endocrine Flashcards
What are the classical endocrine glands?
- hypothalamus
- pituitary
- thyroid
- parathyroid
- pancreas(islet of langerhans)
- adrenal glands
- gonads
- placenta
What are the organs with endocrine function?
brain<br></br>heart<br></br>liver<br></br>GI tract<br></br>kidneys<br></br>adipose
What are the 4 basic functions of the endocrine system(whole body regulation)?
<ol><li>maintain homeostasis</li><li>help body cope with stressful enviro</li><li>regulate cell metabo and energy balance</li><li>regulate mood, growth, devo and repro</li></ol>
What are the effects of hormones acting at the cellular level?
<ul><li>cell division, growth, diff and death</li><li>motility</li><li>secretion</li><li>nutrition uptake, storage & utilization</li></ul>
What are the effects of hormones at the molecular level?
<ul><li>gene transcription</li><li>protein synthesis & degregation</li><li>enzyme and protein activity</li><li>protein conformation</li><li>interaction bw molecules</li></ul>
What is the classical endocrine model?
chemical synth & secreted by glands → blood vessels(µg to pg) → target tissue (bind to receptors) → target tissue has physio repsonse<br></br><br></br>*homone acts as paracine or autocrine fnx
what is a paracrine function?
affects neighboring cells
what is an autocrine function?
works on same cells that produce them
How are hormones excreted from the body?
<ul><li>degraded by target tissue, blood, kidney/liver</li><li>via bile or urine</li></ul>
How does negative feedback effect hormone secretion?
hormones produce physio response that inhibit futher secretion<br></br><ul><li>elevated or dimished release</li></ul>
What are the 3 major classes of hormones?
<ul><li>steroids</li><li>protiens + protein derivites</li><li>tyrosine</li></ul>
What are steroid hormones?
lipids derived from cholesterol
What are the chemical properties of steroids?
lipophilic and hydrophobic
what are the chemical properties of protien hormones?
lipophobic and hydrophilic
what are tyrosine derivatives?
<ul><li>similar to steriods</li><li>catecholemines (protiens)</li></ul>
why is hormone chemistry important?
<ul><li>it determines how they can be taken for efficacy</li><li>how long it stays in your system</li></ul>
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What are the functions of hormone receptors?
<ul><li>cell response based on receptor types available</li><li>up/down regulated</li><li>agonist/antagonist pharm manipulation</li></ul>
what is circhoral hormone secretion?
released every hr
what is ultradian horome secretion?
longer than 1 hr but less than 24 hrs
what is circadian hormones secretion?
released every 24 hrs
what is dinural secretion?
episodes at defined periods of the day
what is circatrigintan secrection?
released ~ 30 days
what type of secrection of GnRH & LH undergo?
cichoral<br></br>hypothalamus releases GnRH → LH release from anterior pituitary
What are the effects of GnRH pulsatility on pituitary gonadotropes?
pulses 60-90 min apart → upregulate GnRH receptors → stimulate gonadotropin release (LH, FSH)
What occurs with the continuous administration of GnRH?
down regulation of receptors → supress release and function
How does endocrine disease develop?
front and back ends<br></br><br></br>endocrine tissue: hypo/hypersecretion<br></br>target tissue: sensitivity defects
What is the bottom line of endocrine hypofunction?
dimished production and secretion of one or more hormones
What are examples of primary deficiency disorders?
hashimoto’s thyroiditis<br></br>addison’s disease
What is a primary deficiency disorder?
elevated hormone levels b/c of normal feedback response
What are examples of secondary deficiency disorders?
2º adrenal insufficiency<br></br>2º hypothyroidism<br></br><br></br>* developed from primary hypopituitarism
What is secondary deficiency disorder?
trophic hormone for target organ is deficient
what is tertiary deficiency disorder?
one step above secondary deficiency
what are examples of tertiary deficiency disorders?
3º adrenal insufficiency<br></br>3º hypothyroidism
what are the 4 main etiologies of endocrine hypofunction?
<ul><li>destruction of endocrine tissue</li><li>lack of gland devo as fetus</li><li>defects in hormone biosynthesis</li><li>idiopathic</li></ul>
What are the 4 etiologies of destruction of endocrine tissue?
<ol><li>autoimmune</li><li>neoplasms</li><li>trauma/ removal</li><li>ischemia/inflamm/infarction</li></ol>
what is the pathophysiology of the autoimmune phenomena?
antibodies produced against target organ → destruction
What two factors are required for the autoimmune phenomena?
<ul><li>genetic predisposition</li><li>environmental trigger</li></ul>
What are examples of endocrine neoplasms?
<ul><li>craniopharyngiomas (slow growing, rathke's pouch)</li><li>null-cell tumors</li></ul>
What is the pathophysiology of endocrine neoplasms?
hypersecretion if cells are cancerous<br></br><br></br>if non-hormone producing tissue in gland → infiltrates gland → destroy hormone producing cells → deficiency
What are the biggest types of hormones?
protiens<br></br>smallest: TRH(3)<br></br>30-225 = protiens
What are examples of Ischemia/Infarction/ Inflamm/ Infiltrative disease?
<ul><li>Sheehan's syndrome</li><li>pancreatitis</li><li>hemochromotosis</li></ul>
What is Sheehan’s syndrome?
postpartum pituitary necrosis or infarction
What develops because of chronic pancreatitis?
develop transient DM type 1 from insufficient insulin secretion
What happens in hemochromotosis?
hypopituitarism<br></br>from hypogonadotropic hypogonadism
What type of endocrine tissue damage can occur with severe head trauma?
hypophysectomy: tearing of pituitary stalk → 2º hypopituitarism<br></br>
What is the most common gland that fails during embryo development?
thyroid glands<br></br>gonads
What causes defects in hormone bio synthesis and what are the results?
cause: congenital defects<br></br>results: mutations in hormones or hormone- producing enzymes
What are the basic treatment principles for endocrine hypofunction?
<ul><li>treat underlying cause</li><li>hormone supplementation</li></ul>
What are the types of endocrine hyperfunction?
1st, 2nd, 3rd
What is Cushing’s Syndrome and its cause in primary form?
disorder of glucocorticoid excess caused by adrenocorticol hypersecretion
What is the cause of secondary form Cushings Syndrome?
hypersecretion of ACTH
What the 5 etiologies of endocrine hyperfunction?
<ol><li>tumors/neoplasm</li><li>autoimmune stimulation</li><li>ectopic production of hormone</li><li>hyperplasia</li><li>iatrogenic/factitious problems</li></ol>
What is the pathophysiology of hyperplasia?
↑ cellularity and hormone overproduction<br></br><br></br>
What is the pathophysiology of autoimmune stimulation for Graves’ disease?
antibodies bind and activate TSH receptors on thyroid
what is the causes and types of hormones can be ectopically produced?
polypeptides:<br></br>ACTH, ADH, calcitonin<br></br><br></br>insulin(rare)<br></br><br></br>*caused by tumors that do not usually produce the hormone
What is an iatrogenic problem and an example?
intentional exogenous administration of the hormone<br></br><br></br>ex: steroids for anti-inflamm conditions
What is a factitious problem and an example?
exogenous administration of hormone by pt w/o clinician’s knowledge<br></br><br></br>ex: thyroid hormone to induce weight loss
What are the treatments for endocrine hyperfunction?
<ul><li>removal</li><li>radiation</li><li>pharmacologic intervention (block production, reception, sequelae control)</li></ul>
what does hormone response require?
<ul><li>normal receptor protein structure</li><li>receptor available</li><li>intact receptor signaling</li><li>normal post receptor events</li></ul>
What can cause tissue resistance/ insenseitivity?
<ul><li>receptor defects/lack of availability</li><li>post receptor defects</li><li>target tissue damage</li></ul>
What types of assays are available for hormone levels?
