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
How are prolactinomas Tx? What are the indications for surgery?
TOC= Cabergoline, Bromocriptine Unresponsive to medical therapy Significant visual loss Apoplexy- hemorrhage leading to stroke Radiation if macroadenomais enlarging while on medical Tx meds
26
What are the two surgical procedures done for prolactinomas? What are the second most common secreting pituitary adenomas?
Transsphenoidal resection - common postop DI to SIADH Tranfrontal craniotomy- if extra sellar extesnion is present GH secreting- 20% also secrete prolactin
27
GH is stimulated by ? It is inhibited by ?
Any process requiring higher metabolic rate Hypothyroid Somatostatin inhib peptide, Hyperglycemia, Glucocorticoids, Inc IGF-1
28
What are the A-Js of Acromegaly?
Athropathy, Boggy hands Carpal Tunnel, DM Enlarged tongue, Fields of vision defects, Gynecomastia, HTN, Inc Hat, shoe, ring size, Jaw enlargement
29
How is acromegaly Dx? What is the imaging modality of choice for Dx acromegaly?
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
30
What are the subtle Sxs of acromegaly? How is it Tx?
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
31
What type of f/u schedule is needed for acromegaly PTs? What physical features regress or are permanent after Tx?
IGF-1 annually Cardiac monitoring Soft tissue improves Permanent bone changes
32
What is the 3rd most common cause of AntPit d/os? What PT population is it more common in?
Corticotropic Adenoma W>M w/ microadenoma more common
33
What happens in PTs w/ Corticotropic Adenomas? Cushing's Syndrome can be caused by what 4 things?
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
34
What are the early signs of Cushings Syndrome? What are the later sings?
HTN, weight gain Truncal obesity Moon face Buffalo hump
35
What are the effects seen from hypercortisolism? PTs w/ Cushings have signs of excess ? and ?
Proximal muscle weakness Thin skin/easy bruising HTN Glucose intolerance Cortisol AND Androgens
36
What are the 3 Dx tests done for Cushings Dz?
Dexamethasone @ 11pm Serum cortisol @ 8AM Inc cortisol= Dx 24hr urine free cortisol and plasma ACTH- 1*, 2* or ectopic Night salivary cortisol test
37
How is Cushings Dz Tx? What causes most gonadotropic adenomas to be detected on imaging?
Transsphenoidal surgery Radiation Possible adrenalectomy Large enough to cause visual disturbances
38
What are the clinical features of gonadotropic adenomas? Pituitary failure d/os can present in what 3 ways as a result of failure where?
HA, Visual disturbance, Hypogonadism Isolated hormone Multiple hormones Panhypopituitary Hypothalamic or pituitary dysfunction
39
What is the most common cause of primary putuitary failure/ What are the 9 I's of pituitary failure d/os?
Invasion of adenoma/CNS tumor Invasion*, Infarct, Injury, Infection, Iatrogenic, Immune, Idiopathic, Isolated, Infiltrative
40
What causes Sheehan syndrome? What are the S/Sxs?
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)
41
Pituitary has a large reserve and can maintain function until _% is lost? Define Empty Sella Syndrome
75% Subarachnoid space extends into sella turcica and fills it w/ CSF causing a flattening of the pituitary gland leading to pituitary failure
42
How will PTs w/ Sheehan's syndrome that have glucocorticoid insufficiency present? How does a pituitary infarct/apoplexy present and what does it cause?
Shock w/ HOTN, Bradycardia that don't respond to fluids/meds Sudden severe HA, AMS, Vomit, Diplopia/Bitemporal hemianopsia, unresponsive HOTN to fluids/meds
43
Pituitary infarct/apoplexy that causes acute hypopituitarism is Tx how? Head injury/trauma usually affects ? part of the brain and presents how?
Immediate gluccocorticoids followed by surgery AntPit w/ GH and gonadotropins deficiency
44
Neuro-Endocrine Dysfunction can present acutely or not for ? long? What labs are used for screening?
3yrs ``` 0800 cortisol TSH, T4 IGF-1 LH/FSH Testosterone/Estradiol ```
45
Pituitary failure usually present with gradual loss of normal pituitary function starting w/ ? hormones? Which one is last/life threatening if decreasing?
