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IPAP > Endo Block 1 > Flashcards

Endo Block 1 Flashcards

1
Q

Facts about polypeptide/protein hormones

Facts about Steroids/Thyronines

A

Large and insoluble
Interact w/ receptors on surfaces
Binding causes cascades of events

Small and lipid soluble that can’t pass through membranes, require ‘chaperone’ to go directly to nucleus and cause change

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2
Q

What is the body’s negative feedback response when hormones levels are high or low?

What is the body’s positive feedback response when hormone levels are high or low?

A

High- dec production
Low- inc production

High- stimulate release
Low- inhibit release

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3
Q

What are the three hyperfunction alterations in endocrine tissue function?

A

Primary- alteration of the hormone secreting gland

Secondary- alteration in pituitary* or hypothalamus

Ectopic- hormone secreted from tissue other than usual source

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4
Q

What are the 3 hypofunction alterations in endocrine tissue function?

A

Primary- alteration of the hormone secreting gland

Secondary- alteration in pituitary/hypothalamus

Resistance- inability of target tissue to recognize the hormones

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5
Q

Define Adenoma

Define Neoplasm

A

Benign enlargement of cluster of glandular cells

Abnormal new grwoth of tissue, usually malignant

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6
Q

Define Hyperplasia

Define Atrophy

A

Benign enlargement of the entire gland

Wasting away of existing cells, hypoplasia form is congenital

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7
Q

What are the hormone levels in hypothyroidism?

A

Primary hypofunction
Starts in thyroid not secreting T3
Hyperplasia of thyroid

High TRH
High TSH
Low T3

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8
Q

A high serum osmolality correlates to a high serum ? level?

What medications/drugs stimulate ADH secreation?

A

Na

SSRI/TCA
Ecstasy/MDMA
NSAIDs
Amiodarone
Neuroleptics
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9
Q

What are the CNS/pulmonary Dzs that can cause SIADH?

A

Trauma STEMS
Trauma Stroke, Tumor, Encephalitis, Meningitis, SAH

No Pos TP
Neoplasm Pos Press Ventilation TB Pneumonia

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10
Q

All PTs with unexplained hyponatremia and oliguria/anuria need to get what test?

What medications can cause SIADH

A

Chest CT/MRI

MOAAN
MDMA- inc ADH release
Opiates
Antineoplastics- powerful
Antidepressants- TCA, SSRI, MAOIs
NSAIDs- inc ADH via prostaglandin inhibition
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11
Q

Since SIADH is a ? problem, not a ? problem, what S/Sxs will they present with?

What will their serum Na be at?

A

Water, not Na
Fatigue, HA, Nausea

125-135 (N=135-145)

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12
Q

How is euvolemic/ASx/Mild SIADH Tx?

How are Sev cases Tx?

A 
Water restriction (500-1L/day)
Democlocycline if PT can't tolerate water restriction
Dietary Na intake

Raise serum Na by 0.5-1mEq/hr w/:
3% hypertonic saline
Furosemide- H2O excretion
Tulvaptan- V2 antagonist

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13
Q

What are the etiologies of central DI?

A

Brain surgery
Damage to infundibulum
Infection
Pituitary infarct- Sheehan Syndrome

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14
Q

What are the etiologies of nephrogenic DI?

A

Meds: Lithium, Demeclocycline, Orilistat, Caffeine
Hypercalcemia
Hypokalemia
Renal Dz

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15
Q

What labs are ordered when working a PT up for suspected DI?

What results will normally be seen?

A 
24hr UA (<2L/day rules out DI Dx)
CMP w/ uric acid and osmolality

Labs will be normal except high Uric Acid and Na

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16
Q

How are PTs tested for central DI?

A

12hr urine measurement
Desmopressin acetate administration
12hr urine measurement
+ test= dec thirst, dec urine output, inc urine osmolality

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17
Q

How are PTs tested for nephrogenic DI?

What are 3 DDx for PTs w/ DI?

A

Measure serum vasopressin during fluid restriction, elevated= + test

Psychogenic water drinker
DM Type 1
Cushing’s Syndrome

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18
Q

How is Central DI Tx?

A

DDAVP w/ E+ monitoring @ lowest possible dose 2-3x/day
Avoid N/V/D or exertion

Acute= Indomethacin
Chronic= Nephrologist for Indomethacin and HCTZ, Desmopressin Acetate/Amiloride combo
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19
Q

What is the overall function of the anterior pituitary?

A

Command center of majority of endocrine organs

Regulates Adrenal, Thyroid, Gonads, and GH and Prolactin release

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20
Q

What hormones are released by the Ant Pit?

A 
FSH/LH
ACTH
TSH
PRL
Endorphines
GH
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21
Q

What hormones are produced in the AntPit?

Most hormone release are controlled by ? with ? big exception

A

GH, ACTCH, TSH, PRL, FSH, LG, MSH

Stimulating hormones
Prolactin- continuous secretion unless inhibited by Prolactin Inhibitory Hormone (dopamine)

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22
Q

What are the S/Sxs of an adenoma that begins to cause space occupying effects?

What are 3 types of vision defects that could be seen?

A

CSF rhinorrhea
HA
Unilateral CN3-6 defects
Bitemporal hemianopsia

Unilateral field loss
Bitemporal/Homonymous hemianopsia

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23
Q

Any PT w/ HA or visual field defects need to have ? issue ruled out?

How are pituitary adenomas Tx?

