Endo Flashcards
GH deficiency in adults
Central obesity, increased LDL and cholesterol, reduced lean muscle mass
Insulin’s affect on GH
When insulin decreases the glucose level, GH should rise, failure to do so indicates pituitary insufficiency
Hormones to replace in panhypopituitarism
First: Cortisone, then thyroxine, testosterone, estrogen, recombinant human growth hormone
2 hormones of the posterior pituitary
Oxytocin and ADH
What are low in panhypopituitarism
TSH, thyroxine, ACTH, Cortizone, LH/FSH, testosterone, estrogen?
GH – pulsatile however, prolactin
Cosyntropin stim test in panhypopituitarism
Should be normal – Cortizone will rise as the adrenal gland is normal – in response to cosyntropin, however if chronic will be decreased as the adrenal gland has atrophied
Causes of nephrogenic DI
Chronic pyelonephritis, amyloidosis, myeloma, SCD
Also, hypercalcemia and hypokalemia may inhibit ADH affect on kidney
Lithium
Treatments for nephrogenic DI
Hydrochlorthiazide, amiloride, indomethacin
Unusual presentations of acromegaly
Carpal tunnel syndrome, body odor, deep voice, big tongue, colon polyps, skin tags, arthralgias, hypertension, cardiomegaly, CHF, erectile dysfunction – increase prolactin
GH abuse may result in similar presentation
Diagnosis and treatment for acromegaly
Initial: I GF – 1
Best: glucose suppression test – glucose will not suppress GH
Will see glucose intolerance and hyperlipidemia
MRI after acromegaly is identified
Treatment: transphenoidal resection of the pituitary
Cabergoline – dopamine will inhibit GH release
Octreotide, pegvisomant- GH antagonist
Radio therapy if unresponsive
GH and insulin
GH is anti-insulin, but it makes insulin like growth factor; and has insulin like effects on proteins and amino acids
What may raise prolactin levels
GH release, hypothyroidism, pregnancy, exercise, renal insufficiency, chest wall stimulation, antipsychotics, methyldopa, metoclopramide, opioids, try cyclic antidepressants, verapamil– The only CCB
Dopamine and Hibbetts prolactin a lease so, meds that inhibit dopamine raise prolactin
Test to get first if high prolactin, and when can you get an MRI
Thyroid function test, pregnancy test, BUN/creatinine, LFTs– Both kidney and liver failure increase prolactin
Can get an MRI after high prolactin is confirmed, secondary causes like meds are excluded, patient is not pregnant
Treatment for hyperprolactinemia
Dopamine agonist: cabergoline is better than bromocriptine
If no response, transphenoidal surgery, radiation is rarely needed
Hypothyroidism is characterized by almost all body processes being slow down except?
Menstrual flow, which is increased
How to treat hypothyroidism based on TSH
If TSH is more than double the upper limit of normal with normal T4, replace hormone
If less than double, get anti– TPO/anti-thyroglobulin antibodies, if positive replace thyroid hormone
What is the cause of the hyperthyroidism? Eye and skin findings? Tender thyroid? Nontender, normal exam? Involuted gland is not palpable? High TSH?
Eye and skin findings: Graves– Only one to have TSH receptor antibodies
Tender thyroid: subacute thyroiditis
Nontender, normal exam: painless – silent – thyroiditis
Involuted gland is not palpable: exogenous is thyroid hormone use
High TSH: pituitary adenoma
Hyperthyroidism treatments
Methimazole > PTU: Block hormone production, PTU inhibits conversion to active form
Iodinated contrast material: block peripheral conversion to active form, also block release of existing hormone
Treatment for eye problems in graves
Steroids, radiation if not responding, severe cases may need decompressive surgery
First step if small mass found on thyroid gland without symptoms or tenderness
Get T4/TSH levels, if + patient has a hyperfunctioning gland, does not need immediate biopsy as malignancy is not hyperfunctioning
If normal T4/TSH and greater than 1 cm: FNA, no need for US or RAIU– These cannot exclude cancer
Presentation of hypercalcemia
Acute: confusion, stupor, lethargy, constipation
Short QT interval, hypertension, osteoporosis, nephrolithiasis, DI, renal insufficiency
When hypercalcemia does not resolve after fluids and bisphosphonates
Calcitonin, works rapidly whereas bisphosphonate take several days to work
Cinacalcet: may work in hyper PTH but not useful for malignancy, as PTH is already maximally suppressed
Prednisones: controls hypercalcemia from sarcoidosis or other granulomatous disease
Treatment for hyperparathyroidism
Surgical removal, if not possible give cinacalcet
Magnesium and calcium
Will magnesium needs to bow calcium because Magnesium is necessary for PTH to be released from the gland, low levels also lead to increased urinary loss of calcium
Albumin and calcium
For every point decrease in albumin, the calcium level decreases by 0.8
However free calcium is normal
EKG in hypocalcemia
Another unique finding?
Prolonged QT
slit lamp exam shows early cataracts
Best initial tests for hypercortisolism
Best: 24 hour urine cortisol
Next: 1 mg overnight dexamethasone suppression test, should normally suppress morning Cortizone levels, if suppressed hypercortisolism can be excluded, Does have false positives: Depression, alcoholism, obesity
Another: midnight salivary cortisol
Determining the cause of hypercortisolism
Best initial: ACTH
if low source is adrenal
If elevated, pituitary – suppresses with high dose dexamethasone
Or ectopic – lung cancer, carcinoid – not suppressed: get MRI, then sample the inferior petrosal sinus after stimulating patient with CRH, as some pituitary lesions are too small to be seen on MRI
If no pituitary lesion scan the chest for an ectopic source
Affects of cortisol
Hyperglycemia, hyperlipidemia, hypokalemia, metabolic alkalosis– Excretes potassium and hydrogen ions at distal tubule
leukocytosis from demargination of wbc’s
Presentation of chronic adrenal failure and acute adrenal crisis
Both: weakness, fatigue, AMS, N/V, anorexia, hypotension, hyponatremia, hyperkalemia, metabolic acidosis, hypoglycemia, high BUN, eosinophilia
Chronic: hyperpigmentation
Acute crisis: profound hypotension, fever, confusion, coma
Adrenal failure diagnosis and treatment
Cosyntropin stimulation test fails to increased cortisol – cosyntropin is synthetic ACTH
Treatment: replace steroids with Hydro Cortizone, fludrocortisonehas mineral corticoid affects
Treatment of hyperaldosteronism
If unilateral: resect by laparoscopy
If bilateral: spironolactone
Diabetes diagnosis
-2 fasting blood glucose levels over 125 mg/dL
-Dash single glucose level above 200 mg/dl with symptoms of diabetes
-Increased glucose level and oral glucose tolerance test
Hemoglobin A-1 C greater than 6.5%
Metformin
Works by blocking gluconeogenesis
Contra indicated in those with renal dysfunction because it can cause metabolic acidosis
Most accurate measure of DKA severity
Serum bicarbonate level, as it is a measure of the anion gap, if bicarb is low the anion gap is increased
How to prevent nephropathy in diabetics
Screen for microalbuminuria annually:between 30–300 mg per 24 hours is positive, Start on ace or ARB which decrease intraglomerular hypertension decreasing damage to the kidneys
Dipstick for urine becomes trace positive at 300 mg per 24 hours– Not as sensitive
Diabetic gastroparesis
Diabetes decreases the ability of the got to stretch, leads to decreased mobility
Treat with metoclopramide and erythromycin
