Endocrine MDT Flashcards by Draper Kauffman

Blood glucose <70mg/dl

Clinical signs of hypoglycemia (confusion, irritability, fatigue, anxiety, sweating, irregular heart rhythm, perioral paresthesia)

Clinical signs resolve with glucose

Whipple’s Triad

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Hypoglycemia symptoms begin at plasma glucose levels at ___mg/dl or less

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Hypoglycemia symptoms that impair brain function start at ___mg/dl

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Two types of spontaneous hypoglycemia

Fasting

Postprandial

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Fasting hypoglycemia is often subacute or chronic and usually presents with ________ as its principal manifestation

Neuroglycopenia

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Postprandial hypoglycemia is relatively acute and is often heralded by symptoms of:

Neurogenic autonomic discharge (sweating, palpitations, anxiety, and temulousness)

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Postprandial hypoglycemia may be seen after _______ surgery

Gastrointestinal surgery

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The clinical manifestations of hypoglycemia are divided into what two broad categories?

Neuroglycopenic

Sympathomimetic

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Most episodes of symptomatic hypoglycemia include ______ dysfunction

Neurological

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Hypoglycemia

Sx: Alterations in consciousness, lethargy, confusion, combativeness, agitation, and unresponsiveness, seizures, and focal neurologic deficit

Neuroglycopenic

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A rapid fall in blood glucose levels or the hypothalamic sensing of neuroglycopenia causes the release of the counter-regulatory hormones, primarily:

Catecholamines
-Epinephrine
-Norepinephrine

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Hypoglycemia

Sx: Anxiety, nervousness, irritability, nausea, vomiting, palpitations, and tremors

Sympathomimetic

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Labs if considering hypoglycemia is auto immune in nature

Serum antibody testing (GAD-65, anti-islet cell, anti-insulin antibodies)

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Labs if considering hypoglycemia is a surreptitious cause

C-Peptide

Serial glucose/insulin levels in supervised setting

Serum Sulfonylurea levels

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Treatment for hypoglycemia

Glucose

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Hypoglycemia

Do not give PO glucose to:

Patients with altered mental status

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Treatment for hypoglycemic patients unable to eat or drink

Glucagon 0.5 or 1mg SC/IM

Dextrose 50-100 mL IV Bolus

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Hypoglycemia

Once patients are alert and safe to do so they should do what in order to prevent immediate hypoglycemia recurrence?

Eat a meal

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Complications of Hypoglycemia

Coma

Brain Damage

Traumatic Injuries

Death

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Essentials of the diagnosis

-Impaired fasting glucose (100-125mg/dl)
-Borderline Hgb-A1C elevation (5.7-6.4%)
-2 Hour post-prandial glucose (140-199mg/dl)

Prediabetes

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Risk factors for Prediabetes

Family history

Obesity

Diet

Physical inactivity

Race

Women who deliver a baby >9 lbs or had gestational diabetes

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Symptoms of Prediabetes

Usually, no physical exam findings

Early sensory nerve toxicity

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Treatment for Prediabetes

Weight loss

Metformin may lower risk by 30%

Increase physical activity

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Complications of prediabetes

Progression to Type 2 Diabetes

Increased cardiovascular / ischemic stroke risk

Peripheral neuropathy

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Metabolic disorder or disease that is brought about by either the insufficient production of insulin or inadequate activity of insulin receptors

Diabetes mellitus

Three categories of Diabetes

Type 1 Type 2 Gestational Diabetes

Symptoms: -Polyuria / Polydipsia -Weight loss -Glucose >126 mg/dl after a fast on more than one occasion -Ketonemia / Ketonuria

Diabetes

Auto immune antibodies May develop in adults up to age 30 Partial or absolute deficiency of endogenous insulin production and require exogenous insulin for survival

Type 1 Diabetes

The presence of polyuria, polydipsia, fatigue, polyphagia, unexplained weight loss, poor wound healing, blurry vision and a high prevalence of infections should lead the IDC to do what test?

