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Flashcards in Endocrine Up to Dates Deck (92)
1

The most common clinical presentation of primary hyperparathyroidism

asymptomatic hypercalcemia detected by routine blood work

2

Clinical manifestations of PHPT

Skeletal manifestations and kidney stones (nephrocalcinosis)

3

Physical findings in PHPT

usually no physical findings. may have a palpable neck mass but that is most likely a thyroid nodule or parathyroid carcinoma

4

Normocalcemic primary hyperparathyroidism

PTH levels are elevated but the serum calcium is normal. For this diagnosis, all secondary causes for hyperparathyroidism must be ruled out and ionized calcium levels should be normal

5

Parathyroid crisis

Very rare condition. Consists of severe hypercalcemia --- above 15 and s/s of hypercalcemia - CNS dysfunction. AMS, bone disease, kidney stones. Can be caused by a life threatening illness, volume loss or an infarction of a parathyroid adenoma

6

Classic PHPT

Combined effects of increased PTH secretion and hypercalcemia. Bones, stones, abdominal moans and psychic groans.

7

Prolonged PTH excess leads to

kidney stones and bone disease

8

Symptoms of hypercalcemia

anorexia, nausea, constipation, polydipsia, polyuria

9

Most common complication of PHPT

kidney stones

10

Ostitis Fibrosa cystica

Most often in those with severe disease or parathyroid carcinoma. Classic manifestation of PHPT bone disease. Characterized by bone pain and radiographically by subperiosteal bone resorption on the radial aspect of the middle phalanges, tapering of distal clavicles and a salt and pepper appearance of the skull, bone cysts, brown tumors of the long bones. Bone tumors are from excess osteoclast activity.

11

Nephrolithiasis PHPT

Kidney stones. Most often comprised of calcium oxalate.

12

Neuromuscular s/s PHPT

Weakness and fatigue. Improved when parathyroid is removed. Bone pain, osteoporosis/osteopenia

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Neuropsychiatric symptoms PHPT

lethargy, depressed mood, psychosis, decreased social interaction, cognitive dysfunction. Decreased concentration, confusion, stupor, coma

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Renal disease s/s PHPT

decrease concentrating ability with a GFR less than 60

15

Cardiovascular s/s PHPT

HTN, arrhythmia, ventricular hypertrophy and vascular and valvular calcification

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Rhem s/s PHPT

hyperuricemia, gout, pseudogout in wrist and knees

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Lab findings PHPT

hypophosphatemia, decreased mg, anemia which responds to a parathyroidectomy

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Causes of secondary hyperparathyroidism

Renal failure: hyperphosphatmia/impaired calcitrol production. Calcium malabsorption from vitamin D deficiency, bariatric surgery, celiac disease, pancreatic disease (fat malabsorption). Renal calcium loss from hypercalciuria or loop diuretics. Inhibition of bone resorption through biphosphonates or hungry bone syndrome

19

PHPT s/s

bone disease, kidney stones, hypophosphatemia, increased production of calcitol (Vitamin D3), proximal renal tubular acidosis, hypomagnesmia, hyperuricemia, gout, anemia

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GI s/s PHPT

Anorexia, n/v, constipation, pancreatitis, Peptic ulcer disease

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Renal s/s PHPT

polyuria, polydipsia, nephrolithiasis, nephrocalcitonosis, distal tubular acidosis, neprogenic DI, acute and chronic renal insufficiency

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cardiovascular s/s PHPT

shortened QT interval, bradycardia, hypertension

23

Treatment options for PHPT

surgical intervention vs. observation

24

Who is surgery recommended for

Hyperparathyroidism with symptomatic disease (polyuria, polydipsia, fragility fx, kidney stones, osteoporosis, pud, pancreatitis, gerd, neurodysfunction)

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Asymptomatic patient who needs surgery

< 50, likely to progress into symptomatic based on GFR, T score < 2.5 (osteoporosis) and calcium greater than 1mg/dL above normal

26

Parathyroid exploration

PHPT as a result of parathyroid cancer or parathyroid crisis, or with recurrent primary hyperparathyroidism

27

Contraindications to parathyroidectomy

contralateral recurrent laryngeal nerve injury and symptomatic cervical disc disease

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Complications of parathyroidectomy

failure to achieve cure of hypercalcemia, hematoma with airway compromise, hypoparathyroidism and laryngeal nerve injury

29

subclinical hyperthyroidism

no clinical symptoms just a low TSH

30

overt hyperthyroidism

dramatic symptoms -- lability, tremors, palpitations, anxiety, sweaty, increased heat intolerance, urinary frequency, hyperdefecation,

31

mild hyperthyroidism

symptoms only to a few organ systems, like weight loss, new afib, menstrual disorders

