Endocrine Diagnosis and Treatment

Question 1

Diagnosis of pregnancy induced hyperthyroidism

Answer 1

High TBG

T3 uptake will decrease (by resin)

Question 2

radionucleotide uptake of plummer’s disease (multinodular toxic goiter)

Answer 2

Decreased TSH

Patchy uptake

Atrophy of thyroid gland

Question 3

Radionucleatide uptake of toxic thyroid adenoma

Answer 3

Atrophy of rest of thyroid

Low TSH

increased uptake in one area

Question 4

Treatment of hyperthyroidism

Answer 4

Immediate control: B blockers
sodium ipodate or iopanoic acid if don’t respond to conventional therapy

Non pregnant:start metimazole
Taper B blocker after 4-8 weeks
Continue methimazole for 1-2 years then measure TBG IgG Ab at 12 months if absent can discontinue therapy, 1 more year of therapy if present

Pregnant: Endocrinology consult
PTU preferred

Elderly, solitary nodule, antithyroid therapy fails: radioactive iodine ablation therapy

Thyroidectomy: reserved for large goiters, allergic to antithyroid drugs or if they prefer surgery

Question 5

Treatment of Thyroid storm

Answer 5

IV fluids, cooling blankets, and glucose

PTU every 2 hours followed by iodine to inhibit thyroid hormone release

B blockers for HR

Dexmethasone impairs T4 to T3 conversion and provides adrenal support

Question 6

Diagnosis of Graves Disease

Answer 6

IgG binds to TSH receptors
Thyroid bruit

Low TSH level-initial test of choice
Next order-T4 level

Radioactive T3 uptake: (give radioactive T3 with resin testing to see if TBG is “filled” and uptake by resin)
Diffuse uptake of radioactive T3

Question 7

Diagnosis and treatment of Hashimotos (chornic lymphocytic thyroiditis)

Answer 7

Goiter is rubbery, nontender and nodular

High TSH

Low free T4

Decreased/ irregular uptake of radionucleotide iodine-

Increased antimicrosomal Abs, antiperoxidase, antithyroglobulin Abs

Elevated LDL and decreased HDL, hypertriglyceridemia, increased AST and ALT, increased creatinine kinase

Treatment: levothyroxine

Anemia: nomracytic

Question 8

Treatment and diagnosis of sublclincal hypothyroidism

Answer 8

TSH elevated with normal T4 level

Elevated LDL levels

Treat with thyroxine if: patient develops goiter, hypercholesterolemia, symptoms of hypthyroidism, or significantly elevated TSH level

Question 9

Treatment and Diagnosis of subacute (viral) thyroiditis

Answer 9

Assoiciated with HLA;B35

painful, tender thyroid gland

Radioiodine uptake is low
Low TSH (transient hyperthyroid state)
High ESR

Treatment: NSAIDs and aspirin for mild symptoms
Corticosteroids for more severe pain

Most recover within a few months to one year

Question 10

Treatment and diagnosis of subacute lymphocytic thyroiditis

Answer 10

Transient thyrotoxic phase of 2 to 5 months followed by hypothyroid phase

Low radioactive iodine uptake-differentiates it from Graves’ disease
no pain or tenderness of thyroid gland

Question 11

Pituitary adenoma diagnosis and treatment

Answer 11

Can release GH, prolactin, ACTH and TSH

Diagnosis: MRI, horomone levels

Treatment: transsphenoidal surgery (except prolactinomas)
Radiation therapy and medical therapy adjunct

Question 12

Hyperprolactinemia diagnosis and treatment

Answer 12

Prolactinoma, psychiatric medications, H2 blockers, metoclopramide, verapamil, estrogen, pregnancy, hypothyroidism

Diagnosis: elevated serum prolactin level
order a pregnancy test and TSH level
CT scan or MRI to identify mass lesions

Treatment: bromocriptine or cabergoline for 2 years
transesphenoidal surgery if non responsive (recurrence is high)