Blood glucose level

Lab findings in a Type 1 diabetic

Glucosuria Ketonemia, ketonuria, or both

The average renal threshold for glucose is approximately

150-180 mg/dl

Testing used if the fasting plasma glucose level is <126 mg/dL in suspected cases, most commonly used to screen for gestational diabetes

Oral Glucose Tolerance Test (GTT)

Form of hemoglobin that is measured primarily to identify the average plasma glucose concentration over time Provides an estimate of glucose control for the preceding 2-3 months

Glycosylated Hemoglobin (HbA1c)

What lab tests are diagnostic for diabetes if confirmed by repeat testing?

Plasma glucose >126 mg/dL or HbA1c of >6.5%

Only medication that is effective in lowering blood glucose levels in type 1 diabetics

Insulin

Insulin supplied in AMMAL

10 mL bottles containing 100 un/ml, short-acting

Immediate short-term goal of Type 1 Diabetes

Control hyperglycemia Maintain serum electrolytes and hydration

Therapeutic goal for long term therapy treatment of Type 1 Diabetes

Maintain normal glucose levels WITHOUT causing hypoglycemia

Type 1 Diabetes Physician monitor blood glucose and HbA1c every __ months until at goal, then every __ months indefinitely

3 months 6 months

Helps control blood sugar and weight

Regular exercise

Drug of choice for diabetes with hypertension because of their renal protection action

ACE inhibitors

Goal for HTN in diabetic patients

<130/80

Dramatically reduces the risk of developing both the microvascular and macrovascular complications of diabetes

Keeping glucose levels at or near normal (Normal A1c = 4.0-6.0)

Type 1 diabetes requires _______ for continued military service

Medical Board

Patients determined to have new onset diabetes should be referred to:

Internal Medicine or Endocrinology

Insulin overdose treatment

Check blood glucose level -Drink 1/2 cup of regular soda or fruit juice -Eat a hard candy -Glucose paste, tablets, or gel Recheck blood sugar after 15-20 minutes

Insulin overdose Patient is still symptomatic after first treatment

Provide 15-20 grams of sugar Once safe to do so patient should eat a meal

Uncontrolled glucose often leads to damage of:

Small arteries and nerves

Most common diabetic complication, affecting 50% of older patients with Type 2

Neuropathies

Diabetic nephropathy is initially manifested by:

Proteinuria

Diabetic nephropathy As kidney function declines, what will accumulate in blood?

Metabolic acids and waste products -Creatinine -Urea

Hypertension from diabetes is most likely from?

Progressive kidney involvement

MI is ____ times more common in DM patients

3-5x

Leading cause of death in Type 2 DM patients

Heart disease (coronary atherosclerosis)

Correlate with both the duration of diabetes and the severity of chronic hyperglycemia

Diabetic cataracts

Diabetic retinopathy after 10-15 years

25-50%

Diabetic Retinopathy after 15 years

75-95%

Diabetic Retinopathy after 30 years

100%

Glaucoma occurs in __% of diabetics

Insulin resistance due to inadequate activity of insulin receptors Most patients are over 40 y/o and obese

Type 2 Diabetes

Random glucose 200 mg/dL or higher Hemoglobin A1c >6.5% HTN, Dyslipidemia, and Atherosclerosis associated Polyuria / Polydipsia Candida vaginitis in women Glucose >126 on more than one occasion

Type 2 Diabetes

DM 2 Resistance to the action of insulin at the ______ level

Receptor

Accounts for 90% of patients with DM

Type 2

Cause of death in over 70% of Type 2 diabetics

Vascular Disease

Symptoms: -Polyuria / Polydipsia -Fatigue -Weight loss -Poor wound healing -Blurred vision -Infections -NO KETONES IN BLOOD

DM 2

Urine dipstick is sensitive to as little as __% glucose

0.1%

Normal Glucose Tolerance Fasting plasma glucose ______ Two hours after glucose load _____ HbA1c _____

<100 <140 <5.7

Impaired Glucose Tolerance Fasting plasma glucose ______ Two hours after glucose load _____ HbA1c _____

100-125 >140-199 5.7-6.4 (Prediabetes)

Diabetes Mellitus Fasting plasma glucose ______ Two hours after glucose load _____ HbA1c _____

>126 >200 >6.5 (diabetes)

