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Acute Care Seminar 1 > Acute Endo > Flashcards

Acute Endo Flashcards

1
Q

Endocrine Organs

A

-Hypothalamus
-Pineal
-Pituitary Gland
-Thymus gland
-Thyroid gland
-Parathyroid gland
-Adrenal gland
-Ovaries
-Testes

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2
Q

Pituitary Gland (hormones of the anterior lobes)

A

-Adrenocorticotropic hormone (ACTH)
-Follicle stimulating hormone (FSH) & Luteinizing hormone (LH)
-Growth hormone (GH)
-Prolactin (PRL)
-Thyroid stimulating hormone (TSH)
-Oxytocin
-Antidiuretic Hormone (ADH)/Vasopressin

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3
Q

Adrenocorticotropic hormone (ACTH)

A

Regulates cortisol production from the adrenal gland

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4
Q

Follicle stimulating hormone (FSH) & Luteinizing hormone (LH)

A

-Regulates estrogen/progesterone production from the ovaries, ovulation during LH surge
-Regulates testosterone production, spermatogenesis from the testes

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5
Q

Growth hormone (GH)

A

Stimulates linear growth in children
Affects many other tissues – bone, muscle, fat, etc.

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6
Q

Prolactin (PRL)

A

Responsible for milk production during lactation

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7
Q

Thyroid stimulating hormone (TSH)

A

Regulates secretion of thyroid hormones (T4, T3) from the thyroid gland

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8
Q

Antidiuretic hormone (ADH)/vasopressin

A

Regulates retention of water in the body at the level of the kidney

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9
Q

Oxytocin

A

-Causes contractions during the 2nd and 3rd stages of labor
-Acts on the mammary glands during lactation

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10
Q

Pituitary Feedback Loops

A

-both ACTH and cortisol levels should be normal.
-Primary: dysfunction of the endocrine gland itself
-Secondary: dysfunction of the pituitary gland

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11
Q

Thyroid Gland

A

-Controls the burning of energy that directs the body’s metabolism
-Thermogenic regulation
-Thyroid hormones
TSH
T4
T3

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12
Q

Parathyroid Gland

A

-Four small glands on the posterior aspect of the thyroid gland
-Secrete parathyroid hormone (PTH), cause serum calcium levels to rise
*Osteoclast stimulation
*Increased renal resorption of calcium
*Increased GI absorption of calcium

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13
Q

Pancreas

A

-Exocrine function-produce enzymes to assist with the digestion of food
-Endocrine function – regulate blood glucose
-Islet of Langerhans
Alpha cells: Glucagon (to increase BG)
Beta cells: Insulin (to decrease BG)
Delta cells: Somatostatin (reduce acid secretion)

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14
Q

Adrenal Glands

A

-Two glands that sit directly above the kidneys
-Adrenal cortex
-Adrenal medulla

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15
Q

Adrenal Cortex: Adrenal Gland

A

-Zona glomerulosa-mineralocorticoids (aldosterone)
-Zona fasciculata -glucocorticoids (cortisol)
-Zona reticularis -androgens

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16
Q

Adrenal Medulla: Adrenal Gland

A

-Catecholamines

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17
Q

Cortisol

A

-Released by the adrenal gland in the adrenal cortex-zona fasciculata
-Glucocorticoid
-Glycogenolysis (breaks down glycogen to glucose and byproduct), resulting in gluconeogenesis
-Anti-stress and anti-inflammatory
-Stress raises levels
-ACTH from the pituitary controls the production of cortisol

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18
Q

Aldosterone

A

-Adrenal Cortex hormone-Zona glomerulosa-mineralocorticoids
-RAAS system
-Increased renal absorption of sodium-water retension

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19
Q

Androgens

A

-Adrenal cortex hormone-Zona reticularis
-Small amounts secreted
-Sex characteristics

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20
Q

Adrenal Insufficiency

A

-Deficient in cortisol
-Primary adrenal insufficiency/Addison’s Disease
-Secondary Adrenal insufficiency

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21
Q

Primary Adrenal Insufficiency: Addison’s Disease

A

-Destruction of the adrenal glands  deficiency of glucocorticoids and mineralocorticoids
-Most common cause in the US: Autoimmune (80%)
-Most common worldwide: TB
-Bilateral adrenal disease (adrenal hemorrhage, cancer, trauma, etc.)
-Hyperpigmentation, Salt cravings

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22
Q

Secondary Adrenal Insufficiency

A

-Pituitary dysfunction  deficiency of glucocorticoids ONLY
-Most often caused by withdrawal of exogenous steroids
-Others: pituitary issues, opioids, etc.
**much more common