A

Pituitary/Hypothalamus masses via MRI

Surgery
Except- prolactinomas- Tx w/ medical therapy w/ Dopamine agonists and Somatostatin analogs

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24
Q

Prolactin release is normally stimulated by ?

A 
Pregnancy/Feeding
Piercing/Surgery
Chronic chest wall stimulation
Hypothyroidism- TSH stimulates PRL
Infundibulum lesion
Prolactinoma
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25
Q

How are prolactinomas Tx?

What are the indications for surgery?

A

TOC= Cabergoline, Bromocriptine

Unresponsive to medical therapy
Significant visual loss
Apoplexy- hemorrhage leading to stroke

Radiation if macroadenomais enlarging while on medical Tx meds

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26
Q

What are the two surgical procedures done for prolactinomas?

What are the second most common secreting pituitary adenomas?

A

Transsphenoidal resection
- common postop DI to SIADH
Tranfrontal craniotomy- if extra sellar extesnion is present

GH secreting- 20% also secrete prolactin

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27
Q

GH is stimulated by ?

It is inhibited by ?

A

Any process requiring higher metabolic rate

Hypothyroid
Somatostatin inhib peptide, Hyperglycemia, Glucocorticoids, Inc IGF-1

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28
Q

What are the A-Js of Acromegaly?

A

Athropathy, Boggy hands
Carpal Tunnel, DM
Enlarged tongue, Fields of vision defects, Gynecomastia, HTN, Inc Hat, shoe, ring size, Jaw enlargement

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29
Q

How is acromegaly Dx?

What is the imaging modality of choice for Dx acromegaly?

A

Random IGF-1
Abnormal= fasting IGF-1
Elevated= give 100g of glucose, re-test 60min
GH >1ng/mL=Dx
Normally, glucose suppress GH, should be <0.3ng/mL

MRI or,
CT w/ contrast

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30
Q

What are the subtle Sxs of acromegaly?

How is it Tx?

A

HA, Obstructive apnea, Hand numbness, DMT2

Transsphenoidal resection- TOC
Rx if incomplete/inadequate surgery= Cabernoline/Bromocriptine, Octreotide/Lanretide, Pegcisomant
If meds and surgery fail- stereotactic radiosurgery

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31
Q

What type of f/u schedule is needed for acromegaly PTs?

What physical features regress or are permanent after Tx?

A

IGF-1 annually
Cardiac monitoring

Soft tissue improves
Permanent bone changes

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32
Q

What is the 3rd most common cause of AntPit d/os?

What PT population is it more common in?

A

Corticotropic Adenoma

W>M w/ microadenoma more common

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33
Q

What happens in PTs w/ Corticotropic Adenomas?

Cushing’s Syndrome can be caused by what 4 things?

A

Pituitary tumor releases ACTH, stimulates adrenal glands to release cortisol causing Cushing’s Dz

Pituitary tumor secreting ACTH
Adrenal gland hyper/neoplasia
Ectopic ACTH secretion
CCS use

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34
Q

What are the early signs of Cushings Syndrome?

What are the later sings?

A

HTN, weight gain

Truncal obesity
Moon face
Buffalo hump

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35
Q

What are the effects seen from hypercortisolism?

PTs w/ Cushings have signs of excess ? and ?

A

Proximal muscle weakness
Thin skin/easy bruising
HTN
Glucose intolerance

Cortisol AND Androgens

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36
Q

What are the 3 Dx tests done for Cushings Dz?

A

Dexamethasone @ 11pm
Serum cortisol @ 8AM
Inc cortisol= Dx

24hr urine free cortisol and plasma ACTH- 1, 2 or ectopic

Night salivary cortisol test

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37
Q

How is Cushings Dz Tx?

What causes most gonadotropic adenomas to be detected on imaging?

A

Transsphenoidal surgery
Radiation
Possible adrenalectomy

Large enough to cause visual disturbances

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38
Q

What are the clinical features of gonadotropic adenomas?

Pituitary failure d/os can present in what 3 ways as a result of failure where?

A

HA, Visual disturbance, Hypogonadism

Isolated hormone
Multiple hormones
Panhypopituitary
Hypothalamic or pituitary dysfunction

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39
Q

What is the most common cause of primary putuitary failure/

What are the 9 I’s of pituitary failure d/os?

A

Invasion of adenoma/CNS tumor

Invasion*, Infarct, Injury, Infection, Iatrogenic, Immune, Idiopathic, Isolated, Infiltrative

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40
Q

What causes Sheehan syndrome?

What are the S/Sxs?

A

Post-partum hemorrhage and HOTN causing vasospasm in the pituitary vessels

Failure to lactate
Prolonged amenorrhea
S/Sxs of hypothyroid or glucocorticoid insufficiency
Acute (delayed lactation) or delayed presentation (10-15yrs)

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41
Q

Pituitary has a large reserve and can maintain function until _% is lost?

Define Empty Sella Syndrome

A

75%

Subarachnoid space extends into sella turcica and fills it w/ CSF causing a flattening of the pituitary gland leading to pituitary failure

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42
Q

How will PTs w/ Sheehan’s syndrome that have glucocorticoid insufficiency present?

How does a pituitary infarct/apoplexy present and what does it cause?

A

Shock w/ HOTN, Bradycardia that don’t respond to fluids/meds

Sudden severe HA, AMS, Vomit, Diplopia/Bitemporal hemianopsia, unresponsive HOTN to fluids/meds

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43
Q

Pituitary infarct/apoplexy that causes acute hypopituitarism is Tx how?

Head injury/trauma usually affects ? part of the brain and presents how?