GH, Gonadotropins, TSH, ACTH PRL
46
How will hypopituitary show across the 5 hormones?
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
47
How is hypopituitarism Tx?
GH: only if Sxs, hGH injections Gonadotropin: Estrogen or Testosterone TSH: Levothyroixine ACTH: Prednisone, Hydrocortisone
48
What are the 4 thyroid hormones?
TRH TSH Thyroxine- T4, major secretory product of thyroid Triiodothyronine- T3, form from de-iodination of T4 and physiologically active form hormone
49
What are the physiologic functions of T3? What are the different lab results seen in hypopituitary hypothyroidism and primary hypothyroidism?
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
50
99% of thyroid hormone in circulation is bound to one of what 3 proteins?
Thyroxine binding globulin- TBG Thyroxine binding prealbuminum- TBPA Albumin
51
What is the single most useful thyroid function test? When will serum TSH be low or High?
TSH and Serum free T4 Low: Primary Hyperthyroid Exogenous hormone Panhypopituitarism High: Primary Hypothyroid Secondary Hyperthyroid Resistance to T3
52
When will serum free T4 be low or high? When will serum free T3 be high?
Low- hypothyroidism High- Hyperthyroidism/Thyrotoxicosis High- thyrotoxicosis
53
What is Anti-Thyroid Peroxidase Abs used to test for? What are Anti-thyroglobulin Abs used to test for?
Hashimotos thyroiditis Graves Dz Hashimotos but less sensitive than anti-TPO Graves Dz
54
What is anti-thyrotropin receptor Abs used to test for? What are the 3 thyroid autoimmunity tests?
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
55
When are RAIU using I-123 scans used?
Thyrotoxicosis Sxs Measure amount of radioiodine needed for hyperthyroidism Tx Nodule/CA evaluation Ectopic tissue evaluation
56
What causes high levels of uptake? What causes low levels of uptake?
Graves Toxic multi-nodular goiter Toxic nodule Dietary iodine insufficiency ``` Exogenous hormone Subacute thyroiditis Anti-thyroid drugs Iodide medications Damage ```
57
What are the different RAIU results in subacute thyroiditis and thyrotoxicosis
Graves/thyrotoxicosis has high uptake | Subacute thyroiditis has little/no uptake
58
# Define Hot Nodule Define Cold Nodule
Take up iodine, least likely to be malignant, recommended to do no further tests Little isotope uptake, 30% more likely to be CA
59
Hyperthyroid toxicosis is seen as excess ? and ? What is the most common cause of thyrotoxicosis?
T3 and T4 Graves Dz
60
What are the 4 causes of hyperthyroid thyrotoxicosis? What are the 4 causes of non-hyperthyroid thyrotoxicosis
Graves Apathetic hyperthyroidism Pituitary tumor secreting TSH Toxic multinodular goiter ``` PASH Thyroiditis Postpartum thyroiditis Acute suppurative thyroiditis Subacute thyroiditis Hashimotos thyroiditis ```
61
What are the two Sxs associated w/ Hyperthyroidism? What are 4 Signs seen and highlighted here?
Palpitations Resting tremor Rapid DTR relaxation Tachy HTN A-Fib*
62
Graves Dz is a ? form of thyrotoxicosis and is the most common cause of ? What PT population does it affect?
Autoimmune Thyrotoxicosis/hyperthyroidism F>M between 20-40
63
What are the chemical levels in Graves? What are the 4 parts of this Dz seen on PE?
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
64
Why do PTs eyes have proptosis (bulging) with Graves Dz? What visual issues can occur?
Inflammation of eye muscles due to lymphocyte infiltration Diplopia Optic nerve compression leads to blindness
65
What has more severe Sxs, Thyroiditis or Graves and why? What will be seen on RAIU in Graves PTs?
Graves, T3 is more active Increase diffuse uptake
66
What are the 3 Tx methods of Thyrotoxicosis
``` 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\
67
What are the MOAs of Methimazole, Propylthiouracil, Oragrafin, Telepaque? Which one is safe for pregnancy?
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
68
What are the s/e of anti-thyroid drugs? When are the iodinated contrast agents Oragrafin and Telepaque used?