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23
Q

S/S of Adrenal Insufficiency

A

Chronic (nonspecific)
-Fatigue, n/v, dizzy, weakness, weight loss, joint pain, diarrhea, amenorrhea, hypoglycemia
Acute
-Usually with unrecognized AI and concomitant illness, Addisonian crisis, dehydration, hotn, acute abdomen, AMS, eosinophilia, hyponatremia, hypokalemia, unexplained fever

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24
Q

Adrenal Insufficiency Testing

A

-ACTH
-Cortisol (Avoid checking cortisol in patients on > 5 mg equivalent of prednisone – should be low)
-Primary AI: Na/K, Renin

Cortosyn stimulation test
-Primary AI-No response to synthetic ACTH.
-Secondary AI: inadequate response, but may be normal

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25
Q

Adrenal Insufficiency Treatment

A

-Glucocorticoid replacement
——-1st line: Hydrocortisone 15-25 mg/day divided 2-3x/day, largest dose in morning (mimics endogenous cortisol), short 1/2 life
——-Prednisone 4-5mg daily as an alternate

Mineralocorticoid replacement
——-Primary adrenal insufficiency only
——-Fludrocortisone 0.05-0.2 mg daily

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26
Q

Adrenal Insufficiency Stress Dosing

A

-Double/triple PO dose of glucocorticoid only x 3 days during illness
-IM steroid to have at home for emergencies (IM dex 4 mg, solu-medrol 40 mg, solu-cortef 100 mg)
*Unsure they have AI by suspicious—stress dose
—Don’t check cortisol after administering hydrocortisone (will be high) or after high dose dex/methylpred (will be low)

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27
Q

Adrenal Disorder: Addisonian Crisis

A

-Don’t delay treatment if suspected
-2-3 liters of NS IVF or D5 NS if hypoglycemic
-High dose steroids (Hydrocortisone 100mg IV bolus or dexamethasone 4 mg IV bolus, then hydrocortisone 50 mg IV q6-8h–taper doses over 1-3 days)
-Frequent vitals and lytes monitoring
-Treat underlying issues
-Mineralocorticoid replacement is not needed

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28
Q

Adrenal Disorder: Cushing Syndrome

A

-Syndrome of excess cortisol
-MOST COMMON cause: glucocorticoid administration (exogenous)
–Endogenous (rare)-ACTH-dependent or indepenent-tumor
* too much ACTH or too much cortisoL

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29
Q

Cushing Syndrome s/s

A

Weight gain (abdomen), extremity wasting, buffalo hump, straie on abdomen, muscle weakness, easy bruising, thinning skin, supraclavicular fullness, acne, hirsutism, osteopenia/osteoperosis, worsening DM, HTN, hypogonadism, emotional liablity

30
Q

Cushing’s Syndrome Workup

A

-Difficult, multiple tests
-24-hour urine for cortisol
-AM/PM cortisol
-ACTH
-Dexamethasone suppression test
-IPSS
-MRI head, CT abdomen… etc.

31
Q

Cushing Syndrome Tx

A

Look for underlying cause & treat it
Treat comorbidities!
HTN
DM
Osteoporosis
Florid Cushing’s – Mifepristone, ketoconazole?

32
Q

Pheochromocytoma

A

Catecholamine producing adrenal tumor

33
Q

Pituitary Disorders: SIADH

A

-(Syndrome of Inappropriate Antidiuretic Hormone) is a common cause of hyponatremia
-results when ADH secretion is not suppressed by plasma sodium concentrations below osmotic threshold (excessive secretion of ADH)
-Classified as a euvolemic, hypo-osmolar hyponatremia (urine osmolality > serum osmolality)

34
Q

SIADH Etiology

A

-Tumor-Lung cancer, GI tract cancers, lymphoma, thymic
-CNS-brain tumors, head trauma, meningitis, encephalitis, abscess, SAH, SDH
-Meds: DDAVP, SSRIs, TCAs, NSAIDs, colchicine, thiazide diuretics, carbamazepine, cyclophosphamide, tramadol, opiates
-Pulmonary-TB, pneumonias, COPD
-MS, GB, HIV

35
Q

SIADH Symptoms

A

-Speed of hyponatremia determines severity
-Severe
Coma, seizures, brain herniation, cerebral edema
-Others: HAs, gait disturbances, anorexia, fatigue, cognitive abnormalities

36
Q

Criteria for Dx of SIADH

A

-Decreased plasma osmolality (< 280)
-Inappropriate urine concentration (urine osmolality > 100)
-Clinical euvolemia
-Elevated urinary sodium excretion (> 40 mmol/L)
-Rule out hypothyroidism, adrenal insufficiency, diuretic use, impaired cardiac or renal function

