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Flashcards in Endocrine Deck (127):
1

Tyrotoxicosis (cause)

Hyperthyroid
#1 Graves - auto immune agonize thyrotropin receptor to stimulate T4/T3
#2 Toxic multinodular Goiter
#3 Toxic nodular goiter

2

Hyperthyroid (symptoms)

Heat intolerance, irritability, fatigue, Shortness of breath, palpitations, Menstrual irregularities

3

Hyperthyroid (PE findings)

pruritis, Moist skin, thinning hair, hyperpigmentation, fine tremor, hyperreflexia,
exophthalmos, tachycardia, Lid lag, goiter, wt loss with increased appetite

4

Graves (PE findings)

exophthalmos, infiltrative dermopathy,
thyroid acropathy, goiter with bruits

5

Hyperthyroid (diagnosis)

Labs,
TSH -decreased,
Elevated free T4,
Elevated Total T3
Imaging - not required
Thyroid scan - diffuse uptake
Ultrasound and dopler

6

Hyperthyroid (treatment)

Symptomatic treatment
Palpitations - Beta blocker = Propranolol, atenolol
Rehydration
Anti thyroid meds
Thionamidies - methimazole start high and taper
down to euthyroid
PTU - used in pregnancy
Radioactive Iodine treatment - treatment of choice
Become hypothyroid forever
Surgery

7

Thyroid storm (cause)

Untreated hyperthyroidism:
stress,

8

Thyroid storm (symptoms, signs)

fever, severe tachycardia, hypertension, neurological, delirium, heart failure, Pulmonary edema, diarrhea, vomiting,

9

Thyroid storm (treatment)

antipyretics,
Iv rehydration
Beta blockers
IV thiourea
Administer iodine compound PO - blocks the release and conversion of T3/T4
Hydrocortisone - adrenal insufficiency (decreases conversion of t4/t3 peripherally)

10

Sub acute Thyroiditis

De quervain's - Caused by viral infection

11

Hypothyroid (symptoms)

dry hair and skin,
lateral eyebrow thinning
periorbital edema
depression
cold intolerance

12

Hypothyroid (causes)

Hashimoto's - #1 in US - inflammatory condition destroys the thyroid
Iodine deficiency - #1 in 3rd world
#2 Thyroidectomy
#3 Central Hypothyroid

13

Hypothyroid (signs)

goiter, bradycardia, weight gain, thinning of hair, puffy face and eyelids

14

Hashimoto's (diagnosis)

Labs
Elevated TSH
Low Free t3
Low T4 and T
_______________
Elevated LDL
Hyponatremia
anemia
decreased Basic metabolic rate

15

Hypothyriodism (treatment)

Levothyroxine - take with water in the morning after overnight fasting
Start low and titrate up (dosed in MICRO grams)
Adjust every 6-8 weeks until 0.3 - 3 mL U/L

16

Mixedema Comas

Severe, life threatening hypothyroidism
Impared cognition, confusion,
mostly elderly or those who have stopped taking drugs
severe hypothermia, hypoventilation, hyponatremia, hypoglycemia, hypotension
rhabdo

17

Myxedema (treatment)

Large dose of Levothyroxine IV
Warm with blankets - not faster d/t cardiovascular collapse
hypercapnia - treat with intubation and ventilation
Treat infection aggressively
Treat concomitant adrenal insufficiency - hydrocortisone

18

Euthyroid sick syndrome

Non-thyroid illness, with abnormal thyroid function findings TSH normal, Normal or low T4/t3

19

Thyroiditis (description)

inflammation of thyroid gland - may be hyper, hypo or euthyroid

20

Subacute lymphocytic thyroiditis

painless,
spontaneous or triggered
50% have antibodies
decipher from graves by little to no thyroid enlargement, no grave's exophthalmos

21

Post partum thyroiditis

2-12 months post partum, painless, 10% of post partum females
usually transient
Hyperthyroid for several weeks then hypo for several months
recurrence rate of 70% to hashimotos

22

Subacute granulomatous thyroiditis

low grade fever, viral cause, painful node, dysphagia,
Must rule out infectious bacterial suppurative thyroiditis

23

Amiodarone thyroiditis

37% of weight is iodine in amiodarone
can occure 3-4 months after starting amiodarone
Significant hypothyroidism
type 1
type 2

24

Thyroiditis (treatment )

treat symptoms,
treat with levothyroxine in hypothyroid state,
do not treat with thionamidies

25

Thyroid cancer (risk factors)

history of radiation,
MEN, medullary carcinoma, family history, hashimoto's?, iodine deficiency ?