Question 13

Acromegaly diagnosis and treatment

Answer 13

Diagnosis: IGF-1 (somatomedin C) elevated
Oral glucose suppression test-glucose fails to suppress GH (as it should in healthy individuals)
MRI of pituitary
Hyperprolactinemia, hyperglycemia, hypertriglyceridemia, and hyperphosphatemia may be seen

Treatment:
Transspenoidal resection of pituitary adenoma-treatment of choice
radiation thearpy if IGF-1 remain elevated
Octreotide to suppress GH secretion

Question 14

Hypopituitarism causes, diagnosis and treatment

Answer 14

causes: radiation therapy, sheehans syndrome, infiltrative processses-sarcoidosis, hemochromatosis, head trauma, caernous sinus thrombosis, surgery

Diagnosis: low levels of target hormones with normal trophic hormones
MRI of the brain

Treatment: replacement of hormones
if want to conceive refer to endocrinologist

Question 15

Central Diabetes insipidus causes, diagnosis and treatment

Answer 15

Causes:
idiopathic, trauma, sarcoidosis, Tb, syphilis, encephaltiis

Diagnosis: colorless urine, thirst and polydipsia, polyuria, hypernatremia
Low urine specific gravity, low osmolality
Plasma osmolality: 280-310
Low ADH level

water deprivation test: no increase in urine osmalality above 280 mOsm/kg after 24 dehydration
Increase in urine osmolality after ADH given

Treatment: Desmopressin
Chlorpropamide increases ADH secretion

Question 16

Nephrogenic Diabetes insipidus causes, diagnosis and treatment

Answer 16

Causes: lithium, hypercalcemia, pyelo, demeclocyline, or congenital

Diagnosis: colorless urine, thirst and polydipsia, polyuria, hypernatremia
Low urine specific gravity, low osmolality
Plasma osmolality: 280-310
High ADH level

water deprivation test:
No increase in urine osmolality above 280 mOsm/kg with dehydration
No response to ADH after 24 hour dehydration

Treatment: sodium restriction and thiazide diuretics
Increased reabsorption of sodium and water in proximal tubule leading to decreased urine volume

Question 17

SIADH causes, diagnosis and treatment

Answer 17

Causes: neoplasms, lymphomas, leukemia
CNS disorders (stroke, head trauma, infection)
Pulmonary disorders (pneumonia, TB)
Venitilators with positive pressure, vincristine, SSRIs, chlorpropamide, oxytocin, morphine, desmopressin, NSAIDs potentiate ADH action, postoperative state

diagnosis: inappropriately concentrated urine, low plasma osmolality (less than 280) and increased urine osmolality (>100-150)
low serum uric acid level
Low BUN and creatinine
Absence of hypervolemia

Treatment:
asymptomatic: water restriction or normal saline with a loop diuretic if need faster results
Lithium carbonate or demecolcycline

symptomatic: restrict water intake, give isotonic saline\
raise .5 mEq/L per hour

Question 18

Pseudohypoparathyrodism diagnosis

Answer 18

hypocalcemia, hyperphosphatemia, high PTH, low urinary cAMP

Question 19

Hypoparathyroidism diagnosis and treatment

Answer 19

Diagnosis: prolonged QT on ECG
low serum calcium, high serum phosphage, serum PTH inappropriately low, low urine cAMP

Treatment: IV calcium gluconate in severe cases
oral calcium in mild to moderate cases
Vitamin D supplementation
Avoid hypercalciuria by keeping serum calcium at 8.0 to 8.5

Question 20

Primary hyperparathyroidism diagnosis and treatment

Answer 20

Diagnosis: HTN, shrotened QT weight loss, polydipsia, polyuria

Hypercalcmia (ionized fraction or ionized Ca level)
PTH elevated relative to serum calcium levels

Hypophosphatemia, hypercalciuria, urine cAMP is elevated

Chloride/phosphorus ratio >33 is diagnostic

Radiographs: subperiosteal bone resorption (radial aspect of second and third phalanges), osteopenia

Treatment: 3D sestambi scintography and US localize before surgery
Surgery indications: age less than 50, marked decrease in bone mass, nephrolithiasis, episode of severe hypercalcemia, urine calcium >400 mg in 24 hours

