Endo 2 Flashcards
Subacute thyroiditis clinical features + RAI result
- precipitated by viral URI commonly
- tender or painful thyroid
- suppressed TSH (inflammation causes leakage of stored thyroid hormone)
- low RAI (due to leakage of stored thyroid hormone)
Graves clinical features + lab features
- pathognomic clinical features but some patients don’t have thyromegaly or extra thyroidal manifestations
- Elevated RAI uptake + elevated thyroglobulin
Pathognomic clinical features of Graves
- thyroid bruit
- eye disease
- dermopathy
Physical exam for toxic adenoma and multi nodular goiter
palpable thyroid nodules
Clinical features of subclinical Cushing syndrome
- cortisol greater than 5 from 1 mg overnight dexamethasone suppression test
- no specific features of Cushing syndrome
Normal plasma aldosterone-plasma renin ratio
Less than 20
Next step after determining patient has adrenal insufficiency
21-hydroxylase antibody (most common cause of primary adrenal insufficiency in the US is autoimmune adrenalitis)
What is secondary adrenal insufficiency?
- adrenal insufficiency due to hypopituitarism
Lab features of secondary adrenal insufficiency
- low serum cortisol + low or inappropriately normal serum ACTH levels
Management of a large, indeterminate adrenal mass
- Adrenalectomy (never biopsy, adrenocortical carcinoma can be missed due to sampling error)
Why patients with primary adrenal failure require both glucocorticoid and mineralocorticoid replacement
Destruction of adrenal cortex causes decreased synthesis of both cortisol and aldosterone
Why you monitor urinary calcium in chronic hypoparathyroidism
Without PTH, urinary calcium excretion is higher than normal for any given serum calcium level
Workup of suspected hypercalcemia from granulomatous disease (Sarcoidosis)
1,25-dihydroxyvitamin D level (macrophages convert 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D)
Lab profile hypercalcemia from granulomatous disease (Sarcoidosis)
- hypercalcemic
- suppressed PTH
Diagnosis of diabetes insipidus
- urine and serum osmolality
- NOT desmopressin challenge or water deprivation test
Treatment of toxic adenoma
Radioactive iodine
Goal A1c in older adults
7.5-8.0
Hypothalamic-pituitary-adrenal gland axis
CRH release from hypothalamus –> acts on pituitary to release ACTH –> ACTH acts on adrenal gland to release cortisol
Thyroid axis
TRH relapse from hypothalamus –> acts on pituitary to please TSH –> TSH acts on thyroid to release T3 and T4
Hypothalamic-pituitary-gonadal axis
GnRH from hypothalamus –> acts on anterior pituitary to release LH, FSH –> LH, FSH act on ovaries and testes to release testosterone and progesterone
RAI uptake in toxic adenoma
increased (it is hyperplasia of follicular cells)
Postpartum thyroiditis clinical features + lab features
Painless + within 1-6 months after delivery
- increased serum thyroglobulin + low RAI take
Mixed cryoglobulinemia disease associations
- chronic HCV, HIV
- SLE
Type 1 cryoglobulinemia disease associatoins
Lymphoproliferative or multiple myeloma
Mixed cryoglobulinemia clinical features
- fatigue, arthralgias
- glomerulonephritis, HTN
- pulmonary: dyspnea, pleurisy
- palpable purpura, LCV
Type 1 cryoglobulinemia clinical features
- often asymptomatic
- hyper viscosity (blurry visino), VTE
- livedo reticularis, purpura
Complement levels in Type 1 cryoglobulinemia
normal
Antiphospholipid antibody syndrome clinical features
- anemia, thrombocytopenia, livedo reticularis, glomerulonephritis
Next step in type 1 cryoglobulinemia
bone marrow biopsy
other lab presentation of primary hyperparathyroidism
- calcium can be normal or high-normal in setting of vitamin d deficiency (vitamin d deficiency and primary hyperparathyroidism often coexist)
- once vitamin D is repleted, patient becomes hypercalcemic + inappropriately elevated PTH level
Calcium, phos, PTH, vitamin d in secondary hyperparathyroidism from renal failure
- calcium = normal to low
- phos = normal to high
- 25 hydroxyvitamin D = normal
1,25 hydroxivitamin D = normal to low - PTH is high
Management of subclinical hypothyroidism
IF TSH greater than 10 –> treat with synthroid