26

Thyroid cancer (S&S)

Painless, palpable nodule, rapid growth, firm cervical masses, vocal cord paralysis, hoarse voice

27

Papillary Thyroid cancer

Most common

28

Thyroid cancer (diagnostics)

Ultrasound 1st -
Fine needle aspiration - diagnostic choice
Labs - TSH, Serum Calcitonin

29

Thyroid cancer (treratment)

Thyroidectomy

30

Diabetes T2 (Diagnosis)

FPG >126
Random BG>200
A1C>6.5
oral glucose test - 2 hour glucose >200

31

Pre diabetes (diagnosis)

FPG 100-125
Oral glucose challenge BG= 140-199
A1C of 5.7-6.4

32

T2DM Risk factors

Family history
Overweight or obesity
Physical inactivity
Previously pre-diabetic
gestational diabetes
PCOS

33

T2DM screening

@ 45 years old
every three years if normal
@ 30 years old with Risk factors

34

T2DM presentation

Insidious onset
polyuria
polydipsia
weightloss
severe hyperosmolar state
neuropathy
CV complications
chronic skin infections

35

T2Dm Exam findings

Acanthosis nigricans (skin darkening)
candida infection
loos of deep tendon reflex @ ankles
dry feet
muscle atrophy
feet ulcers

36

T2DM Treatment goals

weight loss
education and nutrition counseling
Micro and macro vascular eval
avoid exacerbating drugs,
decrease carb absorption rate

37

T2DM CV risk management

Smoking cessation
aspirin
BP control
manage dyslipidemia
diet
exercise

38

Yearly exam with T2DM

A1c (q 3 months)
Urine microalbumin
foot care
ophthalmology
check in on self monitored BG (1-4x daily)

39

GLP-1 Black Box Warning

Causes medullary cancer in mice
contraindicated in personal or family Hx of thyroid cancer

40

DDP-4 are first line therapy in what population

CKD or high risk of hypoglycemia

41

A1C where Meformin is At MDD and Insulin therapy is indicated

A1c>8.5

42

Hyperglycemic
Hyperosmotic
Non-Ketotic state
(Precipitating factors)

Major illness,
glucocorticoids, thiazides
atypical antipsychotics
compliance issues

43

Hyperglycemic
Hyperosmotic
Non-Ketotic state
(clinical presentation)

Polyuria
polydipsia
weightloss
lethargy
decreased skin tugor
dry mucous membranes
tachycardia
hypotension

44

Hyperglycemic
Hyperosmotic
Non-Ketotic state
(lab findings)

Hyperglycemia (may be >1000)
hyperosmolality
pre-renal azotemia (volume depletion)
acidosis and ketones are mild or absent
low potassium, magnesium and phosphate

45

Hyperglycemic
Hyperosmotic
Non-Ketotic state
(treatment)

IV insulin
IV fluids
Electrolyte monitoring and replenishment

46

Adrenal cortex products

Glucocorticoids
Cortisol
Mineralocorticoids
Aldosterone
Androgens

47

Functions of Glucocorticoids (Cortisol)

Stimulate gluconeogenesis
Mobilize fatty acids and amino acids
Inhibit insulin effect
Elevate RBC and Platelet levels
Anti-inflammatory and immune suppressive effect

48

Functions of mineralocorticoids

Balance [Na+]
Balance [K+]
blood pressure regulation by Changing electrolyte balance and therefore water retention

49

Products of the adrenal medula

Catecholamines:
Epinephrine (~80%)
Norepinephrine (~20%)
Dopamine (Some amount)

50

Effects of catecholamines: Epinephrine and Norepinephrine

Increase BP, HR,
vasoconstriction @ dermis and GI tract
Vasodilation @ smooth muscles
glucose metabolism
Dilate pupil
relax bladder
disinhibit spinal nerve reflexes

51

Pheochromocytoma (clinical features)