Stage 1 Glycemic Control in Type 2 patients

Diet (record food eaten) Exercise

Stage 2 Glycemic Control in Type 2 patients

Oral Antidiabetic medications -FIRST LINE: Biguanides (Metformin/Glucophage)

Stage 3 Glycemic Control in Type 2 patients

Insulin

Most important modifiable risk factor

Obesity

Leading cause of diabetic-related deaths

Heart Disease (40% in men; 32% in women)

Leading cause of new cases of blindness in patients aged 25-74 in the United States

Diabetic retinopathy

Patients with diabetic retinopathy are __ times more likely to become blind than those without retinopathy

29 times

__% of new cases of renal failure each year are due to diabetic nephropathy

43%

Diabetes Typical entry on feet is from:

Broken skin secondary to tinea pedis

Diabetes related foot and lower extremity ulcers Account for __% of diabetes related admissions ___% if all lower extremity amputations

20% 60%

Diabetes A comprehensive foot examination should be conducted by a clinical provider ______

Annually

Mothers who have untreated gestational diabetes may give birth to babies with:

Macrosomia (high birth weight) Congenital heart & nervous system anomalies Respiratory distress syndrome Malformations of skeletal muscles

Hyperglycemia >250 mg/dL Acidosis with blood pH <7.3 Serum bicarbonate < 15 mEq/L Serum positive for ketones

Diabetic Ketoacidosis

May be the initial manifestation of both type 1 or type 2 diabetes

Diabetic Ketoacidosis

Commonly occurs with poor compliance in Type 1 diabetes During Infection, trauma, myocardial infarction, or surgery May develop in type 2 diabetics under severe stress

DKA

Common serious complication of insulin pump therapy

DKA

Symptoms: -Dehydration -Rapid deep breathing with "fruity" bread odor -Hypotension with tachycardia -Mild Hypothermia -Abdominal pain and tenderness in the absence of abdominal disease

DKA

Treatment for DKA

Fluids & Insulin

Initial management priority for DKA

Fluids (LR fluid of choice)

DKA fluid treatment When blood glucose falls to 250 mg/dL or less, use 5% glucose solutions to maintain blood glucose _____ mg/dL while continuing insulin to clear serum ketones

200-300 mg/dL

DKA Intravenous fluids may be reduced to maintenance levels when:

Vital signs improve Hyperglycemia is 250 mg/dL or less Adequate urine output of 30-50 mL/h

The cornerstone therapy for acute hyperglycemia is restoration of ________ and reperfusion of vital organs, especially the kidneys

Intravascular volume

DKA Fluid Treatment Excessive fluid replacement may contribute to acute respiratory distress syndrome or cerebral edema

>5L in 8h

Mainstay therapy for DKA

Insulin plus fluid and electrolyte replacement

DKA insulin treatment dosage

0.15 unit/kg as IV Bolus Follow by: 0.1 unit/kg/h

DKA Insulin treatment If plasma glucose level fails to fall at least __% in the first hour, give repeat loading dose

10%

DKA complications Cerebral edema occurs rarely and is prevented by avoiding sudden reversal of marked hyperglycemia Maintain glycemic levels of _______ mg/dL for the initial 24 h after correction of severe hyperglycemia reduces this risk

200-300 mg/dL

Abnormal growth of the thyroid gland. Can be normal, decreased, or increased thyroid production depending on the cause.

Goiter

Iodine deficiency disorder Common in regions with low-iodine diets Most adults with endemic goiter are found to be euthyroid

Endemic Goiter

Most common cause of endemic goiter is:

Iodine deficiency

Mild-to-moderate and sometimes severe iodine deficiency exists in ___ countries

Usually, asymptomatic Can cause tracheal compression, respiratory distress and failure, and dysphagia if large enough

Goiter

Lab findings for Goiter

T4 and TSH are normal Thyroid Radioactive Iodine Uptake is ELEVATED

Treatment for endemic goiter

Addition of Potassium iodine to table salt Surgery for cosmetic reasons or compressive symptoms

Weakness, cold intolerance, constipation, depression, menorrhagia, hoarseness, dry skin, bradycardia Delayed return of deep tendon reflexes Serum free tetraiodothyronine aka Thyroxin (T4) LOW TSH hormone elevated in primary disease