A

Immediate gluccocorticoids followed by surgery

AntPit w/ GH and gonadotropins deficiency

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44
Q

Neuro-Endocrine Dysfunction can present acutely or not for ? long?

What labs are used for screening?

A

3yrs

0800 cortisol
TSH, T4
IGF-1 
LH/FSH
Testosterone/Estradiol
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45
Q

Pituitary failure usually present with gradual loss of normal pituitary function starting w/ ? hormones?

Which one is last/life threatening if decreasing?

A

GH, Gonadotropins, TSH, ACTH

PRL

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46
Q

How will hypopituitary show across the 5 hormones?

A

GH:
Kids= hypoglycemia, short
Adults= inc fat, LDL, BP

Gonadotropin-
Lack of development/regression of sexual characteristics

TSH-
Hypothyroid w/ low TSH, T3, T4

ACTH- Weak, HOTN, CV collapse or Addisons

PRL- ASx
If post partum- ceased lactation

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47
Q

How is hypopituitarism Tx?

A

GH: only if Sxs, hGH injections

Gonadotropin: Estrogen or Testosterone

TSH: Levothyroixine

ACTH: Prednisone, Hydrocortisone

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48
Q

What are the 4 thyroid hormones?

A

TRH
TSH
Thyroxine- T4, major secretory product of thyroid
Triiodothyronine- T3, form from de-iodination of T4 and physiologically active form hormone

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49
Q

What are the physiologic functions of T3?

What are the different lab results seen in hypopituitary hypothyroidism and primary hypothyroidism?

A

Inc O2 consumption, metabolic rate, heat, lipid synthesis, cholesterol excretion, protein synthesis/degradation

Hypopituitary- Low TSH, T3, T4

Primary hypothyroid- High TSH, Low T3, T4

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50
Q

99% of thyroid hormone in circulation is bound to one of what 3 proteins?

A

Thyroxine binding globulin- TBG
Thyroxine binding prealbuminum- TBPA
Albumin

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51
Q

What is the single most useful thyroid function test?

When will serum TSH be low or High?

A

TSH and Serum free T4

Low:
Primary Hyperthyroid
Exogenous hormone
Panhypopituitarism

High:
Primary Hypothyroid
Secondary Hyperthyroid
Resistance to T3

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52
Q

When will serum free T4 be low or high?

When will serum free T3 be high?

A

Low- hypothyroidism
High- Hyperthyroidism/Thyrotoxicosis

High- thyrotoxicosis

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53
Q

What is Anti-Thyroid Peroxidase Abs used to test for?

What are Anti-thyroglobulin Abs used to test for?

A

Hashimotos thyroiditis
Graves Dz

Hashimotos but less sensitive than anti-TPO
Graves Dz

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54
Q

What is anti-thyrotropin receptor Abs used to test for?

What are the 3 thyroid autoimmunity tests?

A

Dx Graves
Absent in other forms of thyrotoxicosis

anti-TPO: Hashimotos/Graves
anti-Tg- Hashimotos/Graves but less than anti-TPO
anti-TSH- Dx Graves, absent in other forms of thyrotoxicosis

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55
Q

When are RAIU using I-123 scans used?

A

Thyrotoxicosis Sxs
Measure amount of radioiodine needed for hyperthyroidism Tx
Nodule/CA evaluation
Ectopic tissue evaluation

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56
Q

What causes high levels of uptake?

What causes low levels of uptake?

A

Graves
Toxic multi-nodular goiter Toxic nodule
Dietary iodine insufficiency

Exogenous hormone
Subacute thyroiditis
Anti-thyroid drugs
Iodide medications
Damage
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57
Q

What are the different RAIU results in subacute thyroiditis and thyrotoxicosis

A

Graves/thyrotoxicosis has high uptake

Subacute thyroiditis has little/no uptake

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58
Q

Define Hot Nodule

Define Cold Nodule

A

Take up iodine, least likely to be malignant, recommended to do no further tests

Little isotope uptake, 30% more likely to be CA

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59
Q

Hyperthyroid toxicosis is seen as excess ? and ?

What is the most common cause of thyrotoxicosis?

A

T3 and T4

Graves Dz

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60
Q

What are the 4 causes of hyperthyroid thyrotoxicosis?

What are the 4 causes of non-hyperthyroid thyrotoxicosis

A

Graves
Apathetic hyperthyroidism
Pituitary tumor secreting TSH
Toxic multinodular goiter

PASH Thyroiditis
Postpartum thyroiditis
Acute suppurative thyroiditis
Subacute thyroiditis
Hashimotos thyroiditis
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61
Q

What are the two Sxs associated w/ Hyperthyroidism?

What are 4 Signs seen and highlighted here?

A

Palpitations
Resting tremor

Rapid DTR relaxation
Tachy
HTN
A-Fib*

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62
Q

Graves Dz is a ? form of thyrotoxicosis and is the most common cause of ?

What PT population does it affect?

A

Autoimmune
Thyrotoxicosis/hyperthyroidism

F>M between 20-40

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63
Q

What are the chemical levels in Graves?

What are the 4 parts of this Dz seen on PE?

A

Low TSH, High T3 and T4
High anti-TSH

Thyrotixic Sxs
Smooth goiter, bruit
Ophthalmopathy
Dermopathy- non-pitting edema and thickening of skin on anterior tibia

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64
Q

Why do PTs eyes have proptosis (bulging) with Graves Dz?

What visual issues can occur?

A

Inflammation of eye muscles due to lymphocyte infiltration

Diplopia
Optic nerve compression leads to blindness

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65
Q

What has more severe Sxs, Thyroiditis or Graves and why?