Tumor of the adrenal medulla.
Sustained or labile hypertension
paroxysms of:
headache
diaphoresis
palpitations
N/V/ abd pain
anxiety
tachycardia

52

Pheochromocytoma (Diagnosis)

24 hr urine collection - metanephrine, total catecholamines, creatinine
Abd CT
ABD MRI

53

Pheochromocytoma (management)

Alpha adrenergic blockade (10-14 days)
and Beta adrenergic blockade (2 days) before surgical resection
Laparoscopic if <8cm

54

Primary Hyperaldosteronism (clinical features)

hypersecretion of aldosterone
due to adrenal etiology
Indicated by low plasma renin
Conn's syndrome
adrenal adenoma
bilateral cortical nodular hyperplasia

55

Secondary Hyperaldosteronism (clinical features)

hypersecretion of aldosterone
(may be appropriate release of aldosterone due to decreased flow at the JGA)
Indicated by high plasma renin

56

RAAS system negative feedback loop

Kidney ->
renin->
Angiotensin 1 -> Angiotensin 2 ->
Adrenal cortex ->
aldosterone secretion ->
renal fluid retention

57

Primary Hyperaldosteronism (clinical findings)

Diastolic HTN, Hypokalemia
metabolic alkalosis
Low plasma renin
Hypersecretion of aldosterone = Inc. renal secretion of H+ and exchange of Na+ and K+,

58

Primary Hyperaldosteronism (Diagnosis)

Must have hyposecretion of renin when stimulated and hyper secretion of aldosterone that cannot be suppressed by volume expansion
Labs:
Hypokalemia (v K+)
Hypernatremia (^ Na+)
metabolic alkalosis
Low plasma renin
EKG with U waves, ST depression, Prominent P waves,, Prolonged PR interval
L ventricular hypertrophy criteria
CXR = cardiomegaly
Proteinuria

59

Primary Hyperaldosteronism (treatment)

Na+ restrict patient for renin hyposecretion test
Salt bomb - causes renin to drop and aldosterone should drop but doesn't
Abdominal CT or MRI
Surgical excision of adenoma
Diet with Na+ restriction and Aldosterone agonist (spironolactone)

60

Secondary Hyperaldosteronism (causes)

edema types:
nephrotic syndrome
ascites
CHF (Severe)
HTN types:
Renin over production
(renal artery stenosis)
or (Renin producing tumor)

61

Cushing's syndrome (causes)

Prolonged exposure to endogenous or exogenous (Most common)glucocorticoids
Exogenous steroids can cause Cushings Up to 1 year after D/c
Endogenous - usually due to Pituitary over production of ACTH

62

Cushing's syndrome (clinical findings)

Weight gain (moon face, buffalo hump)Dermis thinning (Red/purple striae, easy bruising)
proximal muscle wasting
sexual dysfunction
depression, lability,
head ache, vision changes, polyuria, nocturia
increased infections
poor wound healing
osteoporosis
HTN and edema
Peptic ulcer disease?
galactorrhea, hypothyroid

63

Cushing's syndrome (diagnosis)

24 hr urine cortisol (>300 Positive for cushings, <90 negative for cushings)
1mg dexamethasone - suppression test (should decrease cortisol in normal physiology)
ACTH level at 4pm
ACTH low = no pathology
ACTH high = brain mri
ACTH normal = abd CT/ MRI

64

Cushing's syndrome (treatment)

Surgical resection
(transphenoidal if Pituitary mass) (Adrenalectomy if adrenal mass, failed pituitary resection, ectopic unresectable ACTH mass)
Medical management (SECONDARY)
ketoconazole - decreased cortisol production
Metyrapone - blocks cortisol synthesis

65

Addison's disease

Adrenocortical insufficiency
>10% functional adrenal cortex
Usually autoimmune (80%)
May be due to TB, hematological malignancies, AIDS, Drugs, Abd radiation (2-7 year delayed onset)

66

Addison's Disease (Clinical presentation)

Insidious onset:
weakness, fatigue
hypotension/ orthostasis/ dehydration
Weightloss
Hyperpigmentation
N/V/D/ Abd Pain

67

Addison's Disease (Diagnosis)