37
Q

SIADH Tx

A

Chronic
-May not need treatment if sodium > 130
-Treat underlying conditions
-Fluid restriction of < 800-1000 mL/day
-Oral salt/high solute intake
-Possibly use oral urea, demeocycline, vasopressin receptor antagonists
Acute
-IV hypertonic saline 3%, bolus or infusion
-Don’t correct Na too quickly-4-6 mEq/L increase in plasma Na over several hrs

38
Q

Pituitary Disorders: Diabetes Insipidus

A

No secretion of or no response to ADH
-Central/hypothalamic (more common): head trauma/surgery, inherited, tumors, sarcoidosis, metastases, granulomatous disease
-Nephrogenic: kidneys do not respond to ADH

39
Q

S/S of DI

A

Polyuria (> 4-5 L/day)
Polydipsia (2-20 L of fluid/day)
Inability to concentrate urine

40
Q

DI Workup

A

-Hypernatremia with high serum osmolality
-Low urine osmolality
-Water deprivation test (outpatient)
-Desmopressin challenge
-Head MRI

41
Q

DI Tx

A

-Underlying cause if possible
-Desmopressin (nasal spray, tablets, IV) is first line for central DI
-Caution – don’t over treat!
? IV steroids
-Drink to thirst
-Nephrogenic: Diuretic (HCTZ, amiloride), NSAID (indomethacin)

42
Q

Pituitary Disorder: Acromegaly

A

Syndrome of growth hormone excess after fusion of the epiphyses

43
Q

Thyroid Disorders: Hyperthyroidsim

A

-Syndrome of excess thyroid hormone
-Hypersecretion of T4 and T3
-Low TSH (Hypopituitarism patients always have low TSH – check T4)

44
Q

Hyperthyroidism Etiology

A

-Graves’ disease (most common)
-Toxic adenoma
-Plummer’s disease (toxic multinodular goiter)
-Thyroiditis

45
Q

Graves Disease

A

is autoimmune – antibodies causing hypersecretion of thyroid hormone.
-Smoking makes this worse

46
Q

Hyperthyroidism S/S

A

-Hyperactivity
Irritability or nervousness
Palpitations, Fatigue
Weight loss despite normal appetite, Diarrhea or more frequent bowel movements
Polyuria, Heat intolerance
Menstrual dysfunction
Eye symptoms

-Tachy, afib, enlarged thyroid gland, tremors, thinning of hair & skin, hyperreflexia, exophthalmos, pretibial myxedema, mucsle weakness, warm/dray skin

47
Q

Workup for Hyperthyroidism

A

-TSH
-Free T4
-Total T3
-Thyroid autoantibodies (Graves’): TrAB, TSI
-Imaging
Ultrasound  highly vascular, diffuse, enlarged gland

48
Q

Hyperthyroidism Tx

A

-Ablation of thyroid tissue w/RAI
-Surgery
-Anti-thyroid medications
Methimazole: start 10-30 mg/day
PTU: start 150-400 mg/day (3 divided doses/day)
-Can use beta blockers (propranolol) to prevent arrhythmia and thyroid storm

49
Q

Subacute Thyroiditis

A

-Also known as painful thyroiditis or de Quervain’s thyroiditis
-Typically occurs after common cold/viral infections, and usually only ONCE

Treatment
-NSAIDs +/- analgesics
-Glucocorticoids as second line (pred 40-60 mg daily for several weeks and taper based upon response)

50
Q

Drug Induced Thyroiditis: Amioderone

A

-Contains a large amount of iodine
-Long half time (~100 days)
-Often masked as the beta blocking activity of amiodarone minimizes symptoms
-Arrhythmias
-Exacerbated IHD or HF
-Weight loss
-Restlessness
-Fever

AIT
Type 1  methimazole 30-40 mg daily
Type 2  prednisone 40-60 mg daily
D/c on slow taper, outpatient follow-up

51
Q

Thyroid Storm

A

-Emergency!!
-Deadly hypermetabolic state
-Causes: trauma, major stress, infection, thyroid surgery, uncontrolled DM, antithyroid drug OD, pregnancy, abrupt withdrawal of antithyroid medications

52
Q

Thyroid Storm S/S

A

Think of the s/sx of hyperthyroidism x 10
Fever
Flushing
Excessive diaphoresis
Seizure
Arrhythmias/tachycardia
Hyperglycemia
Jaundice
Diarrhea
Vomiting

53
Q

Thyroid Storm Tx

A

-Antithyroid meds: PTU, Methimazole
-Propranolol
-Glucocorticoids
-Thyroid inhibitors: Iodine, SSKI, Lugols solution
-Decrease stimuli
-Antipyretics
-Possible bile acid sequestrants
-DON’T GIVE ASA-interferes with binding T4
-Thionamide blocks new hormone synthesis