Hypothyroidism

Primary hypothyroidism is due to:

Thyroid gland disease

Secondary hypothyroidism is due to:

Lack of pituitary TSH

Maternal hypothyroidism during pregnancy results in cognitive impairment in child. Generally, increase dose of thyroid replacement hormone by ___%

30%

Drugs that can cause hypothyroidism

Lithium Amiodarone Propylthiouracil Methimazole Phenylbutazone Sulfonamides Interferon

Causes of hypothyroidism with goiter

Autoimmune (Hashimoto's, Thyroiditis) Subacute Iodine deficiency Genetic thyroid enzyme defects Hep C Drugs Infiltrating diseases

Causes of hypothyroidism without goiter

Thyroid Surgery, Irradiation, or Radioiodine treatment Deficient pituitary TSH Severe illness Drugs

Sub-clinical hypothyroidism (High TSH and Normal T4 occurs commonly in elderly women ___%

10%

Early Symptoms: Fatigue, lethargy, weakness Arthralgias, myalgias, muscle cramps Cold Intolerance Difficulty concentrating Constipation Dry Skin Headache Weight Gain Menorrhagia

Hypothyroidism

Late Symptoms Slow speech Peripheral edema Pallor Hoarseness Decreased senses of taste, smell, and hearing Dyspnea Absent sweating Amenorrhea or menorrhagia Galactorrhea

Hypothyroidism

Early signs Thin, brittle nails Thinning of hair Pallor Poor turgor of mucosa Delayed return of deep tendon reflexes

Hypothyroidism

Late signs Goiter Puffiness of face and eyelids Thinning of outer eyebrows Tongue thickening Hard pitting edema Pleural, peritoneal, pericardial, and joint effusions

Hypothyroidism

Hypothyroidism Serum TSH is Increased in:

PRIMARY Hypothyroidism

Hypothyroidism TSH is low or normal in _______ hypothyroidism

Secondary

Hypothyroidism Free T4 may be:

Low or Low Normal

Hypothyroidism Serum cholesterol, triglycerides, liver enzymes, creatine kinase, prolactin ________

INCREASED

Lab findings: -Hyponatremia -Hypoglycemia -Anemia (MCV normal or increased)

Hypothyroidism

Treatment for hypothyroidism

Levothyroxine (T4) 25-75 mcg/day

Hypothyroidism treatment Thyroid function tests should be repeated every ___ weeks for medication titration until TSH is at goal

4-6 weeks

Complications of hypothyroidism

Myxedema coma (long term untreated, 'Hypo' everything) Increased susceptibility to infection Megacolon Organic psychoses with paranoid delusions Angina Pectoris, CHF, dysrhythmias Adrenal crisis

Sweating, weight loss, heat intolerance, menstrual irregularity, tachycardia, tremors, eye stare

Hyperthyroidism

Goiter, often with bruit Ophthalmopathy Thyroid stimulating immunoglobulins (active TSH receptor in thyroid gland)

Grave's disease

In primary hyperthyroidism the thyroid is acting:

Autonomously (independent from pituitary gland)

In primary hyperthyroidism, what would the lab values for T4, T3 and TSH be?

Increased Free Thyroxine (T4) and Triiodothyronine (T3) Low TSH

Most common cause of hyperthyroidism

Grave's disease

Signs: -Fever -Tachycardia -Diaphoresis -Tremors -Disorientation/psychosis -Goiter -Exophthalmos -Hyperreflexia -Pretibial myxedema

Hyperthyroidism

Symptoms: -Weight loss despite INCREASED appetite -Dysphagia or dyspnea due to goiter -Rash/pruritis/hyperhidrosis -Palpations/Chest pain -Diarrhea -Myalgias and weakness -Nervousness/anxiety -Menstrual irregularities -Heat Intolerance -Insomnia and fatigue

Hyperthyroidism

Eye signs in hyperthyroidism

Stare and lid lag Ophthalmopathy Diplopia

Skin symptoms in hyperthyroidism

Moist warm skin Fine hair Onycholysis Dermopathy

Heart symptoms in hyperthyroidism

Palpitations or angina pectoris Arrythmias Thyrotoxic cardiomyopathy due to thyrotoxicosis Heart failure (Rarely)