Cortrosyn Stimulation Test
Check baseline plasma cortisol & Aldosterone levels
inject IV ACTH
30-60 minutes later check plasma cortisol & Aldosterone levels
Diagnostic if minimal to no change in levels

68

Addison's Disease (Diagnosis - expected lab changes)

decreased NA+
Increased K+, Urine Na+, BUN/Cr
ECG- peaked T waves progress to sign waves (d/t hyperkalemia)
elevated TSH
Test for TB (CXR or PPD)
CT abdomen - enlarged, calcified or atrophic adrenals

69

Secondary Adrenal insufficiency (cause)

Hypopituitary ACTH
Suppression by exogenous steroids or
steroids from a tumor
Panhypopituitarianism

70

Secondary Adrenal insufficiency (clinical presentation)

Same as Addison's but NO Hyperpigmentation
Insidious onset:
weakness, fatigue
hypotension/ orthostasis/ dehydration
Weight loss
N/V/D/ Abd Pain

71

Adrenal insufficiency - primary and secondary (treatment and monitoring)

Glucocorticoid -hydrocortisone
2/3 AM
1/3 PM
Mineralocorticoid - fludrocortisone
(with ample sodium intake)
Monitor therapy via:
BP, Insomnia/ irritability, HTN/ DM,
Electrolyte balances,
Weight

72

Adrenal crisis (cause)

exacerbation of chronic adrenal insufficiency
Precipitated by stress or sudden withdrawal of chronic steroids
Many be caused by acute hemorrhagic destruction of bilateral adrenal glands (Water-friderichsen syndrome, anticoagulation, pregnancy Cx)

73

Adrenal crisis (S& S)

Hypotension d/t vascular collapse,
N/V/ Abdominal pain
hyperpyrexia
lethargy and somnolence
Hypoglycemia, hyponatremia, Hyperkalemia,
metabolic acidosis

74

Adrenal crisis (treatment)

IV fluid 2 L NS then D5-1/2 NS
Stress Hydrocortisone 100mg IV q6hr
vasopressors or antibiotics as needed for cause

75

MEN 1 (causes)

hyperparathyroid (#1)
Hypercalcemia
(elevated serum Ca++ and PTH normal)
Pancreatic Islets
Increased gastrin, Insulin, glucagon, Vasoactive intestinal peptide, somatastatin - based on cause
Pituitary
Increased Prolactin, GH, ACTH

76

MEN 1 (Diagnosis)

Hormone or electrolyte imbalance
Provocative testing
CT/MRI

77

MEN 1 (treatment)

Surgical resection - may need multiple
Medical management - Da agonist, or H2 agonist based on type

78

MEN 2a (causes)

Medullary Thyroid Carcinoma, Pheochromocytoma, Hyperparathyroid

79

MEN 2b (causes)

Medullary Thyroid Carcinoma, Pheochromocytoma, mucosal neuroma, marfanoid body habitus

80

MEN 2 (treatment)

Thyroidectomy for MTC
Resection (bilateral) for pheo
Hyperparathyroid resect 3 1/2 with remnant in neck or forearm

81

PTH effect in body

increased serum calcium
bone breakdown (osteoclasts),
absorption through gut
Increases Calcium resorption in kidney
Decrease serum Phosphate
excretion in kidney

82

Calcitriol (Active Vitamin D) effect in body

increases intestinal absorption of calcium
increase serum calcium
Increases serum phosphate

83

Hypocalcemia (cause)

Adults: Renal failure (no active vitamin D created) - CHRONIC KIDNEY DISEASE
Children: Nutritional Deficiencies
Other:parathyroid deficiency, decreased sunlight exposure, rickets, hyperphosphatemia, hungery bone syndrome,

84

Hypoparathyroid (causes)

thyroidectomy or Parathyroidectomy Extensive neck radiation
autoimmune process
congenital

85

Hypoparathyroid and Hypocalcemia (S&S)

emotional labiality, paresthesia, SOB, Voice changes (laryngospasms), Vision changes (cataracts), Tetany (chvostek's sign- face twitch, trousseau's sign - hand spasm)
muscle stiffness and spasms, hypotension , bronchospasm,
Hyperreflexia
Prolonged QT interval

86

Hypoparathyroid and Hypocalcemia (diagnosis)

