Brian's Endocrinology Flashcards
What is the first line treatment for a patient who presents with palpitations and nervousness secondary to hyperthyroidism?
-Beta blockers
What is Hashimoto’s disease?
-an autoimmune cause of hypothyroidism
How does levothyroxine work?
-It is a synthetic T4
What is the most common thyroid cancer?
-Papillary, makes up about 80% of all thyroid cancers.
In a patient with hyperthyroidism will TSH most likely be elevated or decreased?
-Decreased
How do fibrates work to affect the lipid profile?
-They inhibit synthesis of VLDL and elevate lipoprotein lipase
What medication might you use prior to thyroidectomy in a patient with hyperthyroidism?
-Methimazole or propylthiouracil (PTU)
What is included in Whipple’s triad of hypoglycemia?
- Hx of previous hypoglycemia
- serum glucose of < 40
- immediate recovery upon administration of glucose
Positive antithyroid peroxidase and antithyroglobulin antibodies should make you think of what diagnosis?
-Hashimoto’s
What is the treatment for Myxedema?
-Levothyroxine and slow warming
What is the most common cause of hypoparathyroid?
-Post thyroidectomy with the complication of parathyroidectomy.
What is Chvostek’s sign?
-Tap on facial nerve and get a twitch with low Ca.
Cortical adrenal insufficiency is also know as what disease?
-Addison’s disease
What is Trousseau’s sign?
-Inflate BP cuff and hold for 3 minutes. Patient with low Ca will get carpel tunnel symptoms.
What is the most common cause of hyperparathyroidism?
-Single parathyroid adenoma in 80% of cases.
In Cushing’s disease is ACTH elevated or decreased?
-Elevated
What is Grave’s disease?
-The most common cause of hyperthyroidism. It is an autoimmune disease.
What specific breathing pattern is associated with diabetic ketoacidosis?
-Kussmaul respirations, a deep and labored breathing pattern
What is the least aggressive thyroid cancer?
-Papillary
Name two tests you might use to rule out Cushing’s syndrome?
-24 hour free cortisol urine test and dexamethasone suppression test
List two ectopic tumors that may produce ACTH and give a patient Cushing’s syndrome?
- Small cell lung cancer
- pancreatic islet cells
- thymomas
What is the treatment for Addison’s disease?
-Hydrocortisone or prednisone
What is the test to begin if you suspect a pheochromocytoma?
-24 hour urine for catecholamines
Exophthalmos should make you think of what diagnosis?
-Hyperthyrodism
What percentage of diabetes in the US is Type II ?
- 80-90 %
HLA-DR gene is a marker for what endocrine disorder?
-DM type 1
What is the main function of parathyroid hormone?
-Increase serum Ca
List four diagnostic criteria for diabetes?
- Random glucose > 200
- fasting glucose >126
- two hour postprandial glucose >200
- HgA1c > 6.5%
Moans, groans, stones, and bones describe symptoms of what endocrine problem?
-Hyperparathyroid
Stocking glove anesthesia should make you think of what diagnosis?
-Diabetic neuropathy and B12 deficiency neuropathy
Fruity breath should make you think of what diagnosis?
-Diabetic ketoacidosis
As it relates to diabetics, what is the dawn phenomenon?
-Reduced insulin response between 5 and 8 am.
What is the most common cause of hypopituitarism?
-Tumor
How does metformin work? (trade name Glucophage)
-Decreases the hepatic glucose production and increases peripheral glucose uptake
How do sulfonylureas work?
-They stimulate the production of insulin.
What class of medications does piogliazone (Actos) fall into?
-Thiazolidinediones also known as glitazones.
What is the suffix associated with sulfonylureas?
-ide is the suffix. Examples: glipizide, tolbutamide, tolazamide.
Typically what is the first medication started in type 2 DM?
-Metformin
How often should a diabetic’s HgbA1c be checked and what lever should it be?
-Every three months (remember the life of an RBC is 90-120 days) and it should be below 6.6%
What are the 5 criteria for metabolic syndrome?
- HDL < 40 men, BP 135/85
- Triglycerides > 150
- Fasting glucose > 100
- Waist > 40 inches in men, > 35 inches women
What class of medications is the first line treatment for lowering LDL?
-Statins
Which lipid medication may cause flushing?
-Niacin
What life threatening side effect do statins have?
-Rhabdomyolysis
Does niacin increase or decrease HDL?
-increase
What medication class does metformin (Glucophage) fall into?
-Biguanide
List the 5 insulins in order of peak efficasy?
- Lispro 1-2 hours
- Regular 2-4 hours
- NPH 5-7 hours
- Lente 4-8 hours
- Ultralente 8-14 hoursj
Is metformin indicated or contraindicated in renal failure?
-Contraindicated
What is the most common cause of DM type 1?