<ul><li>RIA</li><li>ELISA</li><li>RRA</li><li>FIA</li></ul>
What else can assays measure?
hormone metabolites
What are qualities of a good assay?
both sensitive and specific<br></br>
What is dynamic testing?
endocrine test that provide info about function beyond regular testing
what is dynamic testing based off of and what is the goal of it?
stimulation or supression of endogenous hormone production<br></br><br></br>goal: response to target tissue in vivo
what are stimulation tests used?
hypofuction of gland is suspected and look at reserved capacity of hormone<br></br>
How are stimulation test performed?
<ul><li>admin of exogenous hormone → look at capacity of target gland ↑ hormone production</li><li>admin of drug → secreation of endogenous hormone → effects on target gland hormone levels</li></ul>
What is an example of dynamic testing for adrenal insufficiency diagnosis?
rapid ACTH test (cortrosyn IV/IM)<br></br>cortisol measured at 30-60 mins<br></br><br></br>↑ cortisol: 2/3º AI<br></br>↓ cortisol: 1º AI
When are suppression tests used?
hyperfunction suspected and check negative feedback intact (GH,glucose)
What types of testing/imaging can be used for endocrine diagnosis?
<ul><li>MRI, CT</li><li>biopsy</li><li>genetic testing</li></ul>
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What is some advice for endo?
<ul><li>know chemistry of hormone → unlock info</li><li>know what hormone does physio, then excess and deficient</li><li>dont jump to conclusions with labs</li></ul>
what is hypothalamus part of ?
diencephalon
What are the two main parts of the pituitary?
anterior lobe(andeohypophysis)<br></br>posterior lobe(neurohypophysis)<br></br><br></br>*in sella turcica
what are the 2 important hypothalmic nuclei?
<ul><li>paraventricular</li><li>supraoptic</li></ul>
What are the 5 cell types of the anterior pituitary?
<ul><li>Thyrotropes (5% TSH)</li><li><span>Lactotropes (15% Prolactin)</span><br></br></li><li><div> <div> <div> <div> <div><span>Corticotropes (15% ACTH)</span></div></div></div></div></div></li><li><div><div><span> </span><div><span> </span><div><span> </span><div><span> </span><div><span>Somatotropes (20% GH)</span></div><span> </span></div><span> </span></div><span> </span></div></div></div></li><li><span> </span><div><span> </span><div><span> </span><div><span> </span><div><span>Gonadotropes (15% FSH, LH)</span></div></div></div></div></li></ul>
how many different hormones are secreted by the anterior pituitary and hypothalamus?
anterior (6) influenced by (6/7) of hypothalamus
What are the main regulators of GH secretion?
GHRH and GHIH<br></br>aka somatostatin
How is GH secretion regulated?
<ul><li>indirectly through somatomedins (IGFs) production in liver</li><li>negative feedback</li><li>effects of target tissues</li></ul>
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How often is GH secreted?
pulses at 2-2.5 hrs
when does the largest secretory burst of GH occur?
w/in 1 hr of falling asleep
How does GH secretion vary over a lifetime?
childhood: stable<br></br>puberty: secretory burst<br></br>after puberty: stable<br></br>elderly: lowest level
What are the physiological functions of GH?
<ul><li>more bone laid down for long bones(epiphys plates)</li><li>↓ glucose uptake and utilization (muscle and adipose)</li></ul>
How is prolactin secretion regulated?
not pregnant: inhibited by dopamine (PIH) from hypothalamus<br></br><br></br>pregnant: stimuli for secretion
what are the physiological effects of prolactin in pregnant and post partum women?
<div>post partum</div>
<ul><li>stimulates milk production</li><li>synth + secretion of GnRH → inhibits ovulation → ↓fertility during breastfeeding</li></ul>
<div>preg</div>
<div><ul><li>PRL ↑ → additional breast development → milk production prep</li></ul></div>
what are the physiological effects of prolactin in males?
hyperprolactinemia → inhibit GnRH → ↓spermatogenesis→ infertility<br></br><br></br>galactorrhea
What does LH do in male testes?
stimulates leydig cell → makes testosterone → spermatogenesis
What does FSH do in male testes?
stimulates Sertoli cells → secrete seminal fluid
What should be given to people who make too much GH?
glucose
What does FSH and LH do in females?
menstrual cycle: stimulates ovaries<br></br><br></br>1st half: synth and secrete estradiol<br></br><br></br>2nd half: synth and secrete progesterone
What are the 3 phases of post- natal growth pattern?
<ul><li>infantile (2yrs 30-35 cm)</li><li>childhood( 5-7cm/yr, prepubertal dip)</li><li>pubertal phase (8-14 cm/yr, ↑ gonadal steroids + GH secretion)</li></ul>
What is constitutional short stature?
variation of normal<br></br><br></br>2 SDs + ↓ mean height for kids of that age and sex
what are the hormones made in posterior pituitary and what nuclei do they originate from ?
ADH (SON) and Oxytocin (PVN)
How is ADH stimulated?
↑ plasma osmolality (most important)<br></br>hypovolemia<br></br>↓ in ECF vol 10% +<br></br>↓ in aBP
What does ADH do?
<ul><li>water reabsorbtion by kidneys (V2 receptor bind → ↑h20 permeability)</li><li>contraction of arteriolar vascular smooth muscle (V1 receptor bind → vasocontruction, ↑BP)</li></ul>
What is the pathophysiology associated with ADH?
neurogenic DI → decrease ADH secretion<br></br><br></br>nephrogenic DI → renal insensitivity to ADH (defect in V2 receptor/ signaling)<br></br><br></br>
What are the major clinical manifestations of DI in adults?
<ul><li>large volumes of dilute urine</li><li>excessive/intense thrist</li><li>↑fluid ingestion</li></ul>
<div>* can also happen with primary polydipsia (complulsive water drinking)</div>
What test is used to diagnose DI?
water deprivation test<br></br><br></br>(2-3hrs dep→ measure urine and plasma osmolality → synth ADH given)<br></br><br></br>desmo, urine and plasma osmo measured<br></br>
How is neurogenic DI treated?
desmopressin
how is nephrogenic DI tx’d?
HCTZ
What is SIADH and what signs and symptoms are associated with it?
↑ ADH secretion<br></br><br></br><ul><li>hyponatremia</li><li>plasma hyposmolality</li><li>↑ urinary Na+ excretion</li><li>lung cell carcinoma<div> <div> </div></div></li></ul>
How does oxytocin function in lactation?
suckling on nipple → oxytocin secretion→ contracts mammry alveoli/ ducts → milk ejection
How does oxytocin work in birth?
oxytocin → initiates and ↑ contractions in active uterus
How does oxytocin affect males/females?
<ul><li>cuddle/love hormone</li><li>facilitation of trust</li><li>antidepressant</li><li>empathy</li></ul>
What is genetic short stature?
consitutional short stature in kids with short parents (@ or ↓ 3-5th percentile)
What are the 3 basic steps to diagnose short stature?
<ul><li>hx and presentation</li><li>IGF-1 levels</li><li>GH stimulation tests</li></ul>
What are some causes of short stature?
<ul><li>genetics/ maternal drug, alchy use/ fetal growth retardation</li><li>GH deficiency</li><li>chronic systemic dz/infection</li><li>psychosocial dwarfism</li></ul>
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What is a key finding in clinical presentation for short stature?
slow growth that progressively deviates from previously defined precentile (2+SD’s ↓ mean)
What can cause dysmorphic/disproportinate features associated with short stature?
<ul><li>chromosomal abnormalities</li><li>intrauterine infection</li><li>maternal exposures</li><li>dysplasia/rickets</li></ul>
What is are key tests to determine short stature?
<ul><li>x-ray: hand and wrist</li><li>IGF 1 levels (GH deficiency)</li><li>GH stimulation tests (10ng normal)</li></ul>
What is the gold standard to dx GH deficiency?