Rash- exfoliative dermatitis Agranulocytosis= (Pancytopenia) Nausea/Dyspepsia Severe Sxs and usually as bridge therapy pre-surgery
69
What are the potential complications of removing the thyroid gland in Graves Dz?
Damage to recurrent laryngeal nerve= hoarseness Parathyroid damage Hypothyroidism Continued hyperthyroidism
70
# Define Apathetic hyperthyroidism How does it present?
Thyrotoxicosis in older PTs Depression/New mood d/o, Angina Pectoris, Lethargy/Fatigue, Weight loss
71
# Define Thyroiditis How does it present?
Inflammation and enlargement of the thyroid Sxs of mild hyperthyroidism w/ depression and chronic fatigue w/ passive release of stored T4
72
# Define Acute Suppurative Thyroiditis What PT population is it seen in?
Bacterial infection of thyroid by Streptococcus Immunocompromised Elderly Pre-existing thyroid Dz
73
What is the hallmark of Suppurative Thyroiditis? What labs are drawn for Dx?
Painful thyroid gland CBC, ESR, Culture, FNA
74
How is Suppurative Thyroidits Tx? Subacute Thyroiditis is AKA?
IV ABX guided by Gram Stain and culture Surgical drainage deQuervan's thyroiditis
75
What PT population does Subacute Thyroiditis usually affect? What are the S/Sxs?
Young/middle aged females after viral respiratory infection* Painful gland, transient hyperthyroidism, dysphagia, pharyngitis
76
What labs are drawn for subacute thyroiditis? What is the Tx?
ESR, CRP, TSH/T4 ``` ASA- DOC Usually self resolving Propanolol Oragraf/Telepaque Levothyroxine if transient state has Sxs ```
77
Chronic Lymphocytic Thyroiditis is AKA ? Who does it appear in and what finding is Dx?
Hashimotos Thyroiditis Most common form of thyroiditis Female, anti-TPO Abs is hallmark
78
Hashimoto's usually co-exists with what other type of Dzs? How does it present?
Autoimmune Hyper to hypo thyroid Fatigue, weight gain, dry skin, constipation Non-tender goiter from lymphocytes infiltrating gland
79
Why is RAIU imaging not useful in chronic Hashimotos? How is it Dx and Tx?
Diffuse uptake from normal to high Dx w/ anti-TPO Levothyroxine if clinical hypothyroidism is present
80
What is the major complication that can arise from Hashimoto's Thyroiditis? Postpartum thyroiditis is AkA ?
Primary hypothyroidism Silent/painless thyroiditis Subcategory of chronic lymphocytic thyroiditis
81
How does Postpartum thyroiditis present? How are they Tx?
Possible goiter Hyperthyroid within 6mon of delivery lasting 1-2mon Hypothyroid- lasting 4-8mon post delivery Hyper- Sx treatment Hypo- Tx as needed
82
# Define Reidel's Thyroiditis How does Reidel's present?
Fibrous infiltrates in thyroid of middle aged/elderly female PTs Stony mass within thyroid Possible dysphagia, dysphonea, pain
83
How is Riedel's Dx'd? How is Reide's Tx?
Open biopsy, FNA doesn't get enough of a sample Surgery- relieves compression Tamoxifen- reduces fibroids CCS- short term for pain/compression Sxs
84
# Define Goiter What are the two causes of it?
Diffuse or nodular enlargement of thyroid gland Inc TSH stimulation Thyroid stimulating immunoglobulins
85
Goiters can be present in what two cases? Simple/non-toxic goiters are a response to ? and most commonly due to ?
Thyroiditis Iodine deficiency Inadequate synthesis of thyroid hormone Iodine deficiency
86
How are benign multinodular goiters Tx? Most goiters respond to Tx of ?
Elevated TSH= Levothyroxine Euthyroid goiters= observation Hypo or Hyper thyroid states
87
What is the most common cause of elderly hyperthyroidism? Where does it usually present?
Toxic multinodular goiter >50y/o w/ history of benign multinodular goiters w/ normal function tests
88
What will labs show in Toxic Multinodular goiters? What will be seen on RAIUs?
Inc T3, T4 Low TSH Diffuse patchy uptake
89
How are Toxic Multinodular Goiters Tx?