What will be seen on RAIU in Graves PTs?

A

Graves, T3 is more active

Increase diffuse uptake

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66
Q

What are the 3 Tx methods of Thyrotoxicosis

A 
Sx control: Propanolol
Methimazole
Propylthiouracil
Oragrafin
Telepaque

I-131: ablation of thyroid and TOC for Graves in adults; c/i pregnancy and feeding; contraceptive uses for both genders x 6mon

Surgery- large/obstructive gland
Pregnant uncontrolled PTu
Significant chance of malignancy\

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67
Q

What are the MOAs of Methimazole, Propylthiouracil, Oragrafin, Telepaque?

Which one is safe for pregnancy?

A

M: inhibits T4 production
P: inhibits T4 production and conversion of T4 to T3
O/T: blocks T4 to T3 conversion in peripheral tissues

Propylthiouracil

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68
Q

What are the s/e of anti-thyroid drugs?

When are the iodinated contrast agents Oragrafin and Telepaque used?

A

Rash- exfoliative dermatitis
Agranulocytosis= (Pancytopenia)
Nausea/Dyspepsia

Severe Sxs and usually as bridge therapy pre-surgery

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69
Q

What are the potential complications of removing the thyroid gland in Graves Dz?

A

Damage to recurrent laryngeal nerve= hoarseness
Parathyroid damage
Hypothyroidism
Continued hyperthyroidism

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70
Q

Define Apathetic hyperthyroidism

How does it present?

A

Thyrotoxicosis in older PTs

Depression/New mood d/o, Angina Pectoris, Lethargy/Fatigue, Weight loss

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71
Q

Define Thyroiditis

How does it present?

A

Inflammation and enlargement of the thyroid

Sxs of mild hyperthyroidism w/ depression and chronic fatigue w/ passive release of stored T4

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72
Q

Define Acute Suppurative Thyroiditis

What PT population is it seen in?

A

Bacterial infection of thyroid by Streptococcus

Immunocompromised
Elderly
Pre-existing thyroid Dz

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73
Q

What is the hallmark of Suppurative Thyroiditis?

What labs are drawn for Dx?

A

Painful thyroid gland

CBC, ESR, Culture, FNA

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74
Q

How is Suppurative Thyroidits Tx?

Subacute Thyroiditis is AKA?

A

IV ABX guided by Gram Stain and culture
Surgical drainage

deQuervan’s thyroiditis

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75
Q

What PT population does Subacute Thyroiditis usually affect?

What are the S/Sxs?

A

Young/middle aged females after viral respiratory infection*

Painful gland, transient hyperthyroidism, dysphagia, pharyngitis

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76
Q

What labs are drawn for subacute thyroiditis?

What is the Tx?

A

ESR, CRP, TSH/T4

ASA- DOC
Usually self resolving
Propanolol
Oragraf/Telepaque
Levothyroxine if transient state has Sxs
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77
Q

Chronic Lymphocytic Thyroiditis is AKA ?

Who does it appear in and what finding is Dx?

A

Hashimotos Thyroiditis
Most common form of thyroiditis

Female, anti-TPO Abs is hallmark

78
Q

Hashimoto’s usually co-exists with what other type of Dzs?

How does it present?

A

Autoimmune

Hyper to hypo thyroid
Fatigue, weight gain, dry skin, constipation
Non-tender goiter from lymphocytes infiltrating gland

79
Q

Why is RAIU imaging not useful in chronic Hashimotos?

How is it Dx and Tx?

A

Diffuse uptake from normal to high

Dx w/ anti-TPO

Levothyroxine if clinical hypothyroidism is present

80
Q

What is the major complication that can arise from Hashimoto’s Thyroiditis?

Postpartum thyroiditis is AkA ?

A

Primary hypothyroidism

Silent/painless thyroiditis
Subcategory of chronic lymphocytic thyroiditis

81
Q

How does Postpartum thyroiditis present?

How are they Tx?

A

Possible goiter
Hyperthyroid within 6mon of delivery lasting 1-2mon
Hypothyroid- lasting 4-8mon post delivery

Hyper- Sx treatment
Hypo- Tx as needed

82
Q

Define Reidel’s Thyroiditis

How does Reidel’s present?

A

Fibrous infiltrates in thyroid of middle aged/elderly female PTs

Stony mass within thyroid
Possible dysphagia, dysphonea, pain

83
Q

How is Riedel’s Dx’d?

How is Reide’s Tx?

A

Open biopsy, FNA doesn’t get enough of a sample

Surgery- relieves compression
Tamoxifen- reduces fibroids
CCS- short term for pain/compression Sxs

84
Q

Define Goiter

What are the two causes of it?

A

Diffuse or nodular enlargement of thyroid gland

Inc TSH stimulation
Thyroid stimulating immunoglobulins

85
Q

Goiters can be present in what two cases?

Simple/non-toxic goiters are a response to ? and most commonly due to ?

A

Thyroiditis
Iodine deficiency

Inadequate synthesis of thyroid hormone
Iodine deficiency

86
Q

How are benign multinodular goiters Tx?

Most goiters respond to Tx of ?

A

Elevated TSH= Levothyroxine
Euthyroid goiters= observation

Hypo or Hyper thyroid states

87
Q

What is the most common cause of elderly hyperthyroidism?

Where does it usually present?

A

Toxic multinodular goiter

> 50y/o w/ history of benign multinodular goiters w/ normal function tests

88
Q

What will labs show in Toxic Multinodular goiters?

