Acute Endo Flashcards

Question

Adrenal Insufficiency Treatment

Answer 1

-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

Answer 2

-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)

Answer 3

-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

Answer 4

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

Answer 5

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

Answer 6

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

Answer 7

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

Answer 8

Catecholamine producing adrenal tumor

Answer 9

-(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)

Answer 10

-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

Answer 11

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

Answer 12

-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

Answer 13

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

Answer 14

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

Answer 15

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

Answer 16

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

Answer 17

-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)

Answer 18

Syndrome of growth hormone excess after fusion of the epiphyses

Answer 19

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

Answer 20

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

Answer 21

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

Answer 22

-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

Answer 23

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

Answer 24

-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

Answer 25

-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)

Answer 26

-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

Answer 27

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

Answer 28

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

Answer 29

-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

Answer 30

-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

Answer 31

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

Answer 32

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

Answer 33

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

Answer 34

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

Answer 35

-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

Answer 36

-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

Answer 37

-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

Answer 38

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

Answer 39

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

Answer 40

-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

Answer 41

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

Answer 42

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

Answer 43

-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

Answer 44

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

Answer 45

-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

Answer 46

-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