Endocrine Problems

Question 1

Diabetes Insipidus (DI)

Answer 1

Deficiency of production or secretion of ADH or with decreased renal response to ADH d/t injury to neurohypophyseal system

Question 2

3 types of Diabetes Insipidus (DI)

Answer 2

1. Central 2. Nephrogenic: 3. Primary

Question 3

Central Diabetes Insipidus

Answer 3

(Neurogenic): interference in ADH synthesis or release (brain tumor, head trauma, brain injury, CNS infection)

Question 4

Nephrogenic Diabetes Insipidus

Answer 4

inadequate renal response to ADH (in the setting of N ADH levels) (drug therapy esp. lithium, renal damage or hereditary renal disease)

Question 5

Primary Diabetes Insipidus

Answer 5

(aka psychogenic): excessive water intake (lesion in thirst center, psychological disorder)

Question 6

Clinical Manifestations (Central and Nephrogenic) of diabetes insipidus

Answer 6

◦ Polydipsia, polyuria (5-20 L/day) with very low specific gravity and low urine osmolality (dilute urine) ◦ Serum osmolality is elevated d/t hypernatremia caused by pure water loss from kidneys ◦ Patients compensate by drinking water ◦ May be fatigue from nocturia, may have generalized weakness ◦ If PO intake cannot keep up with urinary losses – hypovolemia results (weight loss, constipation, poor tissues turgor, hypotension, tachycardia, hypovolemic shock) ◦ CNS manifestations – irritability, mental dullness, coma ◦ Primary DI – overhydration and hypervolemia (vs. the dehydration and hypovolemia)

Question 7

Diagnostic studies of Diabetes Insipidus

Answer 7

◦ ID cause – Hx and PE, water deprivation test

Question 8

Thyroid Function

Answer 8

regulates energy, metabolism, growth and development

Question 9

Thyroid Hormones

Answer 9

thyroxine (T3) and triiodothyronine (T3)

Question 10

Thyroid Disorders

Answer 10

enlargement benign and malignant nodule, inflammation, hyper and hypo function

Question 11

Goitre

Answer 11

Enlargement of the thyroid gland; may be associated with hyperthyroidism, hypothyroidism, or normal thyroid function.

Question 12

Most common cause of goitre

Answer 12

Lack of iodine

Question 13

Treatment of goitre

Answer 13

thyroid hormones, surgical removal for large goitres

Question 14

Nodules

Answer 14

palpable deformity, increased incidence with age

Question 15

Malignant nodules

Answer 15

Thyroid CA – most common endocrine CA

Question 16

Thyroiditis

Answer 16

An inflammation of the thyroid gland that may cause hyperthyroid or hypothyroid manifestations.

Question 17

Causes of thyroiditis

Answer 17

1. Viral (subacute granulomatous thyroiditis), bacterial/fungal infection (acute thyroiditis) – abrupt onset painful (T3 T4 high then decrease; TSH low then increases) 2. Chronic autoimmune thyroiditis (Hashimoto’s thyroiditis) - can lead to hypothyroidism; thyroid tissues replaced by lymphocytes and fibrous tissue – most common cause of goitorus hypothyroidism (T3 T4 low, TSH high, antithyroid antibodies present) 3. Silent thyroiditis (T3 T4 high then decrease; TSH low then increases; RAIU decreased) 4. Postpartum thyroiditis

Question 18

Hyperthyroidism

Answer 18

A clinical syndrome characterized by a sustained increase in synthesis and release of thyroid hormones by the thyroid gland

Question 19

Thyrotoxicosis

Answer 19

A hypermetabolic state caused by excessive circulating levels of thyroxine, triiodothyronine, or both.

Question 20

Grave’s Disease

Answer 20

An autoimmune disease of unknown origin, marked by diffuse thyroid enlargement and excessive thyroid hormone secretion. ◦ Develop antibodies that attach to TSH receptors and stimulate the thyroid to produce T3 and/or T4 – cause manifestations/thyrotoxicosis ◦ Disease pattern characterized by exacerbations and remissions and may progress to destruction of thyroid tissue (causes hypothyroidism)

Question 21

Clinical Manifestations of Grave’s Disease

Answer 21

◦ Related to effects/amount of excess hormones ◦ Palpable or visualized goiter – may be able to auscultate bruit d/t increased blood supply ◦ Exophthalmos - protrusion of eyeballs d/t impaired venous drainage – edema, fate deposits ◦ See Table 51-6 p. 1405 for additional manifestations of thyroid hyperfunction

