1. Saline hydration w Loops (furesomide) if crackles are heard 2. Bisphosphonates - inhibit bone digestion by encouraging osteoclasts to undergo apoptosis 3. Calcitonin to inhibit osteoclasts if above not working

MTB 2 Flashcards by Nadia Mahmud

WU for thyroid nodule

TFT’s = TSH and T4

2. If normal - Bx gland with FNA

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What is a hot nodule

Non-cancerous
Produces excess thyroid hormone
Shows up on scan - takes up isotope

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What is a cold nodule

Cancerous
Nonfunctioning
Defects/holes in scan
Solid

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Follicular thyroid cancer

Spread

Hematogenous spread to Lung, Brain, Bone
Invasion of tumor capsule and BVs
Encapsulated

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Papillary Thyroid cancer

Unencapsulated
Local LN involved
Psamomma bodies = ground glass cytoplasm, pale nuclei with inclusion bodies

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MC thyroid cancer

Papillary Thyroid cancer

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MCC of hypercalcemia

Other causes

Primary Hyperparathyroidism

Others: Vit D toxicity, Sarcoidosis, Thiazides, Lithium, Hyperthyroidism, Mets to bone, MM

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Presentation of of hypercalcemia

Confusion
Stupor, Lethargy
Constipation, N/V, Pancreatitis
Short QT syndrome, HTN
Osteoporosis
Nephrolithiasis, DI, Renal insufficiency

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Tx for Hypercalcemia

Saline hydration w Loops (furesomide) if crackles are heard
Bisphosphonates - inhibit bone digestion by encouraging osteoclasts to undergo apoptosis
Calcitonin to inhibit osteoclasts if above not working

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Hyperparathyroidism Labs

EKG

High PTH, Calcium
Low/N Phosphorus
High Chloride
High BUN/Cr
High AP
EKG short QT

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What is osteitis fibrosa cystica?

Presentation?

Increased osteoclastic bone resorption

Bone pain, Fx, swelling, bone cysts, brown tumors

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Hyperparathyroidism TX

Surgical removal of glands

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Causes of Hypoparathyroidism

Neck surgery
Hypomagnesiumemia
Renal Failure

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Role of Magnesium and PTH

Mg needed for PTH to be released from gland

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Renal Failure and Calcium

RF causes hypocalcemia

kidney converts 25 OH to 1,25 OH Vit D

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Albumin and Calcium relationship

Low albumin causes decrease in total Calcium

Free Calcium Normal

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EKG for Hypocalcemia

Prolonged QT

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Diff b/t Cushing Dz and Syndrome

Dz = Pituitary overproduction of ACTH
Syndrome = Hypercortisolism

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MCC of hypercortisolism

Pituitary ACTH = Cushing DZ

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Best initial test Hypercortisolism

24-Hour Urine Cortisol
Or
1 mg overnight dexamethasone suppression test

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Most specific test for Hypercortisolism

24 hour urine cortisol

- Elevation confirms Dx

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Best initial test to determine source or location of hypercortisolism

ACTH testing:
High then source is:
- Pituitary
- Ectopic Production - Lung, carcinoid

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If ACTH is elevated, next step?

MRI brain

- Pituitary lesion - this is the source

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If MRI brain does not show a lesion, next step in hypercortisolism

Inferior Petrosal Sinus sample for ACTH

High ACTH = pituitary is source
if not - scan chest

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Where does Inferior Petrosal sinus drain from

From Cavernous sinus | Joins sigmoid sinus to form internal Jugular Vein

Effects of hypercortisolism - Labs

``` Hyperglycemia Hyperlipidemia Hypokalemia Metabolic Alkalosis Luekocytosis ```

Cortisol relationship w insulin and aldosterone

Antiinsulin | Aldosteronelike effects -> Kidney's distal tubule = excretes Potassium and Hydrogen ions

TX for hypercortisolism if pituitary source

Transphenoidal surgery

TX for hypercortisolism if Adrenal source

Laparoscopic surgery

Low ACTH | High-dose dexamethasone: No suppression

Adrenal source

High ACTH High ACTH in petrosal sinus High-dose dexamethasone: Suppresses

Pituitary source

High ACTH Low ACTH in petrosal sinus High-dose dexamethasone: No suppression

Ectopic source

Hypoadrenalism etiology