GH stimulation tests<br></br><ul><li>Insulin- induced hypoglycemia (15-120 min after injection)</li><li>Arginine (serum GH 0-120 min after)</li></ul>*correct thyroid def 1st
What are the hypothalamic causes of GH deficiency?
idopathic(GHRH secretion)<br></br>hypothalmic tumors
What are the pituitary causes of GH def?
<ul><li>abnormal GH secretion</li><li>tumor, radiation</li><li>trauma/removal</li><li>idiopathic</li></ul>
What are the signs of tall stature?
<ul><li>variation from normal</li><li>accelerated growth</li><li>genetics</li><li>advanced bone age</li><li>taller than peers</li></ul>
what are genetic causes of tall stature?
Klinefelte’s syndrome (2+ X chromosomes in male phenotype)<br></br><br></br>Marfan’s syndrome (inherited autosomal dominate disorder of connective tissue)
What are the features of klinefelter’s syndrome?
<ul><li>long arms and legs<br></br></li><li>learning disabilities (language)</li><li>small testes and gynecomastia</li></ul>
<div><span>MC cause of congenital hypogonadism</span></div>
What are the features of Marfan’s syndrome?
<ul><li>tall</li><li>long, thin fingers</li><li>hyperextension of joints</li></ul>
What are the endocrine causes of tall stature?
<ul><li>pituitary giantism</li><li>precociois puberty</li><li>hyperthyroidism</li></ul>
What is the clinical manifestation of pituitary giantism?
(rare)<br></br><ul><li>GH excess</li><li>Height 3-4 SDs from normal</li><li>headache + VF involvement (tumors)</li><li>rapid growth rate</li><li>excess size for age</li></ul>
What are the features of precocious puberty?
<ul><li>tall</li><li>early epiphys closure</li><li>advanced bone age</li><li>more common in girls</li><li>short adult</li></ul>
what are the causes of precocious puberty?
<ul><li>congenital adrenal hyperplasia</li><li>virilizing adrenal tumors</li><li>testicular and ovarian tumors</li><li>ovarian cysts</li></ul>
What are the features of hyperthyroidism?
overproduction/tx w/ exogenous thyroxine<br></br>↑ growth and advanced bone age
How is pituitary giantism dx’d?
<ul><li>bone age</li><li>TFT</li><li>sex steroid hormone [conc]</li><li>karyotype</li><li>GH studies (IFG 1 Levels, OGTT, MRI)</li></ul>
What is the most common cause of acromegaly?
<div>GH secreting adenoma of the pituitary</div>
what is acromegaly?
excessive GH after puberty
What are other causes of acromegaly?
<ul><li>excess secretion of GHRH by hypothalamic or small cell lug cancers</li><li>ectopic secretion by non- endocrine tumors</li></ul>
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What are the clinical features of acromegaly?
<ul><li>stimulation of tissue growth</li><li>insulin antagonism and lipogenesis</li><li>adenoma</li><ul><li>headache</li><li>visual field defects</li><li>cranial nerve palsies</li></ul></ul>
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What are 3 examples of anopsias?
<ul><li>total blindness (left eye, L optic nerve)</li><li>bitemporal hemianopsia (optic chiasm)</li><li>right homonymous hemianopsia(L optic tract)</li></ul>
What are the clinical features of acrial overgrowth?
<ul><li>enlarged jaw</li><li>enlarged, swollen hands and feet</li><li>enlarged nose and frontal bones</li><li>teeth spread apart</li></ul>
What are the clinical features of articular overgrowth?
<ul><li>enlarged synovial tissue</li><li>hypertophic arthropathy (knees, ankles, hip, spine)</li><li>back pain and kyphosis</li></ul>
What are the clinical features of acromegaly for pituitary function?
macroadenoma: ↓secretion of other pituitary hormones (gonadotropins MC)<br></br><br></br>
What are the clinical features of skin and hear with acromegaly?
<ul><li>thickened skin and skin tags</li><li>hyperhidrosis</li><li>↑ hair growth and hitsutism</li></ul>
what are the soft tissue clinical features of acromegaly?
<ul><li>macroglossia (sleep apnea)</li><li>deepened voice</li><li>hand paresthesias</li></ul>
what are the clinical manifestations of tumors, viscera and others in acromegaly?
Tumors<br></br><ul><li>↑ uterine tumors (benign)</li><li>colonic adenomatous polyps</li><li>adenocarinoma ~10%</li></ul><div>Viscera</div><div><ul><li>enlarged organs</li></ul><div>Other</div></div><div><ul><li>sleep apnea, CV dysfunction, neuropathy, hypogonadism</li></ul></div>
What are the lab abnormailites of acromegaly?
<ul><li>hyperglycemia</li><li>hyperprolactinemia</li></ul>
What is the mortality of acromegaly?
2-3x expected (CV and CA)<br></br>↓10 yr survival average<br></br>lower GH → normal mortaility rate
What are the dental aspects of acromegaly?
<ul><li>macroglossia(indentations from teeth)</li><li>enlarged jaw</li><li>malocclusion (over/underbite)</li><li>teeth spacing</li></ul>
What are other oral aspects of acromegaly?
<ul><li>thick lips</li><li>salivary gland enlargement</li><li>skin folds (face)</li><li>enlarged nasal sinus</li></ul>
what is the best test to dx acromegaly?
IGF-1 [conc]
what other tests can be used to dx acromegaly?
GH supression test(>2ng/ml in 85% post gluc)<br></br>Pituitary MRI
what is the presentation for a male with<span>Hyperprolactinemia?</span>
<ul><li>impotence/ ↓ libido</li><li>infertility</li><li>headache</li><li>perph vision loss</li><li>mood changes</li><li>galactorrhea</li><li>gynecomastia</li></ul>
what is the presentation of females with<span>Hyperprolactinemia?</span>
same as male + :<br></br><ul><li>irregular menstruation</li><li>menopausal symptoms</li><li>weight gain</li><li>increased androgens</li></ul>
what are the causes of hyperprolactinemia?
<ul><li>prolactinoma</li><li>pituitary tumors</li><li>thypothalamic disease</li><li>CKF</li><li>severe 1º hypothyroidism</li><li>med SEs</li><li>idiopathic</li></ul>
What types of meds can cause hyperprlactinemia (PRL level <50-100 ng/mL)?
<ul><li>dopamine receptor antagonist</li><li>dopamine depleting agents</li><li>trycyclic antidepressants</li><li>verapmil</li><li>estrogens and antiantdogens</li><li>opiates</li></ul>
what is a highly suggestive PRL secreting adenoma for a fasting serum?
> 200ng/mL<br></br>prolactinomas(~1% of pop)<br></br><ul><li>microadenoma in women(<10mm)</li><li>macroadenoma in men (>10mm)</li></ul>
what are common clinical features of women with hyperprolactinemia?
<ul><li>amenorrhea</li><li>galactorrhea</li><li>infertility</li></ul>
what are common clinical features of males with hyperprolactinemia?
<ul><li>↓ libido</li><li>headache/vision changes</li><li>impotence/infertility</li></ul>
What is the workup for hyperprolactinemia?
<ul><li>Serum Assays: PRL, FSH, LH, estradiol, testosterone, TSH, renal/hepatic panels, 𝛃 -hCG (females)</li><li>MRI of brain and pituitary</li><li>VF exam</li><li>neuro testing</li></ul>
What is hypopituitarism?
<div>disease of pituitary gland or hypothalamus→ decreased pituitary hormone secretion → multiple hormone deficits</div>
What is the most common cause of hypopituitarism?
pituitary tumor or tx of tumor
What are other causes of hypotiuitarism?
<ul><li>pituitary radiation (exposed to all pituitary) → new ACTH, TDH or LH/FSH defs (4yrs)</li><li>hemochromotosis (infiltrative)</li><li>infarction(Sheehan's syndrome)</li><li>pituitary apoplexy (spontaneous hemorrhage into pituitary)</li></ul>
What is the presentation and treatment of pituitary apoplexy?