Hyper Sxs= Propranolol Propothyouracil and Mehimazole RAI ablation- definitive, especially in elderly in leu of surgery Subtotal thyroidectomy- pressure and cosmetic indications
90
What is a beneficial fact about thyroid nodules? If there is a single thyroid nodule it is one of what 3 things?
95% are benign and not associated w/ lymphadenopathy Benign adenoma- Common Cyst Malignancy
91
Benign thyroid nodules are usually smaller than ? Where are malignant thyroid nodules more common?
<1cm Young adults/men
92
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?
Malignancy/Irradiation Tonsilitis Dysphagia Dysphonia Dyspnea No lymphadenopathy
93
What are the common Sxs of malignant thyroid nodules? How are thyroid nodules assessed?
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
What US findings are suspicious for malignant thyroid nodules?
``` Hetergenous echogenecity- non-uniform, hypo and hyper echoic Irregular margin Microcalcification Complex Vascularity Diamter >1cm ```
95
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?
FNAB Suspicious US Abnormal cervical nodes >1.5cm diameter mixed/solid >2cm with benign features Pure cystic nodule (spongiform)
96
How are thyroid nodules classified?
``` Bethesda Classification 2- Benign 3- Atypical 4- Suspicious, follicular 5- Suspicious for malignancy 6- Malignant ```
97
What determines the treatment schedule of thyroid nodules? How are benign nodules managed?
Biopsy results ``` US Q6mon FNA if increases in size Levothyroxine if TSH is elevated or hypothyroid Surgery- benign but suspicious Total thyroidectomy- malignant ```
98
When is RAI the procedure of choice when teating thyroid nodules? What are the 4 types of thyroid cancer?
Toxic adenomas MNG Graves Papillary- most freq, low agg Follicular- can metastasize Medullary- more aggressive Anaplastic- most aggressive, least frequent
99
Papillary thyroid cancer
``` Radiation exposure (Chernobyl) in childhood Genetic mutations/familial syndromes ```
100
What two thyroid cancers absorb iodine?
Papillary | Follicular
101
Follicular thyroid cancer
2nd most common | Typically metastasizes to neck nodes, bone and lung
102
Medullary Thyroid cancer
No iodine absorption Strong familial ties Arises from parafollicular cells secreting calcitonin Tx- prophylactic thyroidectomy
103
Anaplastic thyroid cancer
Non absorptive | Older PTs w/ goiter Hx
104
What will lab results who in thyroid CA?
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
What is the TOC for thyroid cancer?
Surgery Anaplastic- local resection w/ radiation Medullary- only surgery Papillary and Follicular- surgery w/ RAI
106
When is post-surgery RAI used in thyroid CA? What medication is given to post-thyroid CA PTs?
Papillary and Follicular Levothyroxine
107
# Define Hypothyroidism What is the most common cause?
Primary- failure of thyroid to secrete T3 and T4 Secondary- failure of pituitary to secrete TSH Hashimotos
108
Why is hypothyroidism during pregnancy dangerous? What are the 4 less common Sxs of hypo thyroid?
Lower IQ scores Dec appetite Dec taste/smell Hoarseness Dysphagia
109
What are the key PE findings of hypothyroidism? What is the single best test for hypothyroid?
Diastolic HTN Delayed DTR relaxation Bradycardia Thin hair/brittle nails TSH
110
What will lab results show in primary and secondary hypothyroidism? What are the 4 less likely seen results but usually seen in severe cases?
Primary- inc TSH Secondary- low Low/N T4 Inc cholesterol/prolactin Hypo Na Hypo sugar Anemia Abnormal sperm morphology
111
What complications can arise from hypothyroidism?
``` Cardiac mostly Inc infection risk Megacolon Organic psychosis w/ paranoia "myxedema madness" Infertilit/miscarriage Coma ```
112
How is hypothyroidism Tx? What important PT education piece needs to be given?
T4 replacement Levothyroxine Wait 5wks after adjusting dose to recheck levels Must take in AM w/ only water
113
What 5 things needs to be avoided when taking Levothyroxine?
Fe/Ca Antacid PPI OCPs
114
How much Levothyroxine is used when starting? How much Levothyroxine is given to adults and kids?