Extreme form of thyrotoxicosis that may be triggered by stressful illness, thyroid surgery, or radioactive iodine (RAI) administration Sx: Delirium, severe tachycardia, vomiting, diarrhea, dehydration, very high fever

Thyroid Storm

Treatment for Graves' diseease

Radioactive Iodine

Treatment for hyperthyroid symptoms like tachycardia, tremors, diaphoresis, and anxiety until hyperthyroidism is resolved

Propranolol (Beta Blocker)

Most widely recommended permanent treatment of hyperthyroidism

Radioactive Iodine

Longterm treatment options for hyperthyroidism result in the patient developing hypothyroidism and lifelong need for:

Levothyroxine (Thyroid hormone replacement)

Commonly found during careful thyroid examinations Small nodule on the thyroid Usually, asymptomatic/benign

Thyroid nodule

What tests are mandatory for a thyroid nodule?

Thyroid U/S Thyroid Function Tests

___% of thyroid nodules are benign

90%

Disposition for a thyroid nodule

Referral to endocrinology

Causes of solitary thyroid nodule:

Benign adenoma Colloid nodule Cyst Primary thyroid malignancy or metastatic neoplasm

Thyroid nodule Higher risk of malignancy if:

History of head-neck radiation in childhood Family history of thyroid cancer Personal history of another malignancy

Toxic multinodular goiter and hyperfunctioning nodules can cause:

Hyperthyroidism

Thyroid nodules or multinodular goiter can grow and cause:

Cosmetic embarrassment, discomfort, hoarseness, or dysphagia

Large retrosternal multinodular goiters can cause:

Dyspnea due to tracheal compression

Thyroid nodules with: -Hoarseness or vocal cord paralysis -Nodules in men or young women -Nodule that is solitary, firm, large, or adherent to trachea or trap muscles -Vocal cord paralysis -Enlarged lymph nodes -Distant metastatic lesions

Malignancy

History for distant metastatic lesions in regards to thyroid nodules

Family History of Goiter Residence in area of endemic goiter

Physical characteristics of distant metastatic lesions of thyroid nodules

Older women Soft Nodule Multinodular goiter

Preferred imaging for thyroid nodules for its accuracy

U/S

Thyroid Solid nodules are often:

Malignant

Thyroid Cystic nodules are usually:

Benign

Treatment for thyroid nodules

Refer to endocrinology U/S guided fine-needle aspiration MEDEVAC

Weakness, abdominal pain, fever, confusion, vomiting Low blood pressure, dehydration Skin pigmentation may be increased Insufficient aldosterone will result in elevated serum potassium and low sodium Insufficient cortisol may result in hypoglycemia Dehydration and hypotension may result in poor kidney perfusion

Adrenal Crisis

Primary renal crisis results from:

Destruction of dysfunction of the adrenal cortex

Secondary renal crisis results from:

ACTH hyposecretion

May occur during stress in a patient with latent insufficiency or treated adrenal insufficiency with sudden withdrawal of adrenocortical hormones

Adrenal Crisis

Drugs that if stopped or decreased too quickly will result in the adrenal gland not making cortisol again fast enough to meet the body needs Resulting in adrenal insufficiency

Steroids (glucocorticoids & mineral corticoids)

Symptoms: -Headaches -Lethargy -Nausea/Vomiting -Abdominal pain and diarrhea -Confusion or coma -Cyanosis -Dehydration -Sparse Axillary hair

Adrenal Crisis

Signs: -Skin hyperpigmentation -Fever -Hyperkalemia -Hyponatremia -Hypotension -Eosinophilia

Adrenal Crisis

Lab findings in Adrenal Crisis

Eosinophilia Hyponatremia or hyperkalemia (or both) Hypoglycemia Hypercalcemia (due to renal injury) Blood, sputum, and urine may be positive for bacteria

Diagnostic tests for Adrenal Crisis

Cosyntropin stimulation test with serum ACTH level Early morning (0600-0800) serum cortisol

What tests helps to determine adrenal insufficiency is primary or secondary?