Due to hyperplasia: all four glands removed and small amount of parathyroid tissue is placed in forearm to retain parathyroid function
Due to adenoma: surgical removal of adenoma
Due to carcinoma: remove the tumor, ipsilateral thyroid lobe and all enlarged lymph nodes

Encourage fluids, give diuretics (furosemide) to enhance calcium excretion if hypercalcemia is severe NOT THIAZIDES

Question 21

Dexmethasone suppression test

Answer 21

1. give 1 mg of dexmetasone at 11 p.m. and measure serum cortisol level at 8 a.m.
   If the serum cortisol is less than 5 than Cushing syndrome is ruled out
   Cortisol greater than 5 means check ACTH level
2. Low ACTH=adrenal tumor or hyperplasia (adrenal imaging should be done)
3. High ACTH leads to high dose dexmethasone test
   Greater than 50% suppression=pituitary (MRI)
   less than 50% suppression=ectopic source (chest and abdominal CT, ocretreotide scan)
   Or
4. CRH stimulation test
   + equals pituatry
   - equals ectopic source

Question 22

Treatment of Cushing’s syndrome

Answer 22

Iatrogenic: tapering of glucocorticoid
Pituitary Cushing’s syndrome: surgery (treanssphenoidal ablation)
Adrenal adenoma or carcinoma: adrenalectomy

Question 23

Diagnosis and treatment of pheochromocytoma

Answer 23

Diagnosis: urinary metanephrine, Vanillylmanndelic acid, homovanillic acid normetanephrine
Plasma metanephrines
Urine/serum epi and NE-if epi is elevated tumor must be adrenal or near the adrenal gland
Tumor localization: CT or MRI

Treatment: surgical tumor resection with early ligation of venous drainage
Patients treated with a-blockade (phenoxybenzamine) for 10-14 days prior to surgery (BP control) and B blockade 2-3 days (HR control) prior to surgery
Possible adrenalectomy

Question 24

Diagnosis and treatment of MEN syndrome

Answer 24

Screen with PCR on blood sample and DNA testing

Treatment: total thyroidectomy

Question 25

Primary Hyperaldosteronism diagnosis and treatment

Answer 25

HTN, weakness, polydipsia, noncturnal polyuria hypernatremia and hypokalemia (metabolic alkalosis) Diagnosis: plasma aldosterone:renin ratio is >30 Saline infusion test: infusion of saline will decrease aldosterone levels in normal patients but not with hyperaldosteronism Aldosterone levels are less than 8.5 after saline infusion then primary aldosteronism is ruled out Oral sodium loading: high salt diet for 3 days-high urine aldosterone in setting of high urine sodium confirms diagnosis Diagnose cause: Adrenal venous sampling: high levels of aldosterone on one side=adenoma, bilateral=hyperplasia Renin aldosterone stimulation test CT/MRI of adrenals: adenoma or hyperplasia anatomically Iodocholesterol scanning: functional approach to differentiation Arteriography/venography Treatment: adenoma-surgical resection Adrenal incidentaloma-resection if greater than 6 cm bilateral hyperplasia: spironolactone (NOT surgery)

Question 26

Adrenal crisis diagnosis and treatment

Answer 26

severe hypotension and cardiovascular collapse Treatment: IV hydrocortisone, IV fluids (several liters of normal saline with 5% dextrose)