32

symptoms of hyperthyroidism is the older adult

may have more cardiac and resp symptoms - tachycardia, afib, DOE, apathetic thyrotoxicosis (no symptoms except weakness and asthenia)

33

physical exam with hyperthryoidism

hyperactivity, rapid speech. lid lag/stare. warm skin. thin hair. tachycardia. afib irregular pulse. systolic hypertension. tremor. hyperreflexia. (exophalmus. periorbital edema and limited eye movement only with graves disease)

34

Subclinical hyperthyroid

low tsh but normal t4 t3 free t3 most do not have any clinical s/s of hyperthyroidism Can be mild graves or a multinodular goiter

35

primary hyperthyroidism labs

low tsh, high t3 and/or t4

36

t3 toxicosis

greater increase in t3 than t4, seen in Graves or a nodular goiter. Due to increased t3 secretion and an increased extrathyroidal conversation of t4 to t3

37

t4 toxicosis

low TSH, high t4, normal t3. Found in those with hyperthyroidism with an extrathyroidal condition which decreases conversion of t4 to t3

38

Amiodarone

inhibits extrathyroidal conversion of t4 to t3. In patients with amiodarone induced hyperthyroid will have elevated t4 and a t3 not as elevated.

39

Subclinical hyperthyroid

low tsh but normal t4 t3 free t3 most do not have any clinical s/s of hyperthyroidism Can be mild graves or a multinodular goiter

40

TSH induced hyperthyroidism

very rare, due to TSH secreting pituitary adenoma or a defect in a t3 receptor resisting the feedback of t4 and t3 on TSH secretion. High TSH despite high t4 and t3

41

Central hypothyroidism

low TSH and normal but usually low free t4 and t3

42

meds that can cause a low TSH and a low or normal t3 t4

high dose glucocorticoids, high dose dopamine

43

TSH in pregnancy

physiologically lowers

44

diagnose graves on this criteria - 3 criteria

new onset opthamolopathy, large non-nodular thyroid, moderate to sever hyperthyroidism

45

if diagnosis of hyperthyroidism is not apparent based on clinical presentation, these diagnostic tests can be ordered

measurement of thyrotropin receptor antibodies, determination of radioactive iodine uptake, measurement of thyroid blood flow via ultrasound

46

trAb + antibodies confirms what

graves

47

t3 and t4 high, tsh normal or high...

need to evaluate for a pth producing pituitary tumor - need MRI

48

RAI with toxic multinodular goiter

areas of increased and suppressed uptake

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RAI with toxic adenoma

focal increased uptake

50

tsh low and only T3 high...

graves or thyroid adenoma

51

tsh low and T4 high...

hyperthyroid with a nonthyroidal illness, amiodarone, exogenous t4 ingestion

52

t3 and t4 high, tsh normal or high...

need to evaluate for a pth producing pituitary tumor - need MRI

53

Hyperthyroid testing for pregnancy

no RAI. US or antibodies TRAb.

54

most common cause of hyperthyroidism

graves

55

diffuse goiter could indicate

graves, painless thyroiditis, TSH secreting pituitary tumor

56

skin and hair w hyperthyroid

thin hair, alopecia areata, oncholysis (loosing nails from nail bed) and soft tails, sweating, itching, hives, vitiligo

57

infiltrative dermopathy

only in graves, most commonly over the shins, raised, hyperpigmented, orange peel textured papules

58

eyes in hyperthyroid

lid lag and stare. Due to overactivity from alpha adrenergic receptors of tissues. Eval by having follow finger up and down with eyes + if the sclera can be seen above the iris as the patient looks downward

59

Opthamalopathy

only in graves. Inflammed extraocular muscles and the orbital fat and connective tissue causing proptosis (exopthalmus), impaired eye function and periorbital and conjunctival edema.. can cause diplopia or corneal ulcers

60

cardiovascular s/s hyperthyroid

increased heart rate, palpitations, widened pulse pressure, systolic hypertension, can have CHF or a worsened CHF in those who already have it, a fib in 10-20 percent, which usually spontaneously converts, need anticoagulation.

61

serum lipids with hyperthyroid

low HDL and low total/HDL ratio

62

hyperglycemia with hyperthyroid

interferes with glucose metabolism from increased sensitivity of pancreatic beta cells to glucose leading to impaired glucose tolerace from the increased sensitivity

63

resp with hyperthyroid

DOE, dyspnea, from increased o2 consumption, resp muscle weakness, tracheal obstructions from goiters, exacc asthma from hyperthyroidism

64

GI s/s hyperthyroidism

weight loss from hypermetabolism, increased gut motility, hyperdefecation, malabsorption, celiac more prevalent with graves. can have increased appetite. can be anorexic if older. may have dysphagia due to a goiter,

65

thymic enlargement

in graves this is due to hyperplasia usually discovered for a workup of dyspnea, can be due to autoimmune (thyroid stimulating immunoglobulins binding to the TSH receptor in the thymus leading to thymocyte proliferation

66

treat thymic enlargement

antithyroid meds, radioiodine or thyroidectomy -- all will treat graves and decrease the enlargement (thyroidectomy to remove it and antithyroid and RAI to kill it)

67

hematologic issues with hyperthyroid

plasma volume increased, RBC increased leading to normochromic normocytic anemia. Graves may be a/w other autoimmune disorders like ITP.

