Endocrine

Question 1

Hyperthyroidism General

Answer 1

RF: goiter, h/o autoimmune, radioactive iodine therapy, Fhx, smokers; amiodarone, estrogen, levothyroxine

Types:

• MC: Graves (autoimmune) - thyrotoxicosis (elevated T3/T4) leads to goiter, exophthalmos, pretibial myxedema
• Primary: thyroid tumor producing TH
• Secondary: pituitary TSH-secreting tumor
• Tertiary: hypothalamic TRH secretion

Sxs:

• skin: warmth, pretibial myxedema
• eyes: stare/lid lag, grave’s = exophthalmos
• heme: inc RBC mass, plasma volume
• CV: tachy, afib, HF, HTN
• resp: dyspnea, DOE
• GI: wt loss - metabolic rate and gut motility increased; diarrhea; malabsorption
• Male repro: dec libido, delayed ejaculation
• Female repro: menstrual cycle abn
• neuro: nervous, hyperkinesia, insomnia, fatigue, rapid speech, tremor
• msk: prox muscle weakness, hyperreflexia
• metabolic: hyperglycemia, low HDL

Question 2

Hyperthyroidism Dx/Tx

Answer 2

TSH: low
FT4: high
TSI (thyroid stimulating Ig): Grave's
Thyroid uptake scan I-23: 
- Grave's: diffuse uptake
- Thyroiditis: no uptake
- Toxic nodule: unifocal uptake
- Toxic multinodular goiter: patchy uptake

Tx: refer to endo

• sx tx: BB (propranolol) - dec HR, block conversion of T4 to T3; steroids if severe
• curative: PTU (pregnancy) or methimazole
• surgical: thyroidectomy
• radiological tx: I-131 radioactive ablation (Grave’s toxic adenoma, TMNG)

Question 3

Hypothyroidism General

Answer 3

RF: goiter, h/o autoimmune, Hep C, Fhx, previous radiation
Primary: (MC) problem w/thyroid gland
Secondary: pituitary problem (TSH)
Tertiary: hypothalamus problem (TRH)
Autoimmune: Hashimoto’s Thyroiditis (MC): + TPO abs lead to follicular destruction
Drugs: amiodarone, IFN, IL-2, lithium

MC sxs: fatigue, cold intolerance, wt gain

• skin: cool, pale, lateral eyebrow thinning, dry skin
• eyes: periorbital edema
• heme: anemia
• CV: dec CO
• Resp: fatigue, DOE
• GI: constipation
• renal: dec GFR, impaired ability to excrete water
• repro: same as hyper
• neuro: difficulty concentrating
• endo: hypothermia
• msk: joint pains, aches, stiffness

Question 4

Hypothyroidism Dx/Tx

Answer 4

TSH: high
FT4: low
TPO (thyroid peroxidase): + Hashimoto’s

Tx:
LT4 (levothyroxine): recheck in 6-8wk
- half-life 7d
- may require dose INC during pregnancy

Question 5

Type 2 DM General

Answer 5

RF: h/o gestational DM, HTN, dyslipidemia, obesity
- drugs: steroids, antipsychotics, immunosuppressants, niacin, thiazides, statins, BB

Screening:

• any age w/BMI>25 plus: sedentary, Fhx, ethnic, gestational, PCOS, large baby, HTN, CVD, HLD
• everyone at 45, q 3yr if wnl

Sxs: polyuria, polydipsia, polyphagia

• blurred vision
• recurrent candida infections
• fatigue
• weakness

PE: orthostatics, fundoscopic, thyroid, FOOT exam, skin

Question 6

Type 2 DM Dx/Tx

Answer 6

C-peptide: distinguish between type 1 and type 2
A1c 5.7-6.4 = prediabetes

Diabetes: a1c >6.5, FBG>126 on two readings, one random glucose >200, 2hr OGTT >200

Mgmt:

• glycemic control, a1c <7
• BP < 140/90
• HLD control, smoking cessation, wt loss
• Immunizations: flu, hep B, pneumovax
• screen for depression, sleep apnea
• Insulin for pregnancy
• reassess meds in 3mo

Question 7

Type 2 DM Complications

Answer 7

Retinopathy

• annual dilated exam
• optimize BS/BP control

Nephropathy

• measure Scr, urinary albumin, GFR, K yearly
• do NOT give metformin w/mod-severe CKD
• use ACE/ARB

Neuropathy

• assess annually w/monofilament and sensory
• large fiber: loss of sensation / ataxia in glove stocking region, no pain
• small fiber: includes pain (charcot) or autonomic symptoms (ED, gastroparesis) - [tx: amitriptyline, gabapentin, pregabalin, duloxetine]

Sleep apnea
- refer to sleep specialist

Foot lesions
- always look at feet

Other: Coronary heart disease, stroke, PVD, microalbuminuria, sexual dysfunction, gastroparesis

Question 8

Hypercholesterolemia

Answer 8

Primary (familial): uncommon
Secondary: d/t DM2, nephrotic syndrome, CKD, hypothyroidism, smoking, obesity, drugs

Start screening lipid panel at 35

Sxs: xanthoma, xanthelasma
- assess for other cardiac RF

Dx: FLP, baseline LFTs if starting statin
- f/u FLP and LFTs 1-3mo after starting statin, then q 3-12mo

Tx:

• Mediterranean diet, oily fish, salmon
• INC duration of exercise
• Statin if ASCVD > 7.5%, LDL > 190, DM, or h/o ASCVD disease

Question 9

Hypertriglyceridemia

Answer 9

Levels elevated after eating
high risk for pancreatitis when >1000
>500 = counseling on ETOH

FLP: TG should be less than 200

Tx: dec ETOH, fried/fatty food