<ul><li>severe headache, visual deficits due to pressure (tumor)</li><li>w/o tx: permenant visual damage, hypopituitarism, death</li><li>emergency pituitary decompression</li></ul>
what are the order hormones fall in hypopituitarism?
<div>GH ↓ → LH/FSH → ACTH → TSH → prolactin</div>
How does ACTH definiency present in hypopituitarism?
cortisol deficiency
how does TSH deficiency present in hypopituitarism?
T3/T4 deficiency → lethargy, ↓ appetite, facial puffiness, dry skin, brady, anemia
How does LH/FSH deficiency present in hypopituitarism?
<ul><li>hypogonadism</li><ul><li>women: ovarian hypofunction</li><li>men: testicular hypofunction</li></ul></ul>
how does GH deficiency present in hypopituitarism?
children: short<br></br>adults: <br></br><ul><li>↓ muscle mass, ↑ fat mass</li><li>↑LDL</li><li>↑CVD risk</li><li>↓ bone density</li></ul>
how does PRL deficiency present in hypopituitarism?
inability to lactate after delivery(preg)
How is hypopituitarism dx’d?
<ul><li>↓secretion documentation of hormones</li><li>test each hormone seperately</li><li>consider lesions</li></ul>
how is hypopituitarism treated?
depends on hormone deficit
Where are the adrenal glands located?
Retroperitoneal cavity above each kidney
what are the 3 primary sources the aterial supply arises from?
<ol><li>superior suprerenal arteries</li><li>middle suprarenal artery</li><li>inferior suprarenal arteries</li></ol>
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what is the largest part of the adrenals?
Cortex (80%)
what are the 3 distinct cells of the adrenal cortex?
<ol><li>zona glomerulosa</li><li>zona fasciculata</li><li>zona reticularis</li></ol>
what are the adrenal medulla cells?
chromaffin cells
What hormones are produces in the zona glomerulosa?
mineralocorticocoids → aldosterone
What hormones are produces in the zona fasciculata?
glucocorticoids → cortisol
what hormones are produced in the zona reticularis?
adrenal androgens → DHEA anf Androstenedione
what hormones are produced in the medulla?
epi and norepi
what is the basis for why each layer makes a different steroid?
the presence or absence of certain enzymes
What is the main role of cortisol?
“coping with adversity”
How does cortisol work?
increase glucose (gluconeogenesis, liver) → increase protein + fat breakdown → protect against hypoglycemia
what are the other actions of cortisol?
<ul><li>anti-inflammation</li><li>immune response suppression</li><li>maintain vascular response to NE/Epi</li><li>inhibit bone formation</li><li>maintain/promote ↑ GFR</li></ul>
what is Cushing Syndrome?
excess cortisol due to problem(tumor) in adrenal cortex
what is Cushing Disease?
excess cortisol due excess ACTH (tumor) in anterior pituitary
what is addisons disease (primary adrenal insufficiency)?
↓ cortisol secretion due to AI or fungal infections in adrenal cortex
what is secondary adrenal insufficiency?
↓ ACTH secretion
What are plasma ACTH levels in Cushing Syndrome and Addison disease?
they are high
what is the clinical features of Cushing Syndrome?
hyperglycemia<br></br>osteoporosis<br></br>HTN
why does pathophysiology of addisons cause hyperpigmentation?
it results from elevated ACTH and subsequent metabolism to ⍺-MSH
Does hyperpigmentation occur in 2º adrenal insufficiency
no, they have lower levels of ACTH
which situations can cause an adrenal crisis?
<ul><li>undx'd with serious infection/stress</li><li>dx'd + infection + vomiting(GI, gastroenteritis)</li><li>after bilateral adrenal infarction or hemorrhage</li><li>abrupt withdrawl from steroids</li></ul>
what is the predominant manifestation of adrenal crisis?
shock
what are more common symptoms of adrenal crisis?
<ul><li>anorexia</li><li>N,V, ab pain</li><li>weak/fatigue</li><li>lethargy/fever</li><li>confusion</li><li>coma</li></ul>
what is aldosterone and what is its major function?
a primary mineralocorticoid and controls body fluid volume by ↑ reabs of Na+ in kidneys and ↑ K+ and H+ excretion.
what is the most common cause of conn syndrome (primary hyperaldosteronism)?
adenonma (75%)
what is the cause of idiopathic hyperaldosteronism?
adrenal hyperplasia
what are the two main clinical findings of primary hyperaldosteronism?
HTN and hypokalemia
How is Conn Syndrome treated?
spirolactone + tumor removal
what are the other clinical findings of primary hyperaldosteronism?
<ul><li>EFC volume expansion</li><li>Na+ plasma NOT elevated ( only if dehydrated)</li><li>headaches</li><li>muscle fatigue and weakness (hypokalemia)</li></ul>
How is primary hyperaldosteronism diagnosed?
<ul><li>aldosterone:renin ratio >25ng/dL</li><li>↑aldosterone + ↓ renin(PRA)</li></ul>
<br></br>
What is the saline suppression test?
a test to measure aldosterone excess<br></br><ul><li>2L saline x 4 hrs</li><li>aldosterone measured before + after</li><li>>10ng/dL → primary hyperaldosteronism</li></ul>
what is the next step in primary hyperaldosterone diagnosis after aldosertone:renin and saline suppression?
CT/MRI<br></br><ul><li>if high aldosterone levels, consider solitary tumor (MC)</li><li>if MILD → bilateral adrenal hyperplasia</li></ul>
If MRI/CT is inconclusive, what is the next step in primary hyperaldosteronism diagnosis?
adrenal venous sampling (taken from each gland)<br></br><ul><li>if one side higher → functional adrenal tumor</li><li>same bilaterally → hyperplasia</li></ul><br></br>
how is primary hyper aldosteronism treated?
sugically (take out tumor) or with spirolactone (hyperplasia)
what are the physiological effects of adrenal androgens on women?
it is responsible for pubic and axillary hair devo and libido
what occurs in adrenogenital syndrome (congenital 21𝛃 -hyroxylase deficiency) and what is it caused by?
<ul><li>females become masculinized and virilized</li><li>supressed gonadal function in both sexes</li></ul>
<div>it is caused by an ↑ synth of adrenal androgens (↑DHEA and androstenedione levels)</div>
what causes congenital 17⍺-hydroxylase deficiency and what occurs?
<ul><li>cause: lack of cortisol and adrenal androgens</li><li>occurance: production shunted toward mineralocortocoid pathway</li></ul>
what are the physiological effects of the adrenal medulla hormones?
the effects of epi (synth’d)
what is phenochromocytoma?
a tumor on the adrenal medulla → epi and norepi secretion
what is the etiology of phenochromocytoma?
<ul><li>90% benign tumor</li><li>10% outside adrenals</li><li>10% malignant</li><li>0.1-0.2% w/ HTN</li></ul>
what are the clinical findings of phenochromocytoma and how do they typically present?
<ul><li>HTN</li><li>Headache</li><li>palpatations/tachy/sweaty</li><li>anxiety/tremors</li><li>weight loss/ hypermetabo</li><li>hyperglycemia</li></ul>
<div>usually wax and wane</div>
what is phenochromocytoma commonly misdiagnosed as?
<ul><li>HTN/myocarditis</li><li>anxiety/cocaine/ meth</li><li>unstable angina</li><li>hyperthyroidism</li></ul>
what occurs if phenochromocytoma goes untreated?
<ul><li>MI/Stroke/arrythmia</li><li>shock/renal failure</li><li>dissecting aortic aneurysm</li><li>death</li></ul>
how is phenochromocytoma diagnosed?
