects on calcium and PTH?
**Hypocalcemia + Increased PTH**
* **Increased phosphate/calcium binding** —\> Hypocalcemia —\> Increased PTH
* **Directly stimulates** increased PTH production
* **Decreases renal production of calcitriol** (1,25-dihydroxyvitamin D) —\> Decreased intestinal calcium absorption —\> Hypocalcemia —\> Increased PTH
156
Hypocalcemia + hyperphosphatemia + Increased PTH
Secondary Hyperparathyroidism 2/2 **Renal Failure**
157
Use ____ w/ Radioactive Iodine Ablation in Graves disease due to risk of \_\_\_\_
* **Use glucocorticoids w/ RAI** due to risk of **worsening of Graves ophthalmopathy 2/2 increased TRAB titers**
* Use Propylthiouracil or Methimazole w/ RAI due to risk of radiation-induced hyperthyroidism
158
Thyrotropin Receptor Antibodies (TRAB)
**Graves autoimmune disease**
| (TSH receptor antibodies)
159
Graves ophthalmopathy MOA
**Thyrotropin receptor** antibody damage to **TSH receptors** on retro-orbital fibroblasts and adipocytes
160
First line hyperthyroidism Tx (e.g. Graves)
**Propylthiouracil or Methimazole**
161
Propylthiouracil
**Antithyroid drug** for **Graves or hyperthyroidism**
(along with methimazole)
162
Lid lag
**Hyperthyroidism**
| (e.g. Graves)
163
Insulin effect on K+
**Pushes K into cells**
* **Can cause hypokalemia** (C BIG K)
* Via enhancing activity of **Na/K ATPase** in skeletal muscle
164
Insulin effect on cells
* **Increases hepatic glycogen stores (increased glycogenesis, decreased glycogenolysis)**
* **Increases glycogen storage in adipocytes and skeletal muscle**
* **Increases protein synthesis in skeletal muscle**
165
Insulin inserts ___ into peripheral tissue membrane of adipose & muscle cells
**GLUT4** transporter
166
C-Peptide
Indicates **endogenous** insulin production
(pancreatic beta cells are producing their own insulin)
167
A1C goal in pts w/ risk of hypoglycemia
**7-8%**
168
A1C goal in diabetics
**6-7%**
169
Benefit of intensive glycemic control in diabetes (A1C \<6.5%)
**Less microvascular complications**
| (retinopathy, nephropathy)
170
Pretibial myxedema
**Graves disease**
| (or can be Hashimoto)
171
Nonpitting swelling of the skin and underlying tissues giving a waxy consistency
**Myxedema**
(severe hypothyroidism)
* Due to deposition of mucopolysaccharides in dermis
* Mucopolysaccharides include glycosaminoglycans, hyaluronic acid, chondroitin sulfate
172
Hoarseness in hypothyroidism
**Due to**:
* **Vocal cord thickening** **from mucopolysaccharide build-up due to low T4 levels** (same path as myxedema)
* **Thyroid cyst, nodule, or inflammation** (Hashimoto)
* **Can present as** “**fullness in throat**”
173
Free T4, Serum cortisol, and Aldosterone in panhypopituitarism
**Low, Low, Normal**
174
Hypercortisolism (Cushing) work-up
**Low TH**en **High**
* **Low**-dose dexamethasone suppression test
* AC**TH** level
* **High**-dose dexamethasone suppression test
175
Distinguishes post-anesthesia pheochromocytoma vs. thyroid storm
Fever = Thyroid storm (pyrexia)
No fever = Pheo
176
Dawn Phenomenon
**Increased fasting hyperglycemia in early morning hours**
(2/2 diurnal increase in counterregulatory hormones)
177
Insulin preparations, fast to slow acting
(**LAGIN DG**)
* **L**ispro (fast-acting; post-prandial)
* **A**spart (fast-acting; post-prandial)
* **G**lulisine (fast-acting; post-prandial)
* Regular **I**nsulin
* **N**PH
* **D**etemir
* **G**largine (basal; peakless coverage; ~24 hrs)
178
3 therapies for Graves disease (TRAb autoimmune disease) are:
* Antithyroid Rx (MMI or PTU)
* RAI
* Thyroidectomy
When is Antithyroid Rx indicated?
* Mild disease
* Pregnant
* Older w/ limited life expectancy
* Otherwise, always treat w/ RAI or Thyroidectomy
## Footnote
* Use w/ beta blocker for hyperthyroid sx*
* beta blockers alone if only thyrotoxic phase of silent or painless thyroiditis (Hashimoto/anti-TPO)*
179
Calcium levels in CKD
**Decreased**
(hypocalcemia)
* due to decreased renal production of vitamin D
180
Adrenal hemorrhage occurs in
1. Warfarin user w/ acute stress (e.g. sepsis) even if within INR range
2. Meningococcemia (children)
3. Pseudomonas sepsis (children)
181
Cosyntropin Test
**ACTH Stimulation Test**
(Cosyntropin = ACTH synthetic analog)
* Used to identify pts w/ primary adrenal insufficiency (positive if minimal increase in cortisol)
* If suspecting HYPERcortisolemia--use Low THen High diagnostic steps:
* Low dex suppression test
* ACTH level
* High dex suppression test
182
Treats infertility in PCOS
**Clomiphene Citrate**
| (through ovulation induction)
183
Stabilizes uterine lining
**Estrogen**
* Progesterone stimulates *endometrial differentiation*
184
Stimulates endometrial differentiation
**Progesterone**
* Estrogen stabilizes uterine lining
185
Pancreatic tail tumor
**VIPoma**
(VIPail-oma)
* +watery diarrhea (secretory)
* +hypokalemia
* +episodic flushing in face
* Age 30-50yo
* Can have MEN1 (PPP: **P**ituitary, **P**arathyroid, _Pancreatic/Gastric neuroendocrine_ tumors)
* +Hypercalcemia (increased bone resorption)
* +Achlorydia (or hypochlorydia--due to decreased gastric acid secretion)
* Confirmation: VIP level \>75 (vasoactive intestinal peptide)
186
Elevated free T4 + low thyroglobulin
**Exogenous hormone intake** (or factitious)
187
Autoimmune disorder of the exocrine glands
**Sjögren Syndrome**
* p/w dry eyes, dry mouth, & dysphagia w/ solids
* ANA+
* Usually younger pts; if older pt, more likely age-related sicca syndrome (age-related exocrine gland atrophy of lacrimal & salivary glands, due partially to decreased blink rates, oxidative damage, & use of anticholinergic meds)
188
Carpopedal spasm
**Hypocalcemia**
189
Increased extracellular pH (e.g. respiratory alkalosis) effect on calcium?
