Endocrine Flashcards
Pt with recent h/o trauma/surgery now has tachycardia, hypertension, cardiac arrhythmias, high fever, tremor, altered mentation, and lid lag.
Diagnosis & Management
Thyroid storm (thyrotoxicosis) Propanolol, PTU, Prednisone, Potassium
*triggered by surgery, trauma, infection, iodine contrast, or childbirth.
Thyroid nodules first step in assessment:
_______
After that, what else should be done?
____ & _____
Physical examination*
TSH & Thyroid U/S
*Evaluate the size, mobility, and firmness of the thyroid nodule & check for enlarged cervical lymph nodes.
Pt with thyroid nodule on physical exam with no concerning u/s features and a low TSH
Next best step management?
Radionuclide thyroid scan using iodine
RAIU
A hypofunctioning (“cold”) nodule (decreased isotope uptake compared to surrounding tissue on RAIU) is associated with a ___ cancer risk f/u with ___.
A hyperfunctioning (“hot”) nodule (increased isotope uptake in the nodule on RAIU) is associated with a ___ cancer risk f/u with ___.
High (f/u with FNA)
Low (f/u with Hyperthyroid tx)
Thyroid Nodule >1 cm with certain features u/s: microcalcifications irregular margins vascular are at risk for cancer. Next best step management?
Fine-needle aspiration (FNA)
Noncystic thyroid nodules >2 cm on u/s.
Next best step management?
Fine-needle aspiration (FNA)
____ is an important tumor marker in medullary thyroid carcinoma (MTC).
Get in patients with a thyroid nodule + FMH MTC
or
FNA of the nodule is consistent with MTC.
Calcitonin
Pt with painless ulcer
(typically at weight-bearing pressure sites on the sole of the foot like bony prominences of metatarsal bones)
+/- “Punched out” irregular borders w/ necrosis
+/- adjacent callus
Neuropathic ulcers
(MCC: Diabetes)
2/2 repeated pressure, friction, or trauma due to lack of sensation in the local tissues
Thyroid function tests are often abnormal in patients with severe, acute illness. The most common pattern is:
__ TSH
__ T4
__ T3
which may represent an adaptive response to severe illness.
Normal T4 and TSH with low T3
euthyroid sick syndrome
Management of Euthyroid sick syndrome in recently critically ill patient (2)
Observe without treatment
F/U thyroid test done once pt is at baseline health
Risk Factors:
Severe acute illness, ICU stay, given glucocorticoids
s/t Decreased peripheral conversion of T4 to T3
Euthyroid Sick Syndrome
High circulating levels of glucocorticoids and inflammatory cytokines (TNF)
Euthyroid Sick Syndrome
Early levels: __T3, __T4, __TSH
Late levels : __T3, __T4, __TSH
↓ T3, – T4, –TSH
↓T3, ↓T4, ↓TSH
Pt with recent blood transfusion now has:
Numbness/Paresthesias in the fingertips & around lips
Muscle cramps (intact strength)
Chvostek (wrist spasm) & Trousseau signs (face spasm)
Paresthesias
Hyperreflexia/tetany
Seizures
Prolonged QT
Diagnosis:
Hypocalcemia
High-volume blood transfusion → pt w/ impaired hepatic fxn (liver lac, cirrhosis, shock) → chelation (binding) of ionized Ca by citrate from transfused blood → Hypocalcemia
*Other potential features of severe hypocalcemia include laryngospasm, encephalopathy, & HF
Causes of Acute hypocalcemia: \_\_\_\_\_\_\_ Pancreatitis Sepsis (impairs hepatic fxn) \_\_\_\_\_\_\_ Tumor lysis syndrome Acute alkalosis (↑ albumin binding Ca)
Parathyroidectomy (Neck surgery) Blood transfusion (Chelating citrate)
Treatment of Acute hypocalcemia:
IV calcium gluconate/chloride
Hyperprolactinemia, likely s/t a prolactin-secreting pituitary adenoma (prolactinoma) causessuppressionof __manifesting as ____.
Initial treatment usually includes ____.
If non-responsive treat with _____.
GnRH (thus FSH/LH)
central hypogonadism
Dopamine Agonists (cabergoline, bromocriptine)
Transsphenoidal surgery
Indications for treatment of hyperprolactinoma include pts with:
(3)
central hypogonadism (low E = osteoporosis/fractures) galactorrhea mass effect symptoms (HA, visual defects)
The most common complication seen post Thyroidectomy or Para-thyroidectomy (Neck surgeries)
Hypocalcemia/Hypoparathyroidism
*other causes of Hypoparathyroidism include:
post surgical/autoimmune parathyroid destruction
defective calcium-sensing receptor
Classic triad: episodic headache, sweating & tachycardia
Medication resistant HTN or HTN accompanied by unexplained ↑ glucose
Pheochromocytoma
↑ urine or plasma metanephrines
Family history or familial syndromes associated with pheochromocytoma (3-4)
MEN2 (A&B)
NF1
VHL
Management of pheochromocytoma
3
FIRST preoperative alpha blockers
THEN beta blockers
Lastly, surgical resection
The primary treatment for papillary thyroid cancer.
Surgical resection
Postoperative adjuvant therapies for patients at increased risk of recurrence of papillary thyroid cancer include (2)
Radioiodine ablation
&
suppressive doses of thyroid hormone
Parathyroidectomy is recommended for patients <50 or all pts with ____ or _____ .
symptomatic hypercalcemia (polyuria, constipation, depression) complications (Kidney stones, osteoporosis, AMS)
Pt presents with Fever as high as (104-106ºF)
Tachycardia, HTN, CHF, arrhythmias (atrial fibrillation)
Agitation, delirium, seizure, coma
Goiter, lid lag, tremor, warm/moist skin,
Nausea, vomiting, diarrhea or jaundice
Dx and Tx:
Thyroid Storm
β blocker (propranolol)
PTU → potassium iodine (SSKI)
Glucocorticoids (hydrocortisone)
Identify trigger & treat, supportive care
Patient with recent h/o surgery/trauma has hypotension (despite being given IVFs) with tachycardia, abdominal pain, vomiting, and weakness.
Dx & Tx?
Adrenal insufficiency
Fluid resuscitation & IV dexamethasone
Patient with recent h/o surgery/trauma has hypotension/shock (despite being given IVFs) with tachycardia, Fever, abdominal pain, vomiting, weakness, and +/- AKI.
Dx & Tx?
Adrenal insufficiency
Fluid resuscitation & IV dexamethasone
Monitor ‘lytes
Diagnostics for suspected Acute Adrenal insufficiency (4)
Seen in acute illness, injury, or surgery in pts with:
Chronic adrenal insufficiency/glucocorticoid use
Congenital adrenal hyperplasia
Adrenal hemorrhage/infarction
↓ Cortisol
↓ Aldosterone
↑ ACTH
↑/– Renin
CMP ( Na, K, ↑/–BUN/Cr)
*ACTH stimulation test when stable
___ can occur in prolonged immobilization (quadriparesis) due to increased osteoclastic activity.
Treatment:
Hypercalcemia
Tx: Bisphosphonates (prevent bone loss)
Paroxysms of severe hypertension in patients with pheochromocytoma can be precipitated by ___, induction of ___, and medications.
Surgery
anesthesia
(catecholamine-producing tumors from chromaffin cells in adrenal medulla)