<ul><li>24 hr urine catecholamine + metabolites (metanephrine, normetanephrine, wanillymandelic acid VMA)</li><li>plasma catecholamines >2000pg/mL (+)</li><li>imaging(MRI/CT)</li></ul>
what is a clonidine supression test?
clonidine admin to test for phenochromocytoma<br></br><ul><li>92% accurate</li><li>NO fall in levels if phenochromocytoma present (wait 3 hrs after admin to test)</li></ul>
how is a phenochromocytoma treated?
surgery<br></br><ul><li>no carvedilol before</li></ul><div>possbile outcome → vascular instability/shock (excess catecholamines are gone)</div>
how is GH administered and what are the brand names?
subQ<br></br><br></br>brands<br></br><ul><li>-tropin/trope</li><li>saizen</li></ul><br></br>
What is the indication for IGF-1 prep and what is it’s name?
growth failure from primary IGF-1 deficiency<br></br><ul><li>mecasermin</li></ul>
what is the main adverse effect of IGF-1 prep?
hypoglycemia<br></br>(eat right before or after)
what is GHIH (somatostatin) prep indicated for and what are their names?
indicated for acromegaly<br></br><ul><li>octerotide (sandostatin)</li><li>lanreotide</li></ul>
what will acromegaly provoke that causes the need to administer a dopaine agonist?
secretion of high prolactin → cabergoline
What is the inidcation for GHR antagonist and what is its name?
indication: acromegaly<br></br>name: Pegvisomant
what is the MOA of GHR antagonist?
blocks GH receptors and ↓ IGF1 blood levels
what testing is done for pegvisomant(somavert) prior to administration?
LFT’s
what are the names of the dopamine agonist and what are they indicated for?
name: cabergoline, bromocriptine<br></br>indication: prolactinoma
what is the MOA of dopamine agonist?
minic dopamine(PIH)
which dopamine agonist is more effective and why?
cabergoline: more selective for D2 receptors on lactoropes (anterior pituitary)
what is the indication for oxytocin prep and what is its name?
indication:<br></br><ul><li>↑ contraction in labor</li><li>prevent hemorrhage after labor</li></ul><div>name: pitocin</div>
what is the indication for oxytocin in regards to breastfeeding?
stimulate lactation reflex
what is the indication for ADH(vasopressin) and what is its name?
indication: neurogenic (central) DI, primary noctural enuresis(+6yo)<br></br>name: desmopressin
how can DDAVP be administered?
nasal<br></br>oral (only 5% abs)<br></br>IV(control bleeding)
what is the indication for mineralocorticoid and what is its name?
indication: adrenal insufficiency<br></br>name: hyrdocortisone (30-35.7mg/day)<br></br>
what is the indication for increasing the dose of hydrocortisone?
minor or major stress
what are the indications for low potency hydrocortisone/cortisone?
<ul><li>replacement therapy</li><li>minor inflamm conditions</li></ul>
what are the indications for prednisone/prednisolone?
<ul><li>inflamm/allergies</li><li>asthma</li><li>AIs</li></ul>
what are the indications for bethmethasone/budesonide/dexamethasone?
<ul><li>skin disorders</li><li>asthma</li><li>adrenal axis testing</li></ul>
what other mineral corticoid replacement can be used if hydrocortisone is not sufficient replacement?
fludrocortisone(50-200 mg/day oral)
what are the adverse signs that indicate for more mineralocorticoid?
<ul><li>hypotension</li><li>hyperkalemia</li><li>hyponatremia</li></ul>
<div>* opposite indicates for less</div>
what are the names and MOAs of the drugs for Cushing’s syndrome
<ul><li>aminoglutethimide, MOA: inhibit cholesterol → pregnenolone conversion</li><li>metyrapone, MOA: inhibit 11𝛃-hydroylase</li><li>ketoconazole + fluonazole, MOA: antifugal have some 11𝛃-hydroylase inhibition</li></ul>
what are the names of aldosterone receptor antagonist and what is thier indication?
name: eplerenone(more selective to aldosterone receptors) and spirolactone<br></br>indication: hyperaldosteronism
what is the most common alpha blocker and its indication?
phenoxybenzamine<br></br>indication: pre-op (10-14 days) to normalize BP
what is the most common beta blocker and when is it administered?
propanolol<br></br>given AFTER alpha andrenergic
what is the adverse effect of giving propanolol before phenoxybenzamine and why?
perph 𝛃-adrenergics receptors are blocks → vasodilation blocked → greatly ↑ BP
What are the functions of ADH?
↑ serum osmlarity or ↓ intravascular volume
where is ADH synthesized and secreted from?
synthesized: hypothalamus<br></br>secreted: anterior pituitary
what occurs with abnormal ADH levels?
too little/ receptor issues: DI<br></br>too much: SIADH
which type of body composition has has more total body water?
lean (60%)
what are they key differences in fluid volume between infants/children and elderly?
children:<ul><li>higher turnover and lost more h2o (immature kidneys)</li><li>more SA, ↑ insensible losses</li></ul><div>elderly</div><ul><li>↓ thirst response</li><li>meds influence inbalances</li></ul>
what is defined as orthostatic hypotension?
↓ SBP of 20mmHg<br></br>↑DBP of 10mmHG w/in 3 min of standing
what labs are used to test ADH?
<ul><li>BMP (BUN, K+, Na+, Creatinine, gluc)</li><li>H + H & CBC</li><li>Urine osmolality (sp. gravity)</li><li><br></br></li></ul>
<br></br>
what is the hematocrit range for both sexes?
male: 40-54%<br></br>female: 38-47%
what does specific gravity measure?
weight of a substance compared to pure water at same temp
what is the normal range for SG?
1.005-1.030<br></br>(more [conc] ↑ the number)
what is the clinical presentation for someone who is hypovolemic?
<ul><li>↑ thirst</li><li>oliguria</li><li>↓skin turgor + dry membranes</li><li>CNS ↓</li><li>weak + muscle cramps</li><li>↓BP, postural hypotension, ↑pulse</li></ul>
what are causes of hypovolemia?
<ul><li>GI, renal and skin loss</li><li>sequestration w/o loss</li></ul>
what are clinical features of hypervolemia?
<ul><li>SOB, HTN, tachy</li><li>crackles</li><li>JVD</li><li>edema, weight gain</li><li>orthopnea, PND</li><li>hepatojugular reflux</li></ul>
what are the causes of hypervolemia?
<ul><li>overhydration</li><li>↑ Na+ intake</li><li>1º renal Na+ retention (1º hyperaldosteronism/ cushings dz)</li><li>2º renal Na+ retention (heart + liver failure)</li></ul>
what is osmolality, its solutes and normal ranges?
solute or particle [conc] of a fluid<br></br>solutes: Na+, gluc, urea<br></br>range: 280-295mOsm/kg
what are other osmotically active stubstances?
mannitol<br></br>antifreeze, ethanol, methanol
what is water retention influeced by?
<div>thirst and ADH</div>
what is salt retention influenced by?
RAAS, ANP and catacholamines
what does an electrolye panel consist of?
Na+ (135-145)<br></br>K (3.5-5.0)<br></br>Cl- (98-106)<br></br>Co₂ (22-32)
what should be considered when looking at sodium levels?
<ul><li>abnormal ECFV b/c of Na+ control mechanisms</li><li>abnormal [Na+] b/c of water control</li></ul>
<div>*both can coexist</div>
what are the two types of DI?
neurogenic (central)<br></br>nephrogenic
what are the etiologies of neurogenic DI?
<ul><li>idiopathic</li><li>tumors</li><li>neurosx/ trauma</li><li>FHx/congenital</li><li>hypercal or hypoK</li><li>lithium</li><li>sickle cell</li></ul>
what is the pathophysiology of DI?
neurogenic: low synth + secretion of ADH<br></br>nephrogenic: kidney not responding to ADH in blood
who is at risk for nephrogenic DI?
<ul><li>elderly</li><li>sick</li><li>acute/chronic renal insufficiency</li></ul>
what are the clinical manifestations of DI?
<ul><li>large vol. of DILUTE urine (2.5-20L/day)</li><li>excessive/intense thirst (cold drinks)</li></ul>
How is DI diagnosed?