-Autoimmune destruction of the islet cells in the pancreas.
List 4 physical exam findings for Cushing’s syndrome?
- Moon face
- buffalo hump
- purple striae
- central obesity
- supraclavicular fat pads
- easy bruising
Propranolol belongs to what class of medication?
-Beta blockers
During pregnancy which is the preferred treatment of hyperthyroidism – PTU or methimazole?
-PTU
List 4 thyroid cancers?
- Papillary
- Follicular
- Medullary
- Anaplastic
What endocrine complication is relevant to endocrinology?
-Adrenal infarct leading to a Cushing’s syndrome.
How does nicotinic acid work to affect the lipid profile?
-It inhibits secretion of VLDL.
Hyper pigmentation of the skin along creases should make you think of what diagnosis?
-Addison’s disease
Which thyroid cancer is the most aggressive?
-Anaplastic
How do statins work to affect the lipid profile?
-They slow the rate of limiting step of cholesterol synthesis.
Will ACTH be elevated or decreased in Addison’s disease?
-Elevated if the problem is at the adrenal glands
What role does C-peptide play in the diagnosis of diabetes?
-It is a marker of insulin production. Elevated C-peptide points to DM-2. Decreased C-peptide points towards DM 1.
What is the negative feedback loop of hypothalamic-pituitary-adrenal axis?
-in response to stress or low cortisol the hypothalamus secretes corticotropin releasing factor (CRF)
then,
in response to CRF the pituitary releases andrenocorticotropic hormone (ATCH)
then,
in response to ACTH the adrenal glands secrete cortisol
then,
in response to elevated cortisol levels the hypothalamus decreases production of CRF
What is cortisol?
-produced by the adrenal glands in response to stress
What are the main functions of cortisol?
- to suppress the immune response
- to increase available energy by increasing blood sugar levels
- to promote the breakdown of fat and protein
What is Addison’s disease?
- it is the dysfunction of the adrenal glands
- the adrenal glands stop making cortisol
What is the main cause of Addison’s disease?
- autoimmune
- TB in certain countries
- surgery to remove adrenal glands
Which sex gets Addison’s more often?
-women, like all endocrine disorders
What are the usual clinical findings of Addison’s disease?
- sparse axillary and pubic hair
- hyperpigmentation of the skin, especially of creases or pressure areas like the belt line or bra line
- hypotension
What are the blood work findings
of Addison’s?
- Low sodium (Na) and blood sugar (glucose)**
- Elevated–potassium (k)** and calcium and BUN
- ACTH is elevated**
- Plasma Cortisol is low**
What test can you do for Addison’s?
-Cosyntropin stimulation test or ACTH stimulation test
Describe the Cosyntropin test?
- ACTH is injected and the plasma cortisol is then monitored
- plasma cortisol should double in an hour
What two drugs are used to tx Addison’s?
- hydrocortisone is the drug of choice
- prednisone is the next drug to use
What is Adrenal Crisis?
- extremely low cortisol
- is life threatening
Who gets into an Adrenal Crisis?
- it may be a patient’s first presentation of Addison’s
- it may be a patient being tx for Addison’s (poorly managed)
What are the S/Symptoms of Adrenal Crisis?
- Addison’s symptoms (sparse hair of axillary and pubic areas, hyper pigmented skin of bra line and belt line, and hypotension
- plus they have***High fever, very low blood pressure, confusion or coma, and Hypoglycemia
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What are the blood test findings in Adrenal Crisis?
- low sodium (Na)
- elevated potassium (K) calcium and BUN
- ACTH is elevated (in primary adrenal disease)
- Plasma Cortisol is low
- A Cosyntropin (or ACTH) test is done and within an hour cortisol levels should double
What is the Tx for Adrenal Crisis?
- immediate IV glucose
- Immediate IV hydrocortison
-once stabilized the patient becomes a Addison’s patient and is treated with oral hydrocortisone or prednisone
What is excess (hyper function) cortisol production called?
-Cushing’s Syndrome
What are the 4 causes of Cushing’s Syndrome?
-Cushing’ Disease– a pituitary ademoma causing increased ACTH which stimulates the adrenals to produce cortisol
- Adrenal tumor producing increased amounts of cortisol
- Ectopic production of ACTH– small lung cell cancer
- Long term use of corticosteroids in tx of another disease
Central obesity and Buffalo hump and moon faces are found in what disease?
-Cushing’s Syndrome
Is proximal muscle weakness seen in Cushing’s or Addison’s?
-Cushings Syndrome
Is Hypertension seen in Cushing’s syndrome?
-yes
What are the glucose and K+ findings in Cushing’s?
-elevated glucose and hypokalemia
What are the blood cortisol finding in Cushing’s?
-elevated
What are the ACTH findings in Cushing’s Syndrome?