``` Addison Dz AI destruction of gland Infxn Adrenoleukodystrophy Mets ```

Hypoadrenalism Presentation

``` Weakness Fatigue AMS N/V/Anorexia HypoTN Hyponatremia Hyperkalemia Eosinophilia Hyperpigmentation ```

Dx Tests for Hypoadrenalism

Cosyntropin Stimulation test - synthetic ACTH - measure cortisol before and after - Normal - rise in cortisol after cosyntropin admin

Labs in Hypoadrenalism

``` Hypoglycemia Hyperkalemia Metabolic Acidosis Hyponatremia High BUN ```

Tx for Hypoadrenalism

1. Replace steroids with hydrocortisone | 2. Fludrocortisone - high in mineralocorticoid/aldosterone like effect

MCC of Primary Hyperaldosteronism

Solitary Adenoma

Presentation of Primary Hyperaldosteronism

High BP + Low Potassium

Best initial test in Primary Hyperaldosteronism

Ratio of plasma Alosterone to Renin | PAC: PRA

Most accurate test in Primary Hyperaldosteronism to confirm unilateral adenoma

Sample of venous blood draining adrenal | - High Aldosterone

TX for Primary Hyperaldosteronism

Unilateral adenoma: Laparoscopy | Bilateral hyperplasia: Eplerenone or Spironolactone

Best initial test for Pheochromocytoma

Free metanephrines in plasma

Tx for Pheochromocytoma

``` Alpha blocker - non-selective - non-competitive Beta blocker CCB Surgical removal w pre op tx of alpha blocker ```

Diff b/t DM type I and II

Type I = insulin deficiency | Type II = insulin resistance

Dx of Diabetes

``` 2 fasting glucose > 125 OR 1 glucose > 200 + Sx's OR Increased glucose on tolerance test ```

Metformin AEs and MOA

AEs: Metabolic Acidosis MOA: blocks gluconeogenesis

Which hypoglycemic drug increases obesity

Sulfonylureas - increase insulin release from pancreas, driving glucose

Hypoglycemic drug that is CI in CHF

Thiazoladinediones (glitazones)

Hypoglycemic drug ass'd with increased risk of MI

Rosiglitazone

Hypoglycemic drug helps in weight loss

Incretins - Exenatide, Sitagliptin

Which insulin gives steady state for entire day

Glargine

Which insulin has shortest onset of action

Lispro Aspart Glulisine Onset = 5-15 mins, peak at 1 hr, last 3-4 hours

DKA TX

1. Large volume saline and insulin Insulin - Continuous, rapid IV drip until AG corrected. Then bolus 5-10 units regular insulin 2. Replace K+

What electrolyte indicates elevated Anion Gap

HCO3-

If DKA pt is stabilized on IVF and insulin, but blood glucose is increasing, what is best next step?

Add D5 to IVF

When is HCO3- given in DKA?

Severe acidosis where pH < 7 Or losing in stool Or kidneys | Usually wrong answer

What is goal LDL and TGs be in DM pts

LDL -< 100 mg/dL | TG - <150

What is goal BP be in DM pts

< 130/80 | If greater - start ACEi/ARB

Next step if urine microalbumuria

ACEi or ARB

ASA in DM?

Daily over 30 yoa

What is cause of Diabetic Osteomyelitis

Contiguous spread - poor tissue perfusion b/c of arterial insufficiency -> Immune system can't combat infxn in area around ulcer - soft tissue entry to bone Neuropathy - decreases sensation causing ulcers

ACEi or ARB effect on kidney

Decrease rate of progression of nephropathy by decreasing intraglomerular HTN Increase Renal Blood Flow

Tx for Gastroparesis

Metoclopromide | Erythromycin

Diabetic Retinopathy-Nonproliferative Presentation TX

Cotton wool spots, exudates, less severe and more common | TX: Tight glucose control

Diabetic Retinopathy - Proliferative Presentation TX

Neovascularization Vitreous Hemorrhages Tx: Laser Photocoagulation

TX for Diabetic Neuropathy

Pregabalin Gabapentin TCAs - Amitryptiline Persistent - Narcotics, Tramadol

What are Charcot's Joints | Ass'd with?

Loss of sensation due to recurrent injury Chronic, progressive arthropathy Ass'd with Syphilis, Tabes Dorsalis, Syringomyelia,

Presentation of Charcot's Joints

Decreased proprioception, pain and temp | Deformed joints, arthritis, mild pain, Fx, DJD

MTB 2 Flashcards

(69 cards)