Question 22

Complication of Grave’s disease

Answer 22

Thyrotoxic Crisis ‘Thyroid Storm’ – rare – intensified manifestations of hyperthyroid – medical emergency – can be induced by stressors (trauma, infection, surgery); heart and nervous tissue more sensitive to epinephrine and norepinephrine

Question 23

Diagnostic Studies of Grave’s disease

Answer 23

◦ Labs – decreased TSH, elevated free T4(free: unbound to protein – only free T4 is biologically available) ◦ RAIU demonstrated increased and more diffuse uptake than other forms of thyroiditis

Question 24

Goal of treatment of Grave’s disease

Answer 24

block effects of excessive hormones and stop their oversecretion

Question 25

Medications used to treat Grave's disease

Answer 25

ØAntithyroid Drugs ØIodine - high dose, (with antithyroid drugs) – inhibits synthesis of T3 and T4, blocs release of hormones, decreased vascularity of thyroid gland; for use during thyroid storm or prior to surgery ØBeta Blockers: (with antithyroid drugs) symptoms relief – decreased HR, BP

Question 26

Radioactive Iodine Therapy for Grave's disease

Answer 26

treatment of choice (unless pregnant) – damages or destroys thyroid tissue, limiting hormone secretion; high incidence of post treatment hypothyroidism

Question 27

Subtotal Thyroidectomy for Grave's disease

Answer 27

surgical removal; if goiter large and/or compression of trachea, or no response to other therapies

Question 28

Hypothyroidism

Answer 28

Insufficient circulation of thyroid hormones resulting in a hypometabolic state.

Question 29

2 types of hypothyroidism

Answer 29

Primary and Secondary

Question 30

Primary Hypothyroidism

Answer 30

destruction of thyroid tissue, defective hormone synthesis

Question 31

Secondary hypothyroidism

Answer 31

pituitary disease with decreased secretion of TSH or hypothalamic dysfunction with decreased secretion of TRH

Question 32

Causes of hypothyroidism

Answer 32

• May be transient, related to thyroiditis, or from discontinuation of thyroid hormone therapy • Worldwide – iodine deficiency is the most common cause • Canada - adult atrophy of thyroid gland (end result of Hashimoto’s thyroiditis an Grave’s disease); also as a result of treatment for hyperthyroidism – surgical removal, or radioactive iodine therapy; drugs – Amiodarone, Lithium

Question 33

Clinical Manifestations of hypothyroidism

Answer 33

Vary depending on severity and duration of deficiency ◦ Insidious and non-specific slowing of body processes ◦ Onset is slow ◦ Fatigue, lethargy, impaired memory, depression, slowed speech, decreased initiative and concentration ◦ Decreased CO and contractility, decreased exercise tolerance and SOBOE ◦ Anemia, easy bruising, increased lipids and triglycerides ◦ Constipation, cold intolerance, dry skin, hair loss, brittle nails ◦ Menstrual abnormalities – menorrhagia, anovulation, fertility issues ◦ See Table 51-6 p. 1405 for additional manifestations of thyroid hypofunction

Question 34

Myxedema

Answer 34

The characteristic facies of severe, longstanding hypothyroidism (i.e., puffiness, periorbital edema, and masklike affect) caused by an accumulation of hydrophilic mucopolysaccharides in the dermis and other tissues. ◦ Severe longstanding hypothyroidism ◦ Accumulation of hydrophilic polysaccharides in the tissues ◦ Characterize facies- periorbital edema, puffiness, masklike effect

Question 35

Myxedema coma

Answer 35

The progression of the mental sluggishness, drowsiness, and lethargy of hypothyroidism to a notable impairment of consciousness or coma that is a medical emergency.

Question 36

Diagnostic studies of hypothyroidism

Answer 36

Labs: TSH and free T4 (correlated with Hx and PE); increased TSH = defect in thyroid, decreased TSH – defect in pituitary or hypothalamus

Question 37

Goal of treatment of hypothyroidism

Answer 37

restoration of erythroid state

Question 38

Hormone replacement therapy of hypothyroidism

Answer 38

levothyroxine – doses adjusted based on TSH value

Question 39

Acromegaly

Answer 39

A condition caused by excessive secretion of growth hormone and characterized by an overgrowth of the bones and soft tissue

Question 40

Acromegaly in children (Gigantism)