What will be seen on RAIUs?

A

Inc T3, T4
Low TSH

Diffuse patchy uptake

89
Q

How are Toxic Multinodular Goiters Tx?

A

Hyper Sxs= Propranolol

Propothyouracil and Mehimazole

RAI ablation- definitive,
especially in elderly in leu of surgery

Subtotal thyroidectomy- pressure and cosmetic indications

90
Q

What is a beneficial fact about thyroid nodules?

If there is a single thyroid nodule it is one of what 3 things?

A

95% are benign and not associated w/ lymphadenopathy

Benign adenoma- Common
Cyst
Malignancy

91
Q

Benign thyroid nodules are usually smaller than ?

Where are malignant thyroid nodules more common?

A

<1cm

Young adults/men

92
Q

What are the Hx factors indicating malignant neck nodules?

What 3 Sxs are unique and concerning?

What is one Sx that is not associated w/ benign nodules?

A

Malignancy/Irradiation
Tonsilitis

Dysphagia
Dysphonia
Dyspnea

No lymphadenopathy

93
Q

What are the common Sxs of malignant thyroid nodules?

How are thyroid nodules assessed?

A

Single, Firm, Fixed, Larger than 4.5cm

Function w/ TSH
Low TSH- RAIU and US
Hot RAIU- stop, rarely malignant
Normal/High RAIU- US

94
Q

What US findings are suspicious for malignant thyroid nodules?

A 
Hetergenous echogenecity- non-uniform, hypo and hyper echoic
Irregular margin
Microcalcification
Complex
Vascularity
Diamter >1cm
95
Q

What is the preferred procedure for assessing thyroid nodules and what are the criteria for performing it?

What type of nodules don’t need this procedure?

A

FNAB

Suspicious US
Abnormal cervical nodes
>1.5cm diameter mixed/solid
>2cm with benign features

Pure cystic nodule (spongiform)

96
Q

How are thyroid nodules classified?

A 
Bethesda Classification
2- Benign
3- Atypical
4- Suspicious, follicular 
5- Suspicious for malignancy
6- Malignant
97
Q

What determines the treatment schedule of thyroid nodules?

How are benign nodules managed?

A

Biopsy results

US Q6mon
FNA if increases in size
Levothyroxine if TSH is elevated or hypothyroid
Surgery- benign but suspicious
Total thyroidectomy- malignant
98
Q

When is RAI the procedure of choice when teating thyroid nodules?

What are the 4 types of thyroid cancer?

A

Toxic adenomas
MNG
Graves

Papillary- most freq, low agg
Follicular- can metastasize
Medullary- more aggressive
Anaplastic- most aggressive, least frequent

99
Q

Papillary thyroid cancer

A 
Radiation exposure (Chernobyl) in childhood
Genetic mutations/familial syndromes
100
Q

What two thyroid cancers absorb iodine?

A

Papillary

Follicular

101
Q

Follicular thyroid cancer

A

2nd most common

Typically metastasizes to neck nodes, bone and lung

102
Q

Medullary Thyroid cancer

A

No iodine absorption
Strong familial ties
Arises from parafollicular cells secreting calcitonin
Tx- prophylactic thyroidectomy

103
Q

Anaplastic thyroid cancer

A

Non absorptive

Older PTs w/ goiter Hx

104
Q

What will lab results who in thyroid CA?

A

Normal

Exceptions: concomitant thyroiditis, follicular CA

Thyroglobulin- inc w/ papillary and follicular CA, useful monitoring tool

Calcitonin- inc in medullary CA

Carcinoembryonic Ag- elevated in any type

105
Q

What is the TOC for thyroid cancer?

A

Surgery
Anaplastic- local resection w/ radiation

Medullary- only surgery

Papillary and Follicular- surgery w/ RAI

106
Q

When is post-surgery RAI used in thyroid CA?

What medication is given to post-thyroid CA PTs?

A

Papillary and Follicular

Levothyroxine

107
Q

Define Hypothyroidism

What is the most common cause?

A

Primary- failure of thyroid to secrete T3 and T4
Secondary- failure of pituitary to secrete TSH

Hashimotos

108
Q

Why is hypothyroidism during pregnancy dangerous?

What are the 4 less common Sxs of hypo thyroid?

A

Lower IQ scores

Dec appetite
Dec taste/smell
Hoarseness
Dysphagia

109
Q

What are the key PE findings of hypothyroidism?

What is the single best test for hypothyroid?

A

Diastolic HTN
Delayed DTR relaxation
Bradycardia
Thin hair/brittle nails

TSH

110
Q

What will lab results show in primary and secondary hypothyroidism?

What are the 4 less likely seen results but usually seen in severe cases?

A

Primary- inc TSH
Secondary- low
Low/N T4
Inc cholesterol/prolactin

Hypo Na
Hypo sugar
Anemia
Abnormal sperm morphology

111
Q

What complications can arise from hypothyroidism?

A 
Cardiac mostly
Inc infection risk
Megacolon
Organic psychosis w/ paranoia "myxedema madness"
Infertilit/miscarriage
Coma
112
Q

How is hypothyroidism Tx?

What important PT education piece needs to be given?

A

T4 replacement Levothyroxine
Wait 5wks after adjusting dose to recheck levels

Must take in AM w/ only water

113
Q

What 5 things needs to be avoided when taking Levothyroxine?

A

Fe/Ca
Antacid
PPI
OCPs

114
Q

How much Levothyroxine is used when starting?

How much Levothyroxine is given to adults and kids?