<ul><li>24 hr urine</li><li>blood</li><li>plasma + urine osmolality w/ h₂o deprivation</li></ul>
what are differential diagnosis for polyuria?
<ul><li>DM (1st)/DI (SG <1.005, osmo<200)</li></ul>
what are normal results of a water deprivation test?
<ul><li>↑ADH w/ plasma osmolality ↑</li><li>↑ in urine osmolality</li></ul>
what is the treatment for neurogenic DI?
↓urine output (↑ADH)<br></br>replace fluid loss<br></br>DDAVP
What are other drugs that could be given if patient is unresponsive to DDAVP?
<ul><li>chlorpropamide</li><li>carbamazepine/clofibrate</li></ul>
how is nephrogenic DI treated?
<ul><li>treat underlying cause</li><li>hypercal → normalize Ca²+</li><li>lithium → IRREVERSIBLE if renal damage present</li></ul>
what medications can be used to treat nephrogenic DI?
thiazides + low Na+ diet
what is SIADH?
high ADH plasma levels w/o stimulus
what type of patients are suspected to have SIADH?
<ul><li>hyponaturemic</li><li>serum hyposmolality</li><li>Na+ urine excretion >20mmol/24hr</li></ul>
what are the etiologies of SIADH?
<ul><li>tumors</li><li>pulm disease</li><li>major sx</li><li>CNS disturbance</li><li>drugs induced</li></ul>
what is the pathophysiology of SIADH?
water retained → blood diluted → aldosterone ↓ → Na+ + urine removes excess H₂O
what are the main clinical manifestations of SIADH?
hyponatremia
what are signs and symptoms of SIADH?
<div>early</div>
<div><ul><li>N,V</li><li>headache</li><li>muscle cramps/ tremors</li></ul><div>Late</div></div>
<div><ul><li>confusion/miid swings</li><li>hallucinations</li><li>seizure/coma</li><li>death</li></ul></div>
what is the treatment for SIADH?
water restriction and salt administration<br></br>* rapid corrrection → neuro complications*
what are other treatment options for SIADH?
<ul><li>Na+ + loop diuretic</li><li>demeclocycline/lithium</li><li>ADH receptor agonist</li></ul>
How does the thyroid receive blood flow?
external carotids → superior thyroid arteries<br></br>subclavian → inferior thyroid arteries
what causes bruits on the thyroid?
goiter
what is the uncommon variant of blood supply to the thyroid?
brachiocephalic trunk, right common carotid or aortic arch → thyroid IMA artery (7.5% of people)
what are the 2 thyroid cells and what does one secrete?
TGB(thyroglobulin)<br></br>C cells(parafollicular cells) → secretes calcitonin
what are the 2 types of thyroid hormones, how is it converted and which is the most potent?
T₃ (triiodothyronine) + T₄ (thyroxine)<br></br><br></br>thyroid gland → T₄ → T₃ in target tissue<br></br>T₃ most potent<br></br>
what is necessary for normal thyroid hormone synthesis?
iodine (75-150 mcg/day)
what is the difference b/w 1º, 2º and 3º hypothyroidism?
need to enter
what is the 1st and 2nd step of thyroid synthesis?
- gather ingredients: C cells synth + TGB(↑ tyrosine) → dump into colloide <br></br><br></br>2. iodine trapped in Na+/I- pump<br></br><ul><li>pump inhibition</li><ul><li>thyocyanate + perchlorate (no clinical use)<br></br></li></ul></ul>
what is the 3-5th step of thyroid synthesis what is required for this process?
Thyroid peroxidase<br></br>3. oxidize I- →I₂<br></br>4. I₂ + tyrosine TGB → MIT +DIT (organification)<br></br>5. Coupling + colloid storage<br></br><ul><li>MIT+ DIT → T₃</li><li>DIT + DIT → T₄</li></ul>
what are the drugs that inhibit thyroid peroxidase
methinmazole<br></br>propylthiouracin (PTU, also inhibits T₄ → T₃ in perph tissue)
what are the 6-8th step of thyroid synthesis?
- colloid → follicular cells<br></br>7. cleave T₃, T₄, DIT/MIT → blood (T₃, T₄)<br></br>8. deiodination of residual MIT/DIT (<span>via thyroid deiodinase</span>) & recycle I- and tyrosine
what are the actions of TSH?
<ul><li>stimulate TGB synth</li><li>stimulate Na+/I- pump</li><li>activate thyroid peroxidase</li><li>stimulate thyroid follicles (too high → goiter)</li></ul>
what can cause goiters?
hypo/hyperthyroidism
what is the major clinical correlation to TSH/TSI binding?
graves disease
what are the 3 major transport proteins?
<div><ol><li>thyroxine-binding globulin</li><li>thyroxine- binding pre-albumin(TBPA)</li><li>albumin</li></ol></div>
what is the general effect of thyroid hormones?
activate nuclear transciption of genes → protein and receptor synthesis
when is the critical period CNS maturation?
perinatal
what occurs in utero with congenital hypothyroidism?
maternal T₄ crosses placenta to allow normal fetus development
when does fetal thyroid gland function begin?
10-12 weeks<br></br>1º source of thyroid hormone after 1st trimester
what occurs if congenital hypothyroidism goes untreated?
growth retardation and delayed cogitive development
what are the 3 screenings for congenital hypothyroidism and when is it done?
- low T₄ → for high TSH<br></br>2. high TSH<br></br>3. low T₄ + high TSH<br></br><br></br>2-5 days after birth
what are the CNS effects of thyroid hormone in adults?
alertness, concentration/focus
what else does thyroid hormone promote in adults and what occurs with hypothyroidism?
ossification and fusion of bone plates and maturation<br></br>intestinal motility<br></br><br></br>hypothyoidism: bone age is less than chronologic age
what would the TSH plasma levels look like in each hyperthyroid disease?
<ul><li>graves → low</li><li>neoplasms → low</li><li>TSH-secreting adenoma → high</li><li>factitious administration → low</li></ul>
what is a thyroid storm?
FATAL<br></br>exaggeration of usual hyperthyroid symptoms<br></br><ul><li>resting tachy or arrythmia (>140,aFib)</li><li>hypotension/shock</li><li>high fever(104-106)</li><li>severe N,V,D, ab pain</li><li>anxiety/delirium/psychosis/coma</li><li>↑T₃ & T₄, ↓TSH</li></ul>
what causes a thyroid storm?
<ul><li>surgery</li><li>trauma/partition</li><li>infection</li></ul>
what are the clinical manifestations of hypo/hyperthyriodism?
based on what thyroids normally do
what are causes of hyperthyroidism?
<ul><li>graves</li><li>neoplasms</li><li>TSH-secreting adenoma</li><li>facticious admin</li></ul>
what causes hypothyroidism?
<ul><li>hashimotos/thyroiditis</li><li>iodine deficiency</li><li>thyroidectomy</li><li>lack of TSH</li></ul>
what would plamsa levels look like in each primary hypothyroid cause?
<ul><li>hashimotos</li><li>iodine deficiency</li><li>thyroidectomy</li><li>lack of TSH</li></ul>
<div>HIGH TSH → LOW T₄</div>
what is myxedema?
deposition of mucopolysaccharides in dermis → swelling in affected areas<br></br><br></br>severe hypothyroidism
what is myxedema coma?
<span>Medical emergency (30-40% mortalility, rare)</span><br></br>↓CNS and hypothermia<br></br>(shock-like symptoms also present)
what are symptoms associated with myxedema coma?
<ul><li>puffy hands and face</li><li>thick nose</li><li>swollen lips and tongue</li><li>non-pitting extremities</li></ul>
how is myxedema coma managed?
supportive<br></br><ul><li>correct hypothermia</li><li>electrolytes + glucose</li><li>vent</li><li>IV T₄</li></ul>
what are the two mechanisisms hyperthyroidism is caused by and what is used to determine treatment?