EKG
Total Calcium - corrected for low albumin
Ionized calcium
PTH
Vitamin D - calcidiol and Calcitriol
BUN/creatinine
Phosphate
magnesium
Albumin, LFTs, Pt/INR

87

Hypoparathyroid and Hypocalcemia (treatment)

oral calcium (carbonate or citrate)
IV calcium if at deaths door, (Gluconate or chloride - faster by veintoxic)
Vitamin D if Hypoparathyroid, Hungry bone, or deficiency.
Magnesium as needed
Avoid diuretics

88

Hypercalcemia (causes)

Sarcoidosis,
Hyperparathyroidism
Alkali milk syndrome
Metastasis
Paget's
Osteogenesis Imperfecta
Osteoporosis
D vitamin toxicity
Immobility
Retinal tubular acidosis

89

Hyperparathyroid (causes)

Familial tendencies
MEN1, 2A, 2B
Primary:
Single parathyroid adenoma
hyperplasia
Carcinoma
Hypocalciuric Hypercalcemia
Sercondary:
Chronic renal failure
Vit. D deficiency
Tertiary:
Renal transplant

90

Hypercalcemia and Hyperparathyroid (S&S)

Bones,
Stones
Groans
Moans
May have pruritis, skin tentins, hypertension, LVH, anorexia, N/V, renal colic, Bone fractures,

91

Hypercalcemia (Diagnosis)

Ca++ level
PTH
24 hr urinary calcium excretion
Chloride, Phosphate
PTHrP
BUN/Creatinine
Calitriol, Calidiol
ECG - AV block and Shortened Qt

92

Asymptomatic Hyperparathyroid (treatment)

stay active, hydrate, modest dietary calcium, Vit D supp. Bisphosphonates, D/C thiazide Diuretics,
require annual Serum calcium and Creatinine and Bone density scan q 1-2 years

93

Hyperparathyroid (treatment)

for those who are symptomatic or pregnant, or less than 50 Years old:
Surgical resection
Medical therapy:
Fluids, Loop diuretic, calcitonin, cinacalcet, Bisphosphonates, propranolol for Cardiac symptoms

94

Parathyroid cancer (diagnosis)

Ca++ levels >14
PTH 5x normal,
palpable parathyroid

95

Parathyroid Cancer (treatment)

Bilateral neck exploration
excision of tumor and ipsilateral thyroid lobe
Post op:
check Ca levels, 2 weeks, 6 months and annually post op.
Recurrence is rare except in MEN1 patients

96

Paget's (description)

localized bone remodeling with excessive bone resorption and disorganized bone regrowth
70-90% asymptomatic
May have pain, fractures, osteoarthritis, nerve impingement, hearing loss,

97

Paget's (diagnosis)

x ray
alkaline phosphatase elevated,
serum calcium, vit D, serum phosphate

98

Paget's (treatment)

surveillance of asymptomatic patients,
Symptomatic or involving skull, long bones or vertebrae,:
bisphosphonates, IV zolentronic acid,
calcitonin, calcium, vit D
Analgesics

99

Diabetes Insipidus (description)

deficiency of vasopressin (ADH) causes large amounts of dilute urine production
>3L/24 hrs
<300mOsm/Kg

100

Diabetes Insipidus (causes)

Central - decreased ADH secretion
Primary - no pituitary lesion (30%)
Secondary - damage to hypothalamus or pituitary stalk
Tumor of pituitary (25%)
Cranial surgery (20%)
Head trauma (16%)
Nephrogenic - kidney's don't respond to normal ADH levels
Hypercalcemia, lithium toxicity, demeclocycline, steroids, ofloxacin, methicillin, pregnancy, Renal disease, congenital

101

Diabetes Insipitus (S&S)

polyuria, polydipsia, nocturia, uriniary output between 3-20L/day
dehydration, hypotension, hypernatremia

102

Diabetes Insipidus (diagnosis)

24 hr urine collection and analysis
serum electrolytes and glucose (High NA+, Normal Glucose)
Plasma osmolality high, Urine osmolality low
ADH - Central = low, Nephrogenis = high

103

Diabetes Insipidus (treatment)

Hypotonic solution D5W - goal reduce serum sodium 0.5mEq/hr
Central DI: desmopressin intranasal or oral
Nephrogenic: HCTZ daily - diuretic blocks reabsorption of Na+ in kidneys