Corsyntopin stimulation with serum ACTH

Acute abdomen is neutrophilia Adrenal Insufficiency is ________ and ________

Lymphocytosis & Eosinophilia

If symptomatic adrenal insufficiency is suspected, immediately treat with:

Hydrocortisone 100-300 mg IV and saline -Continue 50-100mg IV Q 6h on first day, then Q 8h on second day; taper off

Labs for adrenal crisis

Electrolytes Cortisol ACTH Screen for infection (PNA, UTI)

Patients treated for acute adrenal insufficiency and diagnosed with Addison's disease require lifelong replacement therapy with both:

Glucocorticoids Mineralocorticoids

Weakness, fatigability, anorexia, weight loss; nausea/vomiting, diarrhea; abdominal pain, muscle and joint pains; amenorrhea Sparse axillary hair; increased skin pigmentation especially of creases, pressure areas, and nipples Hypotension, small heart Potassium high, sodium low, blood urea nitrogen high Plasma cortisol levels are low or fail to rise after administration of corticotropic Elevated ACTH level

Chronic Adrenal Insufficiency

Uncommon disorder caused by destruction or dysfunction of the adrenal cortices

Addison Disease

Chronic deficiency of cortisol, aldosterone, and adrenal androgens and causes skin pigmentation that can be subtle or strikingly dark

Chronic Adrenal Insufficiency

Chronic Adrenal Insufficiency Skin pigmentary changes are not encountered when:

ACTH is not elevated

Most common cause of Addison disease in the US

Autoimmune destruction of the adrenals

Leading cause of Addison disease

Tuberculosis

Symptoms: -Weakness and Fatigability -Weight loss -Myalgias -Arthralgia's -Anorexia -Nausea/Vomiting -Anxiety -Mental irritability

Chronic Adrenal Insufficiency

Signs: -Hyperpigmentation skin changes -Hypopigmented skin (Vitiligo 10%) -Hypoglycemia -Hypotensive blood pressure -Nail beds (longitudinal pigmented bands) -Small Heart -Scant axillary and pubic hair

Chronic Adrenal Insufficiency

Lab Findings: -Moderate neutropenia, lymphocytosis, eosinophilia -Low Na+, High K+ Hypoglycemic Low Cortisol High ACTH

Chronic Adrenal Insufficiency

Chronic Adrenal Insufficiency Chest X-ray, look for:

TB Fungal infection Cancer Edema

Chronic Adrenal Insufficiency Abdominal CT, Look for:

Small noncalcified adrenal in autoimmune Addison disease Adrenals are enlarged (85%) Calcification is noted in 50% of TB cases

Drug of choice for Chronic Adrenal Insufficiency

Hydrocortisone

Most Addison patients are well maintained on:

15-30mg of hydrocortisone orally daily in two divided doses

Common endocrine disorder of unknown pathophysiology affecting up to 10% of women of reproductive age

Polycystic Ovarian Syndrome

Menstrual disorders Infertility Hirsutism Obesity Acne Insulin resistance, DM2, metabolic syndrome Dyslipidemia Perinatal complications if able to become pregnant

Polycystic Ovarian Syndrome

Labs for Polycystic Ovarian Syndrome

LH / FSH (Ratio is 2:1 or 3:1; normal is 1:1) TSH Hgb A1c and Fasting Glucose Prolactin Free testosterone

Lab test for Polycystic Ovarian Syndrome if clinical evidence of Cushing Syndrome

Midnight salivary cortisol or dexamethasone suppression test

Treatment for Polycystic Ovarian Syndrome

Weight loss and exercise Metformin Contraceptives

Polycystic Ovarian Syndrome drug of choice that will increase FSH and will increase chances of ovulation

Clomiphene

Deficient testosterone secretion by the testes or sperm production

Hypogonadism

Hypogonadism Insufficient gonadotropin by the pituitary

Hypogonadotropic

Hypogonadism Pathology in the testes themselves

Hypergonadotropic

Fatigue Decreased strength Poor libido Hot flushes Erectile dysfunction Gynecomastia Infertility Small testes

Hypogonadism

Total testosterone General rule is low

<200ng/dl

Total testosterone that is normal

>350ng/dl

For values of free testosterone between 200-350ng/dl measures it with:

Albumin to calculate Bioavailable testosterone

Hypogonadism If testosterone is low, obtain what labs?