- ACTH elevated with pituitary adenoma or ectopic adenoma
- low ACTH with adrenal tumor
The best test for Cushing’s Syndrome is?
-24 hour urine test for cortisol, should be 10 ug/dl is diagnostic
What is the tx for Cushing’s Disease?
-pituitary adenoma transphenoidal resection, then tx with hydrocortisone (like Addison’s)
What is the tx for small lung cell adenoma causing Cushing syndrome?
- surgical removal of tumors, or chemo, or radiation
- then, hydrocortisone (like Addison’s)
What is the tx for adrenal adenoma?
-surgical removal, then hydrocortisone (like Addison’s)
What contributes to one getting Diabetes Type I?
-Genetic factors esp HLA, and then environmental like a viral infection to the islets of beta cells of the pancreas
What happens to insulin in Diabetes Type I ?
-very little or no insulin is secreted by the pancreas
At what age is Diabetes Type I seen?
-average Dx is at age 14
When is ketoacidosis seen in Diabetes?
-ketoacidosis occurs in Diabetes Type I
What are the S/S of ketoacidosis?
- very ill appearance
- nausea/vomiting
- polyruia and polydipsia due to hyperosmolar state
- abd pain
- change in mental state or stupor
- fruity breath****
What are the S/Sx of Type I diabetes?
- ketoacidosis
- weight loss
- poor wound healing
- eyes: blurred vision, glaucoma, cataracts
- orthostatic hypotension from autonomic neuropathy and low plasma volume
- Acanthrosis nigricans, thick velvot skin
- neuropathy: stocking glove distribution, atonic bladder, erectile dysfunction, delayed gastric emptying
A fasting blood glucose level of what level is DX for diabetes?
- > 126 on more than one occasion is DX
A non fasting blood glucose of what level is Dx for diabetes?
- a blood level > 200 for glucose is Dx of diabetes
Describe the oral glucose tolerance test is Dx diabetes?
- A fasting patient consumes 75 g oral glucose, and glucose level of >200 is DX for diabetes.
What is Hemoglobin A1c ?
-a test that indicates sugar levels over the past 3 months is used to monitor glucose control. 3.8-6.3 % is normal.
What urine findings may be seen in Type I Diabetes?
-glocosuria and ketonuria
What other conditions need to be Tx in the care of diabetic patients?
- Tx HTN aggressively, cardio care
- manage hyperlipidemia, cardio care
- podiatrist for foot care
- regular eye exams
What body type gets Type II diabetes?
-overweight, specifically abdominal fat
What ages get Type II diabetes?
-middle aged or older
What ethnic groups are more likely to get Diabetes Type II?
-african americans, Pima Indians, Hispanics
What is the basic physio of Diabeties Type II ?
-pancreas produces insulin but insulin resistance has developed. Receptors and tissues do not respond to the insulin.
What are the S/Sx of Diabetes Type II?
- often no sx,
- NOT ketoacidosis
- increased yeast infections in women
- poor wound healing
- Eyes: blurred vision, glaucoma, cataracts
- orthostatic hypotension
- Acanthosis nigricans, thick velvet skin
- Neuropathy: erectile dysfunction, atonic bladder
Are the labs/blood test glucose levels different than Type I Diabeties?
-Dx values are the same
What are the lipid panel like in Type II diabetes?
- elevated triglycerides 300-400 mg/ld
- Low HDL < 30 mg/d
What are the meds that Stimulate insulin secretion in Type II Diabetes?
-Sufonylureas
glypburide glipizede glimepiride
What is the first line of Tx glucose lowering drugs used in Type II Diabetes?
-Metformin–reduces hepatic glucose production–first line TX
Which diabetes drugs decrease carbohydrate absorption from the intestine?
- acarbose
- miglitol
Which diabetes drugs increase tissue sensitivity to insulin?
Thiazolidinediones
rosiglitiazone pioglitazone
How are Osteomalacia and Rickets similar?
-both involve abnormal mineralization of bones
How are Osteomalacia and Rickets different?
- Rickets occurs before the closing of the epiphyseal plates
- Osteomalcia occurs after the closing of the epiphyseal plates
What is Giantism and What is Acromegaly?
- Acromegaly is usually caused by a pituitary adenoma which secretes GH. Rarely caused by an ectopic location like pancreatic cancer
- Giantism occurs when the growth plates are open and Acromegaly occurs when growth plates are closed.
What is the clinical presentation for Acromegaly and Giantism?
- excessive growth of hands, feet and jaw and internal organs
- Doughy moist handshake
- Amenorrhea
- HTN Cardiomegaly
- Arthralgias and arthritis
- Giantism is excessive GH occurs in childhood before epiphyses are closed
What are the lab findings in Acromegaly and Giantism?