A

50mcg/day, inc every 3-6wks
Target dose= 100-250mcg/day (0.1-0.25mg/day)

1/7mcg/kg/d

115
Q

What is unique when starting young/healthy PTs on this drugs?

How much are older PTs that are sensitive to Levothyroxine started on?

A

Start at target dose

25-50mcg/day

116
Q

What monitoring is done on hypothyroid Pts?

What adjustment is done for pregnant PTs?

A

TSH and Sxs
Keep TSH 0.4mU-2.0mU/L

Inc 20-30% at discovery
Inc at 5th week by 75%

117
Q

When do hypothyroid PTs need to be referred?

When do they need to be admitted?

A

Difficulty titrating levo to normal TSH
CADz needing Levo therapy

Myxedema crisis
Hypercapnia

118
Q

Levothyroxine is known to cause? so watch for ?

Define Cretinism

A

Weight loss
Fluctuating TSHs

Congenital hypothyroidism due to failure of thyroid to migrate to location

119
Q

What are the 4 major signs of Cretinism?

A

Intellectual disability
Puffy hands/face
Thick tongue/poor muscle tone
Deaf/mute

120
Q

Childhood hypothyroidism usually has what etiology?

How is it Tx?

A

Hashimotos

Levothyroxine

121
Q

Define Thyroid Storm

What are 4 precipitating factors that can cause this?

A

Extreme hyperthyroid/thyrotoxicosis
Most often seen s/ Grave’s

Stress
Thyroid surgery
RAI admission
D/c anti-thyroid drugs

122
Q

What are the S/Sxs of a thyroid storm?

A 
Dehydration
High fever
Sweating
Tremor
Restlessness

Delirium
Tachy
A-Fib
Vomit/Diarrhea

123
Q

How are thyroid storms Tx?

A 
Admit to ICU
Anti-thyroid drugs
Potassium Iodine
Propanolol
Hydrocortisone

PTU is preferred over Methimazole due to blocking conversion of T4 to T3 and inhibiting synthesis of T4

Definitive= I-131 ablation or surgery

124
Q

Define Myxedema Crisis

A

Fluid retention from hypothyroidism causing an interstitial accumulation of hydrophilic mucopolysaccharides (lymphocyte infiltration) leading to lymphedema

125
Q

What is mysedema crisis AKA?

What often triggers a Myxedema Crisis?

A

Decompensated hypothyroidism

Infection
Cold exposure
Cardiac/CNS illness
Drug use/stopping

126
Q

Where are myxedema crisis usually seen?

What are the S/Sxs of this crisis?

A

Older female PTs w/ stroke or stopped using meds

Hypo:
Glycemia, HOTN
temp, resp, Na

127
Q

How are Myxedema Crisis Tx?

What must be used with caution?

A

IV Levothyroxine, support and fluids/E+

Opioid sensitivity

128
Q

What are the 3 layers of the adrenal cortex and what regulates each layer?

What are the functions of glucocorticoids?

A

Glomerulosa- RAAS, K, ACTH
Fasciculata- ACTH
Reticularis- ACTH

Break down proteins and fat for energy

129
Q

What can be found in the outer/cortex of the adrenal gland?

A

Glucocorticoids- cortisol
Mineralcorticoids- aldosterone
Androgens- DHEA, Test/Estrgoen

130
Q

What gender usually has an androgen d/o?

Where is CRH produced and what does it do?

A

Females

Hypothalamus
Stims ACTH synthesis and release from AntPit

131
Q

What inhibits CRH and ACTH?

Where is ADH produced and how is it released?

A

Cortisol

Pituitary corticotropes of the AntPit
Diurnal rhythm, highest 04-0600, lowest at night

132
Q

What does ACTH do?

What is the primary aldosterone regulator?

A

Stims for cortisol production, aldosterone secretion and melanocytes to produce melanin

RAAS

133
Q

What is the major glucocorticoid secreted by the adrenal cortex?

When is this secretion increased?

A

Cortisol

Exercise
Trauma
Infection
Stress

134
Q

The release and level of Cortisol is very similar and mimics what other hormone?

What does Cortisol do in the blood?

A

ACTH

Breaks down carbs, fats and proteins for energy use
Suppresses inflammation, immune system, bone formation and dec Ca reabsorption

135
Q

Define Cushing Syndrome

What is the most common cause of spontaneous Cushings Syndrome?

A

Hypercorticolism

ACTH producing pituitary tumor

136
Q

Due to it’s dificulty to Dx, what are the 4 goals of ordering all the labs when working a PT up for Cushing’s Syndrome?

A

No diurnal variation

Reduced cortisol suppression by dexamethasone

Inc cortisol production rate

Supression of plasma ACTH by hypercortisolism from adrenal medulla

137
Q

What are the 3 initial tests ordered for Hypercorticolism?

What is the final/follow on test ordered?

A

Dexamethasone suppression test- 11pm administration, 0800 test, Inc AM cortisol= suggestive of Cushings

24hr urine for free cortisol and creatinine- confirms the hypercorticolism

Late night salivary cortisol- inc is suggestive

4th- who to blame
Serum ACTH to differentiate dependent of independent

138
Q

Define ACTH Dependent causes of hypercorticolism

What are two causes that could be there?

A

Something is secreting ACTH

Pituitary adenoma
Ectopic- will have 10x ACTH levels

139
Q

Define ACTH Independent Hypercorticolism

What are two causes of this?

A

No ACTH is secreted

Exogenous use
Adrenal adenoma/CA

140
Q

What is the down side to PTs w/ Cushing’s Syndrome that are successfully Tx w/ surgery?