LH, FSH, and Prolactin

Hypogonadism High FSH/LH indicates _______ failure

Primary testicular

Hypogonadism High prolactin indicates possible:

Prolactinoma

Hypogonadism Low FSH/LH indciates:

Secondary hypogonadism

Hypogonadism Low FSH/LH should prompt additional screening for:

Hemochromatosis w/ Transferrin, Ferritin, and genotypic for HFE Gene Pituitary mass with MRI of the Sella Anabolic steroid or supplement use

Treatment for Hypogonadism should only be initiated:

With guidance from a medical officer

Testosterone replacement is contraindicated in ______ cancer

Prostate cancer

Testosterone HCT of ___% or greater is of high risk of developing erythrocytosis

55%

Treatment for Hypogonadism

Transdermal testosterone 25-100mg (PREFERRED) IM Testosterone 100mg (LONG ACTING)

Higher doses >100mg of IM testosterone sometimes spread-out injection intervals to ___ weeks

2-4 weeks

Normal hypothalamus-pituitary-gonadal (HPG) axis is down regulated by estrogen sensing in the hypothalamus. This negative feedback mechanism can be blocked by inhibiting the hypothalamic estrogen receptors with:

Clomiphene (Clomid)

Hypogonadism Preferable therapy if patient desires fertility

Clomiphene (Clomid)

Hypogonadism This modality is used to attempt to restore normal physiology before committing life-long testosterone replacement therapy

Clomiphene (Clomid)

Regimen of Clomiphene that may be attempted 3 times

Daily 25mg for 3 months, followed by 6 weeks off

Therapeutic target for testosterone levels

800ng/dl

Do not titrate testone dose to:

Patient-reported symptoms

Sub-areolar glandular hyper density which may be unilateral or bilateral, and may be painful or non-painful Common transient finding in pubertal males which general self-resolves

Gynecomastia

Any condition resulting in excess estrogen, or testosterone which is metabolically linked to the estrogen via:

Aromatase

Gynecomastia Excess estrogen may be from:

Normal Physiology (Aging, obesity, puberty) Endocrine Disease Systemic Disease Neoplasms Drugs

Gynecomastia Physical exam, use what fingers as pincers to examine subareolar tissue as compared to nearby adipose tissue

Thumb and index finger

Tissue that is diffuse and non-tender

Adipose

Tissue that is dense and may be tender

Breast tissue

True Gynecomastia will be localized to ________ region only

Subareolar

Red flags of Gynecomastia

Asymmetry Density located away from subareolar region Nipple retraction Nipple bleeding or discharge Unusual firmness

Gynecomastia What else should you examine for size and masses?

Testicles

All masses or presence of HCG warrant:

Testicular U/S

Labs for Gynecomastia

Free testosterone LH / FSH Liver function panel Renal panel (BUN and Creatinine) Beta HCG (not pregnancy test; specific Tumor Marker) Estradiol Thyroid function panel Prolactin

Treatment for Gynecomastia

Selective estrogen receptor modulator (SERM) -Raloxifine -Tamoxifine Aromatase inhibitor -Anastrozole Testosterone therapy for males with hypogonadism

Treatment for Gynecomastia Refractory cses

Radiation therapy Surgery

Referral for Gynecomastia

Family Practice or Internal Medicine

Constellation of 3 or more of the following: -Abdominal Obesity -Triglycerides 150mg/dl or higher -HDL <40mg/dl for men or 50mg/dl for women -Fasting glucose of 110mg/dl or higher -HTN

Metabolic Syndrome

Metabolic Syndrome Waist measurement if BMI is ____

>25

Metabolic Syndrome Lipid screening every __ years

5 years

Metabolic Syndrome Check fasting glucose or A1c every __ years in patients BMI >25 with one or more additional risk factor

3 years

Metabolic Syndrome Most important modifiable risk factor

Obesity

Management for Metabolic Syndrome

Weight management and physical activity Diet modification Nutrition referral Metformin Blood pressure medications

Endocrine MDT Flashcards

(230 cards)