Answer 40

over growth of bones and soft tissues (epiphyses open) Gigantism

Question 41

Acromegaly in adults

Answer 41

thickening of bones and soft tissues (epiphyses closed) rare Acromegaly

Question 42

What usually causes acromegaly

Answer 42

Usually caused by benign pituitary tumor (adenoma)

Question 43

Clinical manifestations of acromegaly

Answer 43

◦ Slow onset, 3rd-4th decade ◦ enlarged hands and feet with associated joint pain, potential arthritis; enlargement of bones and soft tissues of face and head; ◦ Dysphasia d/t enlarged tongue ◦ Voice deepened d/t hypertrophy of the vocal cords ◦ Sleep apnea d/t narrowed airway ◦ Skin thick, leathery, oily ◦ Peripheral neuropathy and muscle weakness ◦ Menstrual disturbances ◦ Colon CA and polyps ◦ Enlarged pituitary – pressure on surrounding structures – can impact vision, headaches ◦ Mobilizes free fatty acids – atherosclerosis ◦ GH antagonizes insulin – hyperglycemia – DM ◦ Cardiomegaly, ventricular hypertrophy, angina, HTN

Question 44

Drugs used to treat acromegaly

Answer 44

- somatropin analogue (decreases GH levels) - dopamine agonists (suppress GH secretion) - GH receptor agonist ( directly blocked GH action)

Question 45

Prolactinoma

Answer 45

Prolactin secreting adenoma– most frequently occurring pituitary tumor

Question 46

Prolactinoma manifestations in women

Answer 46

ovulatory and menstrual abnormalities, decreased libido, hirsutism

Question 47

Prolactinoma manifestations in men

Answer 47

ED, decreased libido and sperm density

Question 48

Visual problems in prolactinoma due to:

Answer 48

tumor pressure

Question 49

Prolactinoma therapies

Answer 49

drug therapy (dopamine agonists); surgery, radiation (last resort)

Question 50

Hypopituitarism

Answer 50

A rare disorder that involves a decrease in one or more of the pituitary hormones. Ant Pit (ACTH, TSH, FSH, LH, GH, prolactin; Post Pit (ADH, Oxytocin)

Question 51

Hormones of the pituitary gland

Answer 51

Ant Pit (ACTH, TSH, FSH, LH, GH, prolactin; Post Pit (ADH, Oxytocin)

Question 52

Causes of Hypopituitarism

Answer 52

autoimmune disorders, infections, pituitary infarction (Sheehan’s syndrome), trauma, radiation, surgery

Question 53

Hypopituitarism diagnostics

Answer 53

Labs to measure hormone levels; CT/MRI

Question 54

Hypopituitarism treatment

Answer 54

directed at cause, hormone replacement therapy

Question 55

Syndrome of inappropriate antidiuretic hormone (SIADH)

Answer 55

a condition characterized by fluid retention, serum hypo-osmolality, dilutional hyponatremia, hypochloremia, and concentrated urine in the presence of normal or increased intravascular volume; results from an abnormal production or sustained secretion of antidiuretic hormone despite normal or low plasma osmolarity.

Question 56

Clinical Manifestations of SIADH

Answer 56

◦ Dependent on severity ◦ S & S hyponatremia ( cramps, muscle weakness, vomiting, abdominal cramps, muscle twitching, seizures) ◦ Low urinary output and increased body weight ◦ Decreases serum Na and plasma osmolality levels – cerebral edema, headache, seizure, coma

Question 57

SIADH Diagnostic Studies

Answer 57

◦ Urine and serum osmolality (increased urine specific gravity, decrease serum osmolality), ◦ Serum Na level (\< 134 mmol/L)

Question 58

Collaborative care of SIADH

Answer 58

◦ Treatment is directed at cause and based on severity ◦ Goal – restore normal fluid volume and osmolality ◦ Fluid restriction 800-1000mL/24H (mild symptoms, Na \> 125 mmol/L) ◦ Hypertonic IV saline carefully, gentle diuresis(severe, neuro S&S, Na \<120 mmol/L ) ◦ Chronic – fluid restriction, medications ◦ See Table 51-2 for Nursing Assessment/Management of SIADH

Question 59

Collaborative care in Diabetes Insipidus

Answer 59

◦ Based on cause, restoration of fluid and hormonal replacement ◦ Acute DI – hypotonic saline to replace urine output ◦ Hormone replacement – Desmopressin (analogue of ADH) , PO, IV, nasal spray