50mcg/day, inc every 3-6wks Target dose= 100-250mcg/day (0.1-0.25mg/day) 1/7mcg/kg/d
115
What is unique when starting young/healthy PTs on this drugs? How much are older PTs that are sensitive to Levothyroxine started on?
Start at target dose 25-50mcg/day
116
What monitoring is done on hypothyroid Pts? What adjustment is done for pregnant PTs?
TSH and Sxs Keep TSH 0.4mU-2.0mU/L Inc 20-30% at discovery Inc at 5th week by 75%
117
When do hypothyroid PTs need to be referred? When do they need to be admitted?
Difficulty titrating levo to normal TSH CADz needing Levo therapy Myxedema crisis Hypercapnia
118
Levothyroxine is known to cause? so watch for ? Define Cretinism
Weight loss Fluctuating TSHs Congenital hypothyroidism due to failure of thyroid to migrate to location
119
What are the 4 major signs of Cretinism?
Intellectual disability Puffy hands/face Thick tongue/poor muscle tone Deaf/mute
120
Childhood hypothyroidism usually has what etiology? How is it Tx?
Hashimotos Levothyroxine
121
# Define Thyroid Storm What are 4 precipitating factors that can cause this?
Extreme hyperthyroid/thyrotoxicosis Most often seen s/ Grave's Stress Thyroid surgery RAI admission D/c anti-thyroid drugs
122
What are the S/Sxs of a thyroid storm?
``` Dehydration High fever Sweating Tremor Restlessness ``` Delirium Tachy A-Fib Vomit/Diarrhea
123
How are thyroid storms Tx?
``` 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
Define Myxedema Crisis
Fluid retention from hypothyroidism causing an interstitial accumulation of hydrophilic mucopolysaccharides (lymphocyte infiltration) leading to lymphedema
125
What is mysedema crisis AKA? What often triggers a Myxedema Crisis?
Decompensated hypothyroidism Infection Cold exposure Cardiac/CNS illness Drug use/stopping
126
Where are myxedema crisis usually seen? What are the S/Sxs of this crisis?
Older female PTs w/ stroke or stopped using meds Hypo: Glycemia, HOTN temp, resp, Na
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How are Myxedema Crisis Tx? What must be used with caution?
IV Levothyroxine, support and fluids/E+ Opioid sensitivity
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What are the 3 layers of the adrenal cortex and what regulates each layer? What are the functions of glucocorticoids?
Glomerulosa- RAAS, K, ACTH Fasciculata- ACTH Reticularis- ACTH Break down proteins and fat for energy
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What can be found in the outer/cortex of the adrenal gland?
Glucocorticoids- cortisol Mineralcorticoids- aldosterone Androgens- DHEA, Test/Estrgoen
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What gender usually has an androgen d/o? Where is CRH produced and what does it do?
Females Hypothalamus Stims ACTH synthesis and release from AntPit
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What inhibits CRH and ACTH? Where is ADH produced and how is it released?
Cortisol Pituitary corticotropes of the AntPit Diurnal rhythm, highest 04-0600, lowest at night
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What does ACTH do? What is the primary aldosterone regulator?
Stims for cortisol production, aldosterone secretion and melanocytes to produce melanin RAAS
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What is the major glucocorticoid secreted by the adrenal cortex? When is this secretion increased?
Cortisol Exercise Trauma Infection Stress
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The release and level of Cortisol is very similar and mimics what other hormone? What does Cortisol do in the blood?
ACTH Breaks down carbs, fats and proteins for energy use Suppresses inflammation, immune system, bone formation and dec Ca reabsorption
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# Define Cushing Syndrome What is the most common cause of spontaneous Cushings Syndrome?
Hypercorticolism ACTH producing pituitary tumor
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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?
No diurnal variation Reduced cortisol suppression by dexamethasone Inc cortisol production rate Supression of plasma ACTH by hypercortisolism from adrenal medulla
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What are the 3 initial tests ordered for Hypercorticolism? What is the final/follow on test ordered?
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
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# Define ACTH Dependent causes of hypercorticolism What are two causes that could be there?
Something is secreting ACTH Pituitary adenoma Ectopic- will have 10x ACTH levels
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# Define ACTH Independent Hypercorticolism What are two causes of this?