What drugs can be used to make the body stop producing cortisol?

A

Cortisol withdrawal syndrome

Mitatone, Ketoconazole, Metyrapone

141
Q

When are Cushing’s Syndrome PTs referred?

Historically, what used to be the predominant cause of primary adrenal insufficiency?

A

Abnormal dexamethasone suppression test

TB
Bilateral adrenal hemorrhage
Congenital adreanl hypoplasia

142
Q

Why do PTs w/ primary adrenal insufficiency have such a seriour disease when they’re Dx’d?

Often associated with autoimmune endocrine d/os, what can also cause this condition?

A

90% damage before Sxs show

DM Type 1
Hashimoto’s
Vitiligo

143
Q

What are two unique S/Sxs that are seen in Addison’s Dz?

What will lab results show?

A

Anorexia and weight loss

Hypo Na
Hyper k
Hypoglycemia
0800 cortiosl- low
ACTH high meaning primary organ dysfunction
144
Q

How are Addison’s Dx confirmed after 0800 plasma cortisol is low and ACTH is high?

How is this test done and what results will be seen?

A

Cosyntropin stimulation test

Done at any time of day 
ACTH injected
Cortisol levels measured 30-60min later
Primary adrenal insufficiency= low cortisol
Normal= 20mcg or higher
145
Q

Define Secondary Adrenal Insufficiency

What is the most common cause of this?

A

Low secretion of ACTH by pituitary galnd

ACTH suppression from persistent suppression of the pituitary after d/c exogenous glucocorticoid meds

146
Q

What are the S/Sxs of Secondary Adrenal insufficiency?

A

Same as Primary, but Pallor is present “alabaster” skin due to low ACTH levels not stimulating melanocytes

147
Q

What images are done for Primary adrenal insufficiency?

What images are done for Secondary adrenal insufficiency?

A

Abdominal CT- noncalcified adrenal
CXR- for non-autoimmune origins

Eval medications
Pituitary MRI

148
Q

How is Primary Adrenal Insufficiency Tx?

What are the sick day rules for these PTs?

A

Glucocorticoid and Aldosterone replacement

Double glucocorticoid dose for short time
Emergency kit= 100mg IM hydrocortison needle
Braelet

149
Q

How is Secondary Adrenal Insufficiency Tx?

A

Glucocorticoids
No mineralcorticoid replacement needed
Emergency kit
Bracelet

150
Q

What is a common Sxs seen in acute adrenal crisis?

How are these crisis’ Tx?

A

HOTN
Hypoglycemia

Draw cortisol levels but administer Tx without waiting for results
Hydrocrotisone immediately then Q6hrs
Possible broad spectrum ABX

151
Q

How are adrenal crisis’ Dx?

What causes aldosterone to be secreted and what relationship is seen?

A

Give ACTH
Pos test= low cortisol

Angiotensins 2 and Kyperkalemia
Inc aldosterone, Low K

152
Q

Define Primary Hyperaldosteronism

What are the types/causes of primary?

A

Excess produciton from adrenal gland

Conn syndrome
Adrenal hyperplasia
Adrenocortical CA producing aldosterone

153
Q

What causes Secondary Hyperaldosteronims?

How does hyperaldosteronism usually present?

A

Renal artery stenosis
Excess renin
Hypovolemia
CHF

HTN, expecially diastolic

154
Q

How is hyperaldosteronism Dx?

How are these labs differentiated to differ between Primary and Secondary causes?

A

Hypokalemia w/out diuretic

Primary- suppressed renin activity, adrenal cortex producing too much
Secondary- inc/normal PRA. Inc renin from renal artery stenosis causing excess aldosterone

155
Q

How is a hyperaldosteronsim Dx confirmed?

A

24hr urine, Primary will have elevated aldosterone

Abdomen CT/MRI to r/o adrenal carcinoma/bilateral hyperplasia

156
Q

How is hyperaldosteronism Tx?

A

Adenoma= unilateral ectomy
Bilateral hyperplasia= spirinolactone/Eplerenone (better for pregnancy and men)
Stenosis= angioplasty/revascularization

157
Q

How do women with adrenal androgens present?

What enzyme is required for cortisol synthesis?

A

Acne, Hair, Virilization

21 Hydroxylase

158
Q

What are the three most results of defected 21 hydroxylase deficiency?

A

Inc ACTH
Hyperplasia
Inc 17-Hydroxypreogesterone, the precursor to cortisol and converted to androgens

159
Q

What are the 2 types of Congenital Adrenal Hyperplasia

A

Classic- salt wasting
Presents in utero/birth as defifiency of cortisol and aldosterone

Non-Classic-
milder enzyme deficiency
Presents after adrenarche
Most frequent autosomal recessive d/o in humans

160
Q

What 3 populations is Secondary Congenital Adrenal Hyperplasia seen in?

How does classic congenital adrenal hyperplasia present?

A

Yupik Alaskan
Ashkenazi Jew
Native La Reunion Islanders

Death of infant
Masculine female genitals**
Precocious development in males
Short stature from early bone closure

161
Q

How does non-classic congenital hyperplasia present?

A

Signs of androgen excess
Premature puberty/accelerated growth
Female hair/acne, oligomenorrhea and infertility

162
Q

How is congenital adrenal hyperplasia Dx?

Why are these results seen?

A

Measure 17-hydroxyprogesterone, the precursor to 11 Deoxycortisol

Deficiency of 21-hydroxylase leads to ecess 17-hydroxyprogesterone

163
Q

How is classic congenital adrenal hyperplasia Tx?