54
Q

Hypothyroidism

A

-Elevated TSH, low T4
-Hashimoto’s (autoimmune) most common cause
-Subclinical hypothyroidism
Elevated TSH, normal T4
Often seen in setting of recent illness
Recheck 4-6 weeks
–Levothyroxine tx

55
Q

Hypothyroidism S/S

A

Fatigue
Dry skin
Cold intolerance
Constipation
Weight gain
Hair loss/alopecia
Bradycardia
Carpal tunnel-like symptoms
Hyporeflexia

56
Q

Myxedema Coma

A

-Severe hypothyroidism
-Emergency
-Most common in elderly & women
-Hallmark s/s: decreased LOC and hypothermia

57
Q

Myxedema Coma: s/s

A

Hotn, Bradycardia
Hyponatremia, Hypoglycemia
Hypoventilation
Puffiness of hands and face
Thickened nose, Swollen lips
Enlarged tongue

58
Q

Causes of Myxedema Coma

A

-Long term non-compliance with meds
-MI
-Opioids
-Infection
-Cold temperature exposure
-Check TSH, T4, Cortisol

59
Q

Myxedema Coma Tx

A

-Supportive care
-T4 & T3 combos-IV as slow bolus
-T4 (200-400 mcg IV flw by daily 50-100 mcg IV until POs)
-T3: 5-20 mcg IV flw by 2.5-10 mcg q8h)
-Glucocorticoids until AI has been excluded

60
Q

Sick Euthyroid Syndrome/Acquired Transient Central Hypothyroidism

A

-Don’t check thyroid function in ICU unless there is STRONG suspicion of thyroid dysfunction
-Generally advised against treatment with thyroid hormone if no history of underlying thyroid disorder
-Recommend checking outpatient 1-2 weeks post-hospitalization

61
Q

Parathyroid/Calcium Disorder: Hyperparathyroidism

A

-Common: W>M
-Most common cause of hypercalcemia in ambulatory setting
-Causes:
Primary-85% due to benign parathyroid adenoma (most often one)
Secondary-CKD (most common), vitamin D def
Tertiary-Advanced-prolonged CKD causing parathyroid hyperplasia

62
Q

Other causes of hypercalcemia

A

-PTHrP production by tumors, neoplasms, sarcoidosis, TB, Vit D toxicity, thiazides, vit A, aluminum toxicity, Pagets, hypophosphatemia

63
Q

Hyperparathyroidism S/S

A

Most asymptomatic
-Classical
Bones, stones, groans, moans”
General/neuromuscular
Bones 
Renal  Nephrolithiasis
Neuropsychiatric 
Gastrointestinal 
CVD 

64
Q

Hyperparathyroidism Workup

A

-Elevated Ca fund on routine screening-fasting? Repeat
-High Ca
-Low phos
-24 hr urine Ca + creatnine
-Vit D low
-Albumin-40-45% of Ca is bound to albumin

65
Q

Hyperparathyroidism Tx

A

-Mild asymptomatic-observe
-Parathyroidectomy
-Severe HyperCa-albumin corrected Ca–Ionized Ca
-IV hydration: Isotonic
-Calcitonin
-Add bisphonates
-HD

66
Q

Parathyroid/Calcium Disorder: Hypoparathyroidism

A

-Low PTH causing hypocalcemia and hyperphos
-Uncommon-from parathyroidectomy and/or thyroidectomy
-Other causes: PGA type 1, heavy metal toxicity, DiGeorge syndrome

67
Q

Hypoparathyroidism S/S & Dx

A

-Tetany: Chvostek’s sign, Trousseau sign
-Low PTH, Ca
-High Phos
-albumin
-Check vit D
-Mag may be low
-EKG prolonged QT, T wave abnormalities

68
Q

Hypoparathyroidism Tx

A

-Correct hypoCa-
-Ca gluconate in severe cases
-Treat other abnormal lytes

69
Q

Osteoporosis

A

-Disorder of low bone mass, microarchitecural disruption, and skeletal fragility
-Dexa Scan
-Smoking cessation, limit alcohol, fall prevention, weight bearing exercises
-Vit D and Ca
-Bisphosphantes-1st line
-2nd line: Antiresorptive/RANKL inhibitor, estrogen

70
Q

Dexa Scan

A

-Tscore:
-1.0 to -2.4  osteopenia
-2.5 or less  osteoporosis
Z-score: age-matched comparison
Z score < -2.0. Diagnosis of low bone density for age (< 50)
Use FRAX calculator

Acute Care Seminar 1 (31 decks)

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