IF TSH less than 10 –> obtain anti-thyroid peroxidase antibody + treat if meeting indication for treatment
Indications for treatment with subclinical hypothyroidism
- goiter
- symptomatic (**convincing symptoms not vague fatigue or constipation)
- pregnant
- ovulatory dysfunction with infertility
- **elevated anti-TPO titer
- hypercholesterolemia
Differential for hyperprolactinemia
1) **CKD (increased release and decreased clearance of prolactin)
2) meds (antipsychotics)
3) untreated primary hypothyroidism
4) pituitary adenomas
5) following a seizure
Meds causing hyperprolactinemia
- antipsychotics (haldol, risperdol)
- antidepressants (amitriptyline, sertraline)
- reglan
- opiates
Clinical features of adrenal insufficiency
- fatigue + hypotension + hypoglycemia + hyponatremia + high or NORMAL potassium
initial evaluation of clinically-suspected adrenal insufficiency
- 8 AM serum cortisol
- plasma ACTH
- ACTH stim test
Typical clinical course of subacute thyroiditis
hyperthyroidism then euthyroidism then hypothyroidism then recovery
Treatment of subacute thyroiditis
beta-blocker + NSAIDS
IF no improvement with NSAIDS, then prednisone
other term for subacute thyroiditis
Subacute granulomatous thyroiditis (de Quervains)
Common cause of hypogonadism
DM2 and obesity
management of hypogonadism in DM2
**IF markedly low serum testosterone (below 200) or low or *inappropriately normal pituitary hormones or mass effect symptoms– pituitary MRI
Latent autoimmune diabetes of adulthood (LADA) presentation
Type 1 DM + manifesting later in life + commonly FH of autoimmune disease
Diagnosis of LADA
Anti-islet cell + glutamic acid decarboxylase antibodies
Hyperglycemia management in ICU + goal
- put patient on insulin drip
- goal 140-180
What are the meglitinides + examples
- short-acting non-sulfonylurea insulin secretagogues
- repaglinide
What are the thiazolidinediones?
- Pioglitazone
- rosiglitazone
- lobeglitazone
Examples of alpha-glucosidase inhibitors + clinical use
- acarbose, miglitol
- used to control post-prandial glucose excursions
What are the DPP-4 inhibitors? clinical utility?
- linagliptin, sitagliptin, saxagliptin
- CKD patients with intermittent hypoglycemia
GLP-1 agonists
- liraglutide
- exenatide
presentation of myxedema coma
- AMS
- hypothermia
- swelling of the extremities, face, and tongue
- *hypoventilation
What is central hypothyroidism
(another term for secondary hypothyroidism)
Hypothyroidism due to pituitary deficiency
Synthroid management in central hypothyroidism
Base on serum free TF (TSH may not rise due to absence of normal pituitary function)
Management of primary hyperaldosteronism from adrenal hyperplasia
medical therapy (spironolactone, eplerenone)
How to titrate synthroid in hypothyroidism + frequency of dose adjustments
1) based on TSH, NOT T4
2) increase dose every 6 weeks until TSH is within normal range
3) monitor TSH every 6 to 12 months
Initial dose of synthroid in hypothyroidism
IF elderly or CHF – low- dose (25-50)
*75 otherwise
Management of subclinical hypothyroidism if no indication for treatment
- periodically monitor thyroid function studies for progression to overt hypothyroidism
common clinical presentation of hypothyroidism
weight gain + edema
Initial step in workup of Cushings
ACTH
Next step after thyroid ultrasound and TSH obtained
IF normal or elevated TSH + greater than 1 cm – FNA (regardless of findings on US, normal TSH or high suggests increased risk for cancer)
IF low TSH – iodine 123 scintigraphy (likely hyperfunctioning)
Next step after iodine 123 scintigraphy of thyroid nodule
- if hyper functioning – treat (hot nodule)
- if cold or indeterminate – biopsy with FNA
Antithyroid drug therapy of choice for Graves
Methimazole
PTU only if pregnant (methimazole is teratogenic and PTU is hepatotoxic so methimazole is generally preferred)
Goal blood sugars within
- Fasting below 95
- 1 hour postprandial less than 140
- A1c isn’t that helpful (tend to be lower in pregnant women)
- hyperglycemia is associated with adverse fetal outcomes. Gestational DM2 requires tight glycemic control to prevent complications so glycemic targets are lower than in non pregnant patients.