1.↑ thyroid function<br></br>2. not associated with ↑ thyroid function<br></br><br></br>diagnositc:24 hr radioactive irodine uptake (RAIU +/-) scan
what labs are done BEFORE RAIU and scan?
TSH<br></br>Free T₃ + T₄<br></br>preg test
what is a RAIU and scan? What are normal values?
pt ingest iodine and is scanned<br></br>10-30% @ 24 hrs
when is RAIU contraindicated?
pregnancy and breastfeeding
what is a high RAIU and what does it indicate?
> 30% @ 24 → increased thyroid function
what are autoimmune thyroid diseases and what causes them?
diseases: AI hyperthyroidsim/graves<br></br>cause: TSH antibodies → TSI (thyroid stim immunoglobs)<br></br><ul><li>TSI thyroid activity stimulates thyroid independent of TSH</li></ul>
what is the most common cause of hyperthyroidism and what are the lab results? What is a common sign?
graves<br></br>↓TSH ↑T₄<br></br>exopthalmos
what do autonomous thyroid tissue do and what are the labs?
toxic adenoma/multinodular goider develop auto function → make excess thyroid<br></br><br></br>labs:↓TSH,↑T₄
what is a rare cause of hyperthyroidism
↑TSH via TSH-producing macoradenomas?<br></br>
what does TSH-producing adenomas cause and what are their labs?
cause: secondary hyperthyroidism<br></br>labs: ↑TSH and T₄
what is the inidcation for low RAIU and what is it not associated with?
low: <10% @24hrs<br></br><br></br>indication: inflamm or destruction of thyroid tissue → released of pre-formed/extra thyroidal source hormone to circulation<br></br><br></br>NOT ASSOCIATED: ↑ thyroid function
what does thyroiditis result from and what does it cause?
result from: inflammation<br></br><br></br>cause:injury from thyroid follicular cells → transient hyperthyroidism due to pre-formed T₃/T₄
What are the labs for thyroiditis?
↓TSH<br></br>↑T₄
what forms of thyroiditis present with pain and tenderness and what causes it?
subacute(viral,URI)<br></br>infectious(bacterial, staph/strep)<br></br>
what are forms of thyroiditis that present w/o pain and tenderness?
painless(AI, NOT hashis/graves)<br></br>postpartum<br></br>drug-induced(amnio,lithium)
what is the initial presention of thyroiditis followed by?
hypothyroid phase → thyroid fnx recovery (possible)
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Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
what can give rise to exogenous or ectopic hyperthyroidism and when can it occur?
rise: external/interal sources of excess thryroid hormone<br></br><br></br>cause:<br></br><ul><li>factitious</li><li>levo overdose</li><li>struma ovarii</li><li>large metastases from follicular carcinoma</li></ul>
what is struma ovarii?
functioning thyroid tissue in ovarian neoplasm
what causes high RAIU?
↑ thyroid function causes
what causes low RAIU
causes not associated with ↑ thyroid function
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// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
what happens to thyroid function during chronic AI thyroiditis?
gradual, permanent loss of function<br></br><br></br>NO initial hyperthyroid phase
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// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
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<div> <div><img></img></div> <div><img></img></div> </div>
Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
what is rare in the western world but still occurs worldwide?
iodine deficiency
what is an example of infiltrative 1º hypothyroidism?
hemochromatosis
what are the two major disorders of the adrenal cortex?
- adrenal hyperfunction<br></br>2. excess circulating levels
What are the 3 adrenal hyperfunction disorders?
- hyperaldosterism(↑aldosterone)<br></br>2. cushings syndrome(hypercortisolism)<br></br>3. phenochromocytoma(↑ catecholamines)
what are the two forms of hyperaldosteronism and where do they originate from?
primary → adrenal gland<br></br>secondary→ not from gland
what is aldosterone secretion mediated by?
Angiotension II, ACTH and K+ levels
what does aldosterone do?
<ul><li>active reabs of Na+</li><li>passive reabs of H₂O</li><li>active excretion of K+(↑BP/ blood vol. and hypoK)</li></ul>
what happens if there is too much aldosterone?
Na+ retention and K+ loss
what are the primary causes of 1º hyperaldosteronism?
<ul><li>adrenal adenoma/carcinoma</li><li>bilateral hyperplasia of adrenal gland</li></ul>
what is the clinical presentation of hyperaldosteronism and why?
HTN (aldosterone controls BP)<br></br>muscle weakness and paralysis (hypoK)
what are the etiologies of primary hyperaldosteronism?
<ul><li>conn's</li><li>bilateral adrenal hyperplasia</li><li>familial hyperaldosteronism(rare)</li></ul>
what is the cause of Conn’s syndrome?
a benign cortical adenoma
how is primary hyperaldosteronism diagnosed?
<ul><li>plasma aldosterone (AM)</li><li>CMP</li><li>PRA(plasma renin activity) blood test</li><li>Imaging(CT/MRI)</li><li>EKG(AFib)</li></ul>
what are the symptoms of hyperaldosteronism?
<ul><li>↑ BP</li><li>headache/vertigo</li><li>muscle weakness/ fatigue</li><li>periodic paralysis</li><li>polydipsia</li><li>weight gain</li></ul>
when are patients screened for hyperaldosteronism?
If hypoK with ↑K+ doses<br></br>resistant HTN
what are complications of yperaldosteronism?
MI, HF, Stroke
What is the treatment for hyperaldosteronism?
<ul><li>treat cause</li><li>removal (benign adenoma)</li><li>diuretics (bilateral hyperplasia)</li></ul>
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what is secondary hyperaldosteronism?
↑ aldosterone adrenal production from extra-adrenal stimuli
what are the causes of secondary hyperaldosteronism?
<ul><li>liver cirrhosis w/ ascities</li><li>shock</li><li>renin secreting tumors</li><li>HF</li><li>Renal stenosis (resistant HTN)</li></ul>
what is hypercortisolism?
Cushing syndrome/ disease
what are the endogenous causes of cushing syndrome?
tumor in adrenal cortex or pituitary
what are the exogenous causes of cushing syndrome?
medication<br></br>adrenal hyperplasia
what are the endogenous causes of cushing diease?
tumor in the anterior pituitary<br></br>excess ACTH production<br></br>pituitary hyperplasia
what do both cushing syndrome and disease have in common?
THEY ARE THE SAME<br></br>both hypercortisolism and affected by ACTH
Is Cushing syndrome endogenous or exogenous?
exogenous (MC) and temporary
what are the clinical manifestations of Cushings?
<ul><li>HTN</li><li>Moonface/obesity</li><li>osteoporosis/ecchymosis easily</li><li>insulin resistant</li><li>irregular menstration/ body hair</li><li>thin skin</li><li>major depression/mood swings/memory loss/ ↓ [conc]</li></ul>
what are the key symptoms of cushings?
abnormal fat distribution (buffalo hump)<br></br>moon face<br></br>hirsutism<br></br>stretch marks/ thin skin<br></br>
what is the most common cause of endogenous cushing syndrome and what does it do?
adrenal/pituitary adenoma → ectopic ACTH production
what is the most common cause of exogenous Cushing syndrome?
cortisol like meds
what are the most common causes of Cushings disease?
anterior pituitary adenoma(benign)<br></br>pituitary hyperplasia → too much ACTH
who commonly gets cushings syndrome?