104

SIADH (Description)

Syndrome of inappropriate Antidiuretic Hormone
Excessive release of ADH. causes dilutional hyponatremia and low serum osmolality

105

SIADH (S&S)

Headache
N/V
Seizures
Altered mental status
LOC

106

SIADH (Diagnosis)

Urinalysis (high specific gravity, high sodium, high osmolality)
BMP (low sodium)
BUN (Low)
Serum osmolality (low)
ADH (High)
Head CT/MRI
CXR
CT abdomen for malignancies

107

SIADH (treatment)

Asymptomatic: restrict fluids, d/c offending meds, Demeclocycline

Symptomatic: 3% NaCl solution
caution - do not increase NA more than 0.5-1 mEq/L/Hr
Check serum Na+ hourly

108

Psychogenic Polydipsia (description)

polyuria, polydipsia usually in psych patients of unknown cause - must rule out other etiologies
Decreased serum sodium and osmolality
Decreased urine osmolality and urine sodium

109

Psychogenic polydipsia (Treatment)

Fluid restriction, behavioral and pharmacologic modalities

110

Proportionate Dwarfism (causes)

Hypothyroid
Turner syndrome,
nutritional deficits
psychogenic hypopituitary
GH deficiency
Laron Syndrome

111

Disproportionate Dwarfism (causes)

Achondroplasia
spondyloepiphysel Dysplasia,
Diastrophic dysplasia

112

Achondroplasia (cause and signs)

Autosomal dominant trait, spontaneous mutation of FGFR3 gene
normal torso,
short limbs, enlarged skull, central apnea, obstructive apnea, and hydrocephalus

113

Spondylopeiphyseal Dysplasia (signs)

adult height from under 3 ft to slightly over 4 feet
shortened trunk, barrel chest, club feet, cleft palate, severe
osteoarthrisis

114

Diastrophic Dysplasia (Signs)

rare, autosomal recessive
shortened forearms and calves, limited ROM
cleft palate
Deformed hands and feet

115

Disproportionate Dwarfism (signs)

short stature, delayed motor milestones, airway obstruction, pain,
large head, bowed legs
congenital cataracts, myopia
bifid uvula, high arched or cleft palate
acute swelling of pinnae
polydactyly, hitch hiker thumb, clubfoot
long narrow thorax, pear-shaped chest
Cardiac - ASD, single atrium, patent ductus arteriosum , transposition of great vessels

116

Disproportionate Dwarfism (diagnosis and treatment)

based on physical exam findings, genetic testing, perform skeletal xray
treatment: symptomatic relief
tracheotomy, cleft palate repair, leg & Back braces, club foot surgery

117

Pituitary Dwarfism (diagnosis)

rule out other causes then:
IGF-1 test,
IGFBP-3, and bone age
GH provocative test - if low GH then diagnostic
MRI to rule out structural cause of GHD

118

Laron Syndrome (cause)

Mutation in GH receptor
autosomal recessive mutation
GH is normal or High, with severe bone growth deficits

119

Laron Syndrome (S&S)

delayed skeletal maturation - small head circumference, characteristic facies, saddle nose, prominent forehead,
small genitalia and testes, short limb length compared to trunk, osteopenia, and obesity

120

Turner Syndrome (Causes and signs

short stature may be only presenting symptom
square shield chest, webbed neck (pathognomonic), cubitus valgus, genu valgum, shortened 4th metacarpal and madelung deformity of forearm

121

Turner syndrome (diagnosis and treatment)

requires chromosomal analysis

122

Laron Syndrome (treatment)

IFG-1 daily

123

Pituitary GH Dwarfism (treatment)

GH sq daily

124

Sheehan Syndrome (description)

Pituitary infarction d/t postpartum hemorrhage

125

Sheehan Syndrome (s&S)

lethargy, anorexia, weight loss, inability to lactate within the first few days - weeks after delivery
May be severe or mild

126

Sheehan Syndrome (Diagnosis)

MRI
Hormone Eval - adrenal insufficiency is most critical

127

Sheehan Syndrome (treatment and followup)

ACTH, TSH and Gonadotropin treatment
No treatment for GH or prolactin
monitor for hormonal deficiencies, and medical therapies