No ACTH is secreted Exogenous use Adrenal adenoma/CA
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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?
Cortisol withdrawal syndrome Mitatone, Ketoconazole, Metyrapone
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When are Cushing's Syndrome PTs referred? Historically, what used to be the predominant cause of primary adrenal insufficiency?
Abnormal dexamethasone suppression test TB Bilateral adrenal hemorrhage Congenital adreanl hypoplasia
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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?
90% damage before Sxs show DM Type 1 Hashimoto's Vitiligo
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What are two unique S/Sxs that are seen in Addison's Dz? What will lab results show?
Anorexia and weight loss ``` Hypo Na Hyper k Hypoglycemia 0800 cortiosl- low ACTH high meaning primary organ dysfunction ```
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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?
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 ```
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# Define Secondary Adrenal Insufficiency What is the most common cause of this?
Low secretion of ACTH by pituitary galnd ACTH suppression from persistent suppression of the pituitary after d/c exogenous glucocorticoid meds
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What are the S/Sxs of Secondary Adrenal insufficiency?
Same as Primary, but Pallor is present "alabaster" skin due to low ACTH levels not stimulating melanocytes
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What images are done for Primary adrenal insufficiency? What images are done for Secondary adrenal insufficiency?
Abdominal CT- noncalcified adrenal CXR- for non-autoimmune origins Eval medications Pituitary MRI
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How is Primary Adrenal Insufficiency Tx? What are the sick day rules for these PTs?
Glucocorticoid and Aldosterone replacement Double glucocorticoid dose for short time Emergency kit= 100mg IM hydrocortison needle Braelet
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How is Secondary Adrenal Insufficiency Tx?
Glucocorticoids No mineralcorticoid replacement needed Emergency kit Bracelet
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What is a common Sxs seen in acute adrenal crisis? How are these crisis' Tx?
HOTN Hypoglycemia Draw cortisol levels but administer Tx without waiting for results Hydrocrotisone immediately then Q6hrs Possible broad spectrum ABX
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How are adrenal crisis' Dx? What causes aldosterone to be secreted and what relationship is seen?
Give ACTH Pos test= low cortisol Angiotensins 2 and Kyperkalemia Inc aldosterone, Low K
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# Define Primary Hyperaldosteronism What are the types/causes of primary?
Excess produciton from adrenal gland Conn syndrome Adrenal hyperplasia Adrenocortical CA producing aldosterone
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What causes Secondary Hyperaldosteronims? How does hyperaldosteronism usually present?
Renal artery stenosis Excess renin Hypovolemia CHF HTN, expecially diastolic
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How is hyperaldosteronism Dx? How are these labs differentiated to differ between Primary and Secondary causes?
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
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How is a hyperaldosteronsim Dx confirmed?
24hr urine, Primary will have elevated aldosterone | Abdomen CT/MRI to r/o adrenal carcinoma/bilateral hyperplasia
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How is hyperaldosteronism Tx?
Adenoma= unilateral ectomy Bilateral hyperplasia= spirinolactone/Eplerenone (better for pregnancy and men) Stenosis= angioplasty/revascularization
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How do women with adrenal androgens present? What enzyme is required for cortisol synthesis?
Acne, Hair, Virilization 21 Hydroxylase
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What are the three most results of defected 21 hydroxylase deficiency?
Inc ACTH Hyperplasia Inc 17-Hydroxypreogesterone, the precursor to cortisol and converted to androgens
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What are the 2 types of Congenital Adrenal Hyperplasia
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
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What 3 populations is Secondary Congenital Adrenal Hyperplasia seen in? How does classic congenital adrenal hyperplasia present?
Yupik Alaskan Ashkenazi Jew Native La Reunion Islanders Death of infant Masculine female genitals** Precocious development in males Short stature from early bone closure
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How does non-classic congenital hyperplasia present?
Signs of androgen excess Premature puberty/accelerated growth Female hair/acne, oligomenorrhea and infertility
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How is congenital adrenal hyperplasia Dx? Why are these results seen?
Measure 17-hydroxyprogesterone, the precursor to 11 Deoxycortisol Deficiency of 21-hydroxylase leads to ecess 17-hydroxyprogesterone
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How is classic congenital adrenal hyperplasia Tx? How is non-classic Tx?