Question 27

Adrenal insufficiency diagnosis and treatment

Answer 27

``` hypoglycemia, low aldosterone (primary only)-hyponatremia, hyperkalemia and hypovolemia ``` Diagnosis: decreased plasma cortisol Plasma ACTH-low implies a secondary adrenal insufficiency ACTH test: give IV infusion of ACTH and measure cortisol-cortisol does not increase in primary every Cortisol will increase after 4 to 5 days in secondary (aldosterone and renin will also be normal) treatment: primary: daily oral glucocorticoid (hydrocortisone or prednisone) daily fludrocortisone (mineralcorticoid) Secondary: no mineralcorticoid necessary

Question 28

21 hydroxylase deficiency congenital adrenal hyperplasia diagnosis and treatment

Answer 28

Diagnosis: increased 17-hydroxyprogesterone Treatment: cortisol and mineralcorticoid (shuts off ACTH secretion) Surgically: correct female genital abnormalities

Question 29

Diabetes diagnosis

Answer 29

Two fasting glucose measurements greater than 125 mg/dL-preferred (recheck if between 100-126) Single glucose level of 200 mg/dL with symptoms Increased (>200) glucose level on oral glucose tolerance testing (after administration of equivalent of 75 g glucose load hemoglobin A1c>6.5%

Question 30

Diabetes Outpatient management

Answer 30

Monitor HbA1c every 3 months (keeping it below 7.0 is the goal) Check blood glucose levels before meals and at bedtime. Monitor 90 to 120 minutes after meals Screen for microalbuninema once a year (prescribe ACE inhib or ARB) Check BUN and Cr once a year Eye screening yearly Check feet at every visit-encourage patient to do so Check cholesterol once a year: Statin if LDL >100 ACE or ARB if BP >130/80 Daily aspirin in all diabetics over age 30 Pneumoccocal vaccine

Question 31

Treatment goals of diabetes

Answer 31

Glycemic control-HbA1c less than 7%, fasting blood glucose less than 130, and peak postprandial blood glucose less than 180 BP control less than 130/85 LDL less than 100, HDL greater than 40 Smoking cessation daily aspirin

Question 32

Treatment of Diabetes

Answer 32

Diet and exercise Glucose >240=insulin Glucose 140-240=hypoglycemic agents (sulfonylureas, metformin, acrabose, thiazoldinediones) Metformin is first agent of choice Regular insulin give IV for ketoacidosis

Question 33

Diabetic retinopathy complications and treatment

Answer 33

edema of the macula=leading cause of blindness Vitreal hemorrhhage and retinal detachment can lead to blindness Treatment is laser photocoagulation

Question 34

Treatment of diabetic peripheral neuropathy

Answer 34

NSAIDs, gabapentin, tricyclic antidepressants or pregabalin

Question 35

Treatment of diabetic gastroparesis

Answer 35

metoclopramide, exercise and low fat diet

Question 36

Diagnosis and treatment of DKA

Answer 36

Diagnosis: Hyperglycemia (glucose >450) Metabolic acidosis: ph less than 7.3 and serum HCO3- less than 15 increased anion gap Ketonemia: acetoacetate, acetone and B-hydroxybutyrate Hyperosmoalrity Hyponatremia-total body sodium is normal hyperkalemia: total body potassium is low Phosphate and Mg are low Treatment: IV insulin immediately -make sure not hypokalemic Continue insulin until anion gap closes and metabolic acidosis is corrected Give SC insulin when anion gap less than 12, HCO3 >15 and eating again overlap by 1-2 hours Fluid replacment: .9% immediately Add 5% glucose once blood glucose reaches less than 250 to prevent hypoglycemia Replace potassium with IV fluids if less than 5.2 (no insulin if K+ less than 3.3) -initiate within 1-2 hours of starting insulin Bicaronate if ph less than 6.9 Assessment of anion gap and beta-hydroxy-butyrate indicate resolution from DKA

Question 37

Diagnosis and treatment of hyperosmolar hyperglycemic nonketotic syndrome

Answer 37

``` Diagnosis: hyperglycemia >900 Hyperosmolarity >320 Serum pH>7.3 (no acidosis, no ketosis) HCO3->15 elevated BUN-prerenal azotemia ``` Treatment: fluid replacement is most important (normal saline): 1L in first hour another liter in the next 2 hours When glucose reaches 250 mg/DL add 5% glucose insulin-5 to 10 unit IV followed by continuous low dose infusion

Question 38

Diagnosis and treatment of hypoglycemia

Answer 38

Diagnosis: blood glucose below 50 true hypoglycemia: hypoglycemic symptoms brought on by fasting blood glucose less than 50 during an attack glucose admin reduces smptoms Measure: insulin, C pepetide and glucose during fast Treatment: Patient can eat give sugar containing foods If can't eat give D50W IV and switch to D10W as clinical condition improves and glucose level is >100 If alcoholic give thiamine first