- IGF-1 levels are 5 times normal
- Glucose tolerance test with a GH level taken at 1 hour
- Elevated Prolactin
- Fasting blood sugar or glucose tolerance test–patients will usually have an insulin restistance or DM II
What imaging is done in Acromegaly and Giantism?
-MRI will show pituitary adenoma in about 90% of patients and is better than CT
- Radiographs
- thickened skull
- Tufting of terminal phalanges
- Increased thickness of heel pad
What is the surgical Tx for Acromegaly and Giantism?
- Transphenoidal resection of the pituitary adenoma
- Cyberknife or gamma knife is surgical and medical approaches are unsuccessful
If surgery is unsuccessful for the pituitary adenoma of Acromegaly and Giantism what are the medical treatments?
- Dopamine agonist (Cabergoline) will help normalize GH
- Somatostatin analog (Octreotide, Lanreotide acetate)
- GH receptor agonist (Pegvisomant)
What is Diabetes Insipidus?
-Antidiuretic hormone (ADH or vasopressin) deficiency or resistance
What are the causes of Diabetes Insipidus?
- Pituitary/Hypothalamus
- Nephrogenic (kidney issue)
What are the Pituitary/Hypothalamus causes of Diabetes Insipidus?
- Autoimmune response to ADH secreting cells
- Damage to the hypothalamus or pituitary stalk
What are the Nephrogenic causes of Diabetes Insipidus?
- defect in kidney tubules
- Certain drugs may do this
- lithium
- corticosteroids
How do Diabetes Insipidus patients present?
-first of all this is very rare
- Polydipsia of 2 to 20 leters per day*****
- Polyurea****
- Familial autosomal dominant DI symptoms begin at age 2
What are the labs for Diabetes Insipidus?
-24 hour urine for volume and creatinine (ins and outs)
-Sodium, and potassium
-Serum osmolality
-urine osmolality
-Vasopressin
-Vasopressin challenge
urine volume for 12 hours
Desmopressin acetate is then given
Urine volume over the next 12 hours
-MRI may show or not show damage to pituitary or hypothalamus
-No true diagnostic test available. Dx made by clinical judgement
How are the Pituitary/Hypothalamus causes tx for Diabetes Insipidus? (decreased production)
- Desmopressin Acetate
- HCTZ
If caused by nephrogenic reasons how is Diabetes Insipidus Tx? (vasopressin resistance)
- Indomethacin
- HCTZ
What is Metabolic Syndrome?
- insulin resistance syndrome
- (AKA: Syndrome X)
-these people have insulin resistance*
What are the risk factors for Metabolic Syndrome? Who gets it?
- Lack of exercise
- Apple shaped body–centralized obesity
- Genetic factors
- Aging
What type of problems are Metabolic Syndrome people at risk for?
- DM II
- elevated triglycerides
- Lower HDL
- Elevated LDL
- HTN
- Blood clots
- ATHEROSCLEROSIS
How is Metabolic Syndrome DX? What criteria?
-BP > 130/85
-Fasting Glucose > 100
-Waist circumference
Men > 40 inches
Women >35 inches
-Low HDL
Men < 40
Women < 50
-Triglycerides > 150
three or more of the above is Dx for Metabolic Syndrome*
What is the Tx for Metabolic Syndrome?
-Education–lifestyle changes
-Diet
-Exercise, 30 min 5 days a week
-Decrease Cardiac risks
stop smoking
low dose aspirin daily
tight HTN control
What is hypoglycemia?
- blood sugar < 70 mg/dl
- low blood sugar
Describe early vs late postprandial hypoglycemia?
- early 2-3 hrs after eating
- late 3-5 hrs after eating
What are the causes of hypoglycemia?
-Exogenous insulin overdose
-Insulinoma
-Addison’s Disease ( decreased cortisol decreases glucose levels in the blood)
-renal failure
-liver problem (secondary to alcohol) Glycogen storage
-Alcohol related
Liver problems
Alcohol inhibits gulconeogenies
N/V – gastritis
What are the clinical findings of hypoglycemia?
- symptoms often occur after missing a meal
- sweating
- palpitations
- anxiety
- blurred vision
- weakness
- light headed
- slurred speech
- loss of consciousness
What are the lab values in Hypoglycemia?
- glucose level below 70 mg/dl
- symptoms begin around 60 mg/dl
- mental problems and loss of consciousness at about 50 mg/dl
What is Whipple’s Triad of hypoglycemia?
- hx of hypoglycemia
- low serum glucose at time of event
- immediate recovery on administration of glucose
What is the tx for exognenous insulin overdose hypoglycemia?
-eat a cookie
What is the tx for insulinoma in hypoglycemia?
-surgically resect if possible
How do you tx postprandial hypoglycemia?
-small frequent meals every 2-3 hours
How do you tx hypoglycemia caused by Addison’s ?
-oral steroid, hydrocortisone or prednisone