**Hypocalcemia**
Increase in _albumin-bound calcium_ due to alkalosis-induced H+ ion dissociation from albumin, _decreasing ionized calcium_ and thus causing **physiologic hypocalcemia**
190
Timing of:
1. Maximal gout symptoms after onset of gout flare
2. Lyme arthritis onset
1. 12-24 hours
2. Months after initial infection
191
Effect of malabsorption on calcium and phosphate
**Hypocalcemia** & **Hypophosphatemia**
(+elevated PTH)
* Malabsorption → Vitamin D deficiency
* Vitamin D mediates intestinal calcium & phosphorus absorption
192
Felty Syndrome
Advanced RA
193
Purine antimetabolite that treats RA (1st line)
**MTX**
(folate antimetabolite; DMARD; nonbiologic)
* Supplement long-term MTX therapy w/ **folate**
* ADE:
* Stomatitis (e.g. oral ulcers)
* ILD
* Hepatitis
* Macrocytic anemia + other cytopenias (leukopenia, thrombocytopenia)
194
\_\_\_\_ is to low-dose methylpred as GCA is to high-dose methylpred
PMR (Polymyalgia Rheumatica)
195
Hydroxychloroquine side-effect
**Retinal toxicity**
* Treats SLE
* Requires ophthalmologic eval & periodic assessment
196
Lid retraction
Lid lag → Thyroid dysfunction
(sustained lid retraction w/ downward gaze)
197
MOA of hyperthyroid HTN vs. hypothyroid HTN
* Hyperthyroid HTN: **Increased Contractility & CO**
* T3 acts directly on cardiomyocytes
* Decreased SVR
* Inotropic & chronotropic
* Hypothyroid HTN: **Increased SVR**
198
Rapidly progressive hyperandrogenic Sx in older woman
**Ovarian** or **Adrenal tumor**
(Testosterone-secreting)
* Check T & DHEAS levels
* High T + normal DHEAS = ovarian tumor
* High T + high DHEAS = adrenal tumor
* Note: PCOS is diagnosed younger
199
Joint w/ punched-out erosions w/ a rim of cortical bone on XR
**Gout**
200
Leading cause of death in acromegaly
**CVD**
201
Cardiovascular effects of acromegaly
**Concentric myocardial hypertrophy**
(Cardiomyopathy)
* +HTN
* +HF
* +Valvular disease (MR & AR)
202
Rapidly enlarging, firm goiter w/ compressive sx in pt w/ Hashimoto thyroiditis
**Thyroid lymphoma**
* Gland fixed to surrounding structures (does not move up when swallowing)
* Facial plethora from retrosternal tumor extension causing venous compression
* Pemberton sign: more prominent venous distension & facial redness w/ raising arms 2/2 compression of subclavian vein & R internal jugular vein
* Doughnut sign on CT: diffuse enlargement of the thyroid around the trachea
* Papillary thyroid cancer is SLOWLY enlarging & solitary, rather than rapid & diffuse
203
Reidel thyroiditis
**Fibrosis of thyroid gland**
| (chronic & slowly progressive)
204
Proximal Muscle Weakness DDx
| (Short List - covers most but not all)
**M2S2T2N2**
("Ms. Tennessee" can't reach the cookie jar = **Ms. TN**)
* **Myositis**: Polymyositis/Dermatomyositis
* **Steroids**: Glucocorticoids/Cushing
* **Thyroid**: Hypo-/Hyperthyroidism
* **NMJ**: MG/LEMS
205
Effect of hypothyroidism on cholesterol levels
Hypothyroidism **INCREASES** cholesterol levels
(Increased Total cholesterol & LDL)
* LDL is not broken down & removed as efficiently as usual
206
Posterior Pituitary hormones
* **Oxytocin** (released from paraventricular nucleus)
* **ADH** (released from supraoptic nucleus)
Note: Posterior pituitary is neurally-mediated
207
Anosmia + delayed puberty
**Kallmann Syndrome**
* Tx: Pulsatile GnRH therapy
208
Acanthosis nigricans occurs due to
**Hyperinsulinemia**
209
Pituitary stalk compression 2/2 craniopharyngioma (benign, slow-growing, calcified suprasellar tumor) in 5-14yo
Panhypopituitarism
* Growth failure in children (↓ TSH or GH)
* Pubertal delay in children (↓LH & FSH)
* Sexual dysfunction in adults (↓ ADH)
*
210
Give this with antibiotics to reduce the risk of sensorineural hearing loss in Haemophilus influenzae type b meningitis
**Dexamethasone**