First and second line for gestational DM2
Dietary modification
IF blood sugar uncontrolled at follow-up – insulin
LH and FSH in secondary hypogonadism due to hereditary hemochromatosis
- supressed (it is secondary hypogonadism due to iron accumulation in the pituitary gonadotrophs)
Androgen-secreting ovarian tumors vs. congenital adrenal hyperplasia
- androgen-secreting ovarian tumor = postmenopausal women, very high testosterone level (greater than 150) + rapidly progressive
- CAH = younger women + mild elevation in testosterone
Nonclassic 21-hydroxylase deficiency clinical features
- similar to PCOS
Nonclassic 21-hydroxylase deficiency diagnosis
- elevated serum 17-hydroxyprogesterone
Etiology of hypercalcemia + high normal PTH
- primary hyperparathyroidism (high normal or borderline in some patients. Normally even mild hypercalcemia suppresses PTH to very low levels. Therefore, hypercalcemia associated with a non suppressed PTH level suggests inappropriate PTH secretion due to Primary hyperparathyroidism)
mechanism by which sulfonylureas cause hypoglycemia
- accumulate in CKD or with AKI or following bactrim treatment for UTI
Healthcare maintenance for GCA
- osteoporosis screening when starting steroids
- yearly chest x rays (rule out thoracic aortic aneurysms)
indication for with carotid stenosis
- carotidendarterectomy if symptomatic + greater than 70% stenosis
- statin + ASA otherwise + bp control
management of thyroid function after radioactive iodine therapy
- measure T3 and T4 (TSH may remain suppressed for months after treatment even if patient is hypothyroid. Some patients develop hypothyroidism after treatment and need synthroid)
Situation commonly precipitating unmasking of pheochromocytoma
anesthesia induction
Next step after elevated IGF-1 suggesting acromegaly
- confirmatory testing with oral glucose suppression test
lab features of chronic opioid use leading to hypogonadism
- low FSH and LH (leads to decreased GnRH secretion)
hungry bone syndrome labs
- low calcium
- low phos (also reabsorbed with calcium)
- low mag (also reabsorbed with calcium)
- normal (or high) PTH
central hypothyroidism clinical features
- low TSH + low T4
- typically evidence of other hormone deficiencies
workup of central hypothyroidism
- neuroimaging
- pituitary hormone testing (need to rule out associated adrenal insufficiency)
euthyroid sick syndrome lab features
- normal to decreased TSH, T4, and T3
- increased reverse T3
Sheehans syndrome clinical features
- following pregnancy –> failure to lactate, lethargy, weight loss, loss of hair, hypothyroidism
Treatment of milk alkali syndrome
- standard hypercalcemia treatment (normal saline, lasix)
First and second line treatment of hyperhidrosis
First line: topical aluminum chloride solution
Second line: botox injections
preferred prophylaxis of chronic cluster headaches
verapamil
Diabetic amyotrophy clinical features
- acute, asymmetric, focal lower extremity weakness, followed by pain + atrophy + areflexia + autonomic dysfunction + weight loss
- it’s a lumbosacral plexopathy affecting lumbosacral nerve roots and peripheral nerves
Treatment of diabetic amyotrophy
- symptomatic (PT, pain control, BS control)
contraindications to HPV vaccination
- pregnancy (unclear safety profile)
First line treatment of OCD
- SSRIs
- CBT
Inpatient management of DM2 per boards
- basal, bolus insulin, NOT sliding scale
Management of DKA patient with blood glucose less than 200
switch to D5- half normal with ***KCL (only time you should give maintenance fluids without KCL is if K is greater than 5.2)
Management of amiodarone-induced hypothyroidism
- continue Amio + start synthroid (hypothyroidism is easily corrected by synthroid and patients typically need Amio)
Initial management of amiodarone-induced hyperthyroidism
- RAI scan + thyroid US
painless thyroiditis clinical features
- typically 1 year post pregnancy (but can also occur in non postpartum women and men)
- 1-2 months of mild hyperthyroid symptoms, followed by hypothyroid symptoms
Management of painless thyroiditis
symptomatic (beta blockers)
Painless thyroiditis vs Graves disease
- RAI scan (markedly decreased uptake in painless thyroiditis due to release of preformed thyroid hormone)
Next step after thyroid nodule with TSH and US obtained
IF TSH normal or elevated – consider FNA based on US
IF TSH low – thyroid scintigraphy (this will differentiate between cold and hot nodules, which is impt because hot nodules are rarely malignant. Cold nodules are and require FNA based on size, US findings and pt characteristics)
what is a cold and hot nodule
low RAI uptake or high RAI uptake
SE of spironolactone
- anti-androgenic effects due to testosterone receptor blockade (not just gynecomastia but also low libido, and fatigue)
- hyperkalemia
MEN Type 1 disorders
- primary hyperparathyroidism
- pituitary tumors
- pancreatic tumors
MEN Type 2A disorders
- medullary thyroid cancer
- pheochromocytoma
- parathyroid hyperplasia
MEN Type 2B disorders
- medullary thyroid cancer
- pheochromocytoma
- marfanoid habitus
- mucosal and intestinal neuromas