Replace steroids w/ prednisone, cortisol, dexamethasone Mineral replacement w/ spirinolactone Glucocorticoids before pubarche onset OOCPs for androgen excess Anti-androfgen like Spirinolactone for women
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Catecholamines decrease what 3 functions? What causes their release?
Visceral blood flow Urine output GI motility Dec BP, Volume, Glucose Stress, Illness
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Pheochromocytoma secretes ? Paragangliomas secrete ?
Epi and NorEpi NorEpi only
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What is the Sx triad of a pheochromocytoma? How is it different from panic attacks?
HA, Sweating, Palpitations Paroxysmal and more severe
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What triggers can start a Pheo attack? What are the major S/Sxs during the attack?
Exertion, stress, Caffeine/Nicotine, Surgery ``` HTN from excessive NorEpi Pallor/molted cyanosis Tachy Syncope Psychosis/Seizure ```
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What lab result obtained during a Pheo crisis is indicative of no Pheo issue? If this test is Pos, what is the next test?
Normal metanephrine test 24hr urine for Catecholamine, metanephrines (gold standard)
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What is the imaging modality of choice to Dx Pheo? What if this comes back negative?
CT w/ contrast CT whole abdomen, pelvis and chest
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Why would a RAI scan be ordered for supected Pheo?
MIBG for non-adrenal paraganglioma Can also be done if abdominal CT is suspicious for secretory paraganglioma
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How is Pheo prepared for Tx?
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
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What is the Tx of choice for Pheo? What can be used for HTN management during Tx?
Surgery IV Nicardipine or IV Nitroprusside
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What is required for post-op Pheo Tx monitoring? What is the Tx if the pheo is inoperable?
BP and catecholamines Metyrosine- reduces synthesis but w/ CNS s/e
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Pheo is more likely to be malignant if its bigger than ? MEN1 is AKA?
>7cm Wermer Syndrome
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Wermer syndrome is most commonly ? syndrome 95% of PTs present with ?
Multiglandular Hyperparathyroidism
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What is often the first clinical sign seen in MEN1? What is the second most common finding? When do Sxs usually appear?
Hypercalcemia Facial angiogibromas 3-4th decade of life
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MEN2a is AKA? What is the most common and second most common finding?
Sipple Syndrome Medullary thyroid Ca Bilateral pheos
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How is MEN2a Tx? What has to be done prior to Tx?
Prophylactic thyroidectomy before 6yrs old Only after screening for Pheo first
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What is major and second major Sx of MEN 3? How is this form Tx?
Mucosal/GI neuromas Medullary thryoid CA Prophylactic thyroidectomy before 6mon
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What MEN Syndrome has a Marfan like habitus? Any adrenal adenoma bigger than ? is removed?
MEN 3 4cm
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What three metabolites may be seen in higher amounts/for longer in Pheo Pts? MEN syndromes are sometimes AKA ?
Metanephrine or Normetenephrine reducing to VMA Polyglandular Syndromes
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How many are there? How are they passed along through generations?
MEN 1, 2/2a, 3/2b, 4 Autosomal Dominant
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What is less severe for medullary thyroid cancer, MEN2a or MEN3? What is a different finding in MEN2a than other MENs?
MEN2 is less severe than 3 Hischprungs
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What is included in MEN4?
Parathyroid, Pancreatic, Pituitary tumors | Adrenal Cortex, Thyroid adenomas
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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?
Parathyroid MEN3
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What do MEN2 and MEN3 have in common? Which one is more likely to have each finding
Medullary thyroid CA Pheo MEN2- thyroid CA MEN3- pheo
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Which form of MEN would facial angiofibrinomas and colagenomas be more likely? How often are adrenal incidentalomas found?
MEN1 4% of PTs
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Most adrenal incidentalomas are non-functioning but they can be ? What labs are ordered for these PTs?
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
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How are adrenal incidentalomas managed w/ normal labs? When is surgery indicated?
Serial CT Q6-12mon If non-functioning and <4cm, repeat CT Q2-3yrs >4cm despite lab results
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What are the 'red flags' of secondary HTN?
``` 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 ```