68

GU hyperthyroid

urinary frequency and nocturia, primary polydipsia, hypercalciurea

69

bone s/s hyperthyroid

stimulates bone resorption causing increased porosity of cortical bone and reduced trabecular bone -- increased bone turnover.

70

psych s/s hyperthyroid

thyrotoxicosis will have agitation, psychosis, depression, anxiety, restlessness, irritable, insomnia

71

geriatric hyperthyroid

apathetic not hyperactive with tremors but have a higher prevalence of weight loss, SOB and afib

72

hyperthyroid with a normal or high RAI uptake indicates

de novo synthesis of hormone (normal creation of hormone from a molecular form) treat with a thionamide such as methimazole which will interfere with this synthesis

73

hyperthyroid with near absent RAI indicates

inflammation and destruction of thyroid tissue with release of preformed hormone into circulation or an extrathyroidal source of thyroid hormone. Thyroid hormone is not being actively synthesized due to the inflammation and thionamide therapy (methimazole) is not helpful

74

hyperthyroid is more common in men or women?

women 5:1, also more common in smokers.

75

graves most common in

young women

76

toxic nodular goiter more common in

older women

77

disorders causing a normal or high RAI

de novo synthesis --> graves, hashitoxicosis, toxic adenoma, toxic multinodular goiter, iodine induced hyperthyroidism, trophoblastic disease and germ cell tumors,TSH mediated hyperthyroidism, epoprostenol

78

Graves disease definition

Most common cause of hyperthyroidism. Autoimmune resulting from TSH antibodies/Thyroid stimulating immunoglobulins stimulating thyroid growth and thyroid hormone synthesis.

79

Risk factor for Graves

high iodine intake, stressful life events

80

Hashitoxicosis

hashimoto plus thyrotoxicosis autoimmune thyroid disease presenting with hyperthyroid and a high radioiodine uptake caused by TSH antibodies similar to Graves leads to hypothyroidism by the lymphocytes and autoimmune destruction of the thyroid tissue similar to Hashimotos Thyroiditis

81

Toxic Adenoma and Toxic Multinodular Goiter

focal or diffuse hyperplasia of the of thyroid follicular cells who produce TSH from somatic mutations of genes. Mutation of the TSH receptor gene is the most common. Common in areas where iodine intake is relatively low.

82

Iodine induced hyperthyroidism

Can occur after an iodine induced CT or iodine rich drugs like Amiodarone

83

Trophoblsatic disease and germ cell tumors

Women with hydatidiform mole or choriocarcinoma (both are tumors in the uterus) and men with testicular germ cell tumors directing stimulating the TSH receptors. Therapy directed at the tumor.

84

TSH Mediated hyperthyroidism

neoplastic or nonneoplastic. Neoplastic are pituitary adenomas. Causes goiter and at times visual field defects and galactorhea. Tx is Octreotide and surgery,

85

Hyperthyroidism with near absent rai uptake

Either inflammation or destruction of thyroid tissue or ingestion. -- Thyroiditis (inflammation), ingestion of thyroid hormone, or Ectopic production of thyroid hormone (excess in circulation)

86

Thyroiditis

Inflammation of thyroid tissue with transient hyperthyroidism due to hormone release from the colloids space followed by hypothyroidism and recovery,

87

Subacute granulomatous thyroiditis

viral or post viral syndrome characterized by fever, malaise, and a very painful goiter

88

Silent thyroiditis or Subacute lymphocytic thyroiditis

autoimmune, painless, can occur postpartum usually

89

Chemical thyroiditis

from amiodarone, meds ending in 'nib' --> destruction, lithium

90

Therapy for thyroiditis

symptom control w betablockers, antiinflammatory drugs like aspirin, NSAIDs, and if severe - prednisone

91

Exogenous and ectopic hyperthyroidism

Hyperthyroidism resulting from excess thyroid hormone originating from outside the thyroid gland from ingestion of hormone, levothyroxine overdose, ovarian neoplasm called struma ovarii, or thyroid cancer mets

92

in osteitis fibrosa cystica, brown tumors of long bones result from what? What is the brown color from?

excess osteoclast activity; brown color is due to hemosiderin deposition.