How is non-classic Tx?

A

Replace steroids w/ prednisone, cortisol, dexamethasone
Mineral replacement w/ spirinolactone

Glucocorticoids before pubarche onset
OOCPs for androgen excess
Anti-androfgen like Spirinolactone for women

164
Q

Catecholamines decrease what 3 functions?

What causes their release?

A

Visceral blood flow
Urine output
GI motility

Dec BP, Volume, Glucose
Stress, Illness

165
Q

Pheochromocytoma secretes ?

Paragangliomas secrete ?

A

Epi and NorEpi

NorEpi only

166
Q

What is the Sx triad of a pheochromocytoma?

How is it different from panic attacks?

A

HA, Sweating, Palpitations

Paroxysmal and more severe

167
Q

What triggers can start a Pheo attack?

What are the major S/Sxs during the attack?

A

Exertion, stress, Caffeine/Nicotine, Surgery

HTN from excessive NorEpi 
Pallor/molted cyanosis
Tachy
Syncope
Psychosis/Seizure
168
Q

What lab result obtained during a Pheo crisis is indicative of no Pheo issue?

If this test is Pos, what is the next test?

A

Normal metanephrine test

24hr urine for Catecholamine, metanephrines (gold standard)

169
Q

What is the imaging modality of choice to Dx Pheo?

What if this comes back negative?

A

CT w/ contrast

CT whole abdomen, pelvis and chest

170
Q

Why would a RAI scan be ordered for supected Pheo?

A

MIBG for non-adrenal paraganglioma

Can also be done if abdominal CT is suspicious for secretory paraganglioma

171
Q

How is Pheo prepared for Tx?

A

Alpha blockade w/ Phenoxybenzamine or Nifdipine

BP control for 4-7 days minimum

BBs- worsen HTN from unopposed Alpha constriction
Only used in persistent Tachy/arrhythmias and only after alpha blocker and pT is tachy

172
Q

What is the Tx of choice for Pheo?

What can be used for HTN management during Tx?

A

Surgery

IV Nicardipine or IV Nitroprusside

173
Q

What is required for post-op Pheo Tx monitoring?

What is the Tx if the pheo is inoperable?

A

BP and catecholamines

Metyrosine- reduces synthesis but w/ CNS s/e

174
Q

Pheo is more likely to be malignant if its bigger than ?

MEN1 is AKA?

A

> 7cm

Wermer Syndrome

175
Q

Wermer syndrome is most commonly ? syndrome

95% of PTs present with ?

A

Multiglandular

Hyperparathyroidism

176
Q

What is often the first clinical sign seen in MEN1?
What is the second most common finding?

When do Sxs usually appear?

A

Hypercalcemia

Facial angiogibromas

3-4th decade of life

177
Q

MEN2a is AKA?

What is the most common and second most common finding?

A

Sipple Syndrome

Medullary thyroid Ca
Bilateral pheos

178
Q

How is MEN2a Tx?

What has to be done prior to Tx?

A

Prophylactic thyroidectomy before 6yrs old

Only after screening for Pheo first

179
Q

What is major and second major Sx of MEN 3?

How is this form Tx?

A

Mucosal/GI neuromas
Medullary thryoid CA

Prophylactic thyroidectomy before 6mon

180
Q

What MEN Syndrome has a Marfan like habitus?

Any adrenal adenoma bigger than ? is removed?

A

MEN 3

4cm

181
Q

What three metabolites may be seen in higher amounts/for longer in Pheo Pts?

MEN syndromes are sometimes AKA ?

A

Metanephrine or Normetenephrine reducing to VMA

Polyglandular Syndromes

182
Q

How many are there?

How are they passed along through generations?

A

MEN 1, 2/2a, 3/2b, 4

Autosomal Dominant

183
Q

What is less severe for medullary thyroid cancer, MEN2a or MEN3?

What is a different finding in MEN2a than other MENs?

A

MEN2 is less severe than 3

Hischprungs

184
Q

What is included in MEN4?

A

Parathyroid, Pancreatic, Pituitary tumors

Adrenal Cortex, Thyroid adenomas

185
Q

What tumor would most likely be found in PT with MEN1?

Which form of MEN would mucosal/GI tumors be more likely to be found?

A

Parathyroid

MEN3

186
Q

What do MEN2 and MEN3 have in common?

Which one is more likely to have each finding

A

Medullary thyroid CA
Pheo

MEN2- thyroid CA
MEN3- pheo

187
Q

Which form of MEN would facial angiofibrinomas and colagenomas be more likely?

How often are adrenal incidentalomas found?

A

MEN1

4% of PTs

188
Q

Most adrenal incidentalomas are non-functioning but they can be ?

What labs are ordered for these PTs?

A

Cortisol
Pheo
Aldosteronoma
Metastatic

24hr urine metanephrines, atecholamines- r/o Pheo
Free cortisol- r/o Cushings
Serum K and Aldosterone- r/o Conn syndrome
Plasma renin

189
Q

How are adrenal incidentalomas managed w/ normal labs?

When is surgery indicated?

A

Serial CT Q6-12mon
If non-functioning and <4cm, repeat CT Q2-3yrs

> 4cm despite lab results

190
Q

What are the ‘red flags’ of secondary HTN?

A 
Hypokalemia w/out diuretic
Young w/out FamHx of HTN
New presentation +50y/o
Higher degree of severity if DBP +110
Well controlled gone refractory
Paroxysmal BP
Absence of obesity

IPAP (212 decks)

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