women 20-40 yo
arenal carcinomas are <span>[…]</span> and produce <span>[…]</span> of androgens
arenal carcinomas are <span>larger</span> and produce <span>excessive amounts</span> of androgens<br></br>
adrenal adenomas are <span>[…]</span> and mostly produce <span>[…]</span>
adrenal adenomas are <span>benign, small</span> and mostly produce <span>cortisol</span><br></br>
ectopic causes of <span>[…]</span> are <span>[…]</span> and are NOT inhibited by <span>[…]</span>
ectopic causes of <span>ACTH secretion</span> are <span>malignant tumors, bilateral adrenal hyperplasia</span> and are NOT inhibited by <span>cortisol or other steroids</span><br></br>
the most common cause of <span>[…]</span> cushing syndrome is <span>[…]</span> because they i<span>[…]</span> secretion → <span>[…]</span>
the most common cause of <span>exogenous</span> cushing syndrome is <span>chronic use of steroids</span> because they i<span>nhibit CRH and ACTH</span> secretion → <span>bilateral adrenocorticol atrophy</span><br></br>
the 3 components of glucocorticoids are <span>[…]</span>, <span>[…]</span> and <span>[…]</span>
the 3 components of glucocorticoids are <span>cortisone</span>, <span>cortisol</span> and <span>cotricosterone</span><br></br>
gluconeogenesis occurs mainly in the <span>[…]</span> and makes <span>[…]</span> from <span>[…]</span>
gluconeogenesis occurs mainly in the <span>liver</span> and makes <span>glucose</span> from <span>non-carb sources</span><br></br>
glycoysis is the <span>[…]</span> → <span>[…]</span> and <span>[…]</span>
glycoysis is the <span>breakdown of glucose</span> → <span>pyruvate</span> and <span>energy</span><br></br>
glycogenolysis is the <span>[…]</span> to release glucose which occurs on the <span>[…]</span> and is stimulated by <span>[…]</span>
glycogenolysis is the <span>breakdown of glycogen</span> to release glucose which occurs on the <span>liver and muscle</span> and is stimulated by <span>epi and glucagon</span><br></br>
gluconeogenesis is stimulated by <span>[…]</span>, <span>[…]</span> and <span>[…]</span> that have <span>[…]</span> and <span>[…]</span>
gluconeogenesis is stimulated by <span>mobilized amino acids from extrahepatic tissues</span>, <span>fat breakdown in adipose</span> and <span>inhibits glucose uptake in muscle and adipose tissue</span> that have <span>anti-inflammatory</span> and <span>immunosuppressive properties</span><br></br>
mineralocorticoids and glucocorticoids are released from the adrenal cortex via the <span>[…]</span> of the <span>[…]</span> that releases <span>[…]</span> → <span>[…]</span>
mineralocorticoids and glucocorticoids are released from the adrenal cortex via the <span>feedback loop cycle</span> of the <span>hypothalmic-pituitary-adrenal axis</span> that releases <span>CRH from hypothalamus</span> → <span>ACTH from pituitary</span><br></br>
CRH is produced by the <span>[…]</span> and is carried via <span>[…]</span> to pituitary that <span>[…]</span> in pituitary
CRH is produced by the <span>hypothalamus</span> and is carried via <span>hypophysial artery</span> to pituitary that <span>stimulates ACTH</span> in pituitary<br></br>
ACTH follows the <span>[…]</span> and is <span>[…]</span>. They control the <span>[…]</span> and <span>[…]</span>
ACTH follows the <span>circardian rhythm</span> and is <span>undetectable by midnight</span>. They control the <span>production and release of sterids</span> and <span>stimulate cholesterol to pregnenolone(precursor)</span><br></br>
adrenal insufficiency is caused by <span>[…]</span> that is caused by <span>[…]</span> at any level of <span>[…]</span>
adrenal insufficiency is caused by <span>insufficient circulating gluco/mineralcorticoid hormone</span> that is caused by <span>abnormailites</span> at any level of <span>hypothalamic-pituitary-adrenal axis</span><br></br>
what are the risk factors for adrenal insufficiency?
<ul><li>genetics</li><li>medications(rifampin)</li><li>withdrawl</li><li>hypercoagulable states</li><li>severe sepsis</li></ul>
what are the etiologies of primary adrenal insufficiency?
<ul><li>autoimmune (80%)</li><li>infection</li><li>metastatic invasion</li><li>adrenal hemorrhage(sepsis)</li><li>inflintrative (sarcoidosis, hemochromatosis)</li><li>bilateral adrenalectomy</li></ul>
primary adrenal insufficiency is the <span>[…]</span> with <span>[…]</span> that are <span>[…]</span>
primary adrenal insufficiency is the <span>inability for the adrenal gland to release hormone</span> with <span>skin manifestations</span> that are <span>common but not diagnostic</span><br></br>
what are common clinical manifestations of primary adrenal insufficiency?
<ul><li>insidious</li><li>chronic malaise</li><li>fatigue (worse with exertion, better with rest)</li><li>anorexia/weight loss</li><li>GI</li><li>hypotension</li></ul>
what are key clinical manifestations of primary adrenal insufficiency?
<ul><li>hyponatremia(salt craving)</li><li>hyperK</li><li>hypoglycemia</li><li>hyperpigmentation (hair, nails, freckles become darker, patchy)</li></ul>
Addison’s is the <span>[…]</span> due to <span>[…]</span> that results from the <span>[…]</span> where at least <span>[…]</span>
Addison’s is the <span>hyposecretion of cortisol and aldosterone</span> due to <span>adrenal gland failure</span> that results from the <span>progresive destruction of the adrenal cortex</span> where at least <span>90% of the cortex is destroyed</span><br></br>
Addisons dieases is <span>[…]</span> and usually occurs at <span>[…]</span>
Addisons dieases is <span>uncommon</span> and usually occurs at <span>30-50 yo</span><br></br>
Addisons is diagnosed with <span>[…]</span> consisting of <span>[…]</span> along with <span>[…]</span> and <span>[…]</span>
Addisons is diagnosed with <span>labs</span> consisting of <span>Na+,K+, AM cortisol and ACTH</span> along with <span>chest/ab x-ray</span> and <span>flu test</span><br></br>
the treatment for Addison’s is <span>[…]</span>, <span>[…]</span> and <span>[…]</span>
the treatment for Addison’s is <span>IV hydorcortison</span>, <span>fluid restiction</span> and <span>steroid replacement</span><br></br>
they key differences in clinical presentation of 2º and 3º adrenal insufficiency are <span>[…]</span> or <span>[…]</span>, <span>[…]</span> and less common <span>[…]</span>
they key differences in clinical presentation of 2º and 3º adrenal insufficiency are <span>no hyperpigmentation</span> or <span>ACTH↑</span>, <span>no hyperK</span> and less common <span>GI, hyponatremia and hypotension</span><br></br>
what are the eitologies for 2º adrenal insufficiency?
<ul><li>hypopituitarism</li><li>pituitary infiltrative disease</li><li>Sx</li><li>acute interruption of prolonged steroid use</li></ul>
what are the etiologues of 3º adrenal insufficiency?
<ul><li>head trauma</li><li>sepsis</li><li>hypothalamus insufficiency</li><li>invasive neoplasms</li></ul>
2º and 3º adrenal insufficiency is diagnosed with <span>[…]</span>, <span>[…]</span>, <span>[…]</span>, t<span>[…]</span>, <span>[…]</span>, <span>[…]</span>
2º and 3º adrenal insufficiency is diagnosed with <span>↓cortisol levels in morning <3</span>, <span>ACTH stim test</span>, <span>cortisol <5</span>, t<span>hyroid panel+ TSH</span>, <span>CT/MRI/CXR</span>, <span>Renin and Aldosterone</span><br></br>
Increaced <span>[…]</span> with low <span>[…]</span> helps confirm <span>[…]</span>
Increaced <span>ACTH</span> with low <span>cortisol</span> helps confirm <span>1º adrenal insufficiency</span><br></br>
2º and 3º adrenal insufficiency is treated with <span>[…]</span> in mild cases and <span>[…]</span> for moderate/sev cases. Treatmet for severe cases like adrenal crisis calls for <span>[…]</span>
2º and 3º adrenal insufficiency is treated with <span>hydrocortisone</span> in mild cases and <span>hydrocortisone/prednisone + florinef</span> for moderate/sev cases. Treatmet for severe cases like adrenal crisis calls for <span>admission to ICU</span><br></br>
Adults with adrenal insufficiency are monitered <span>[…]</span> and ped every <span>[…]</span> by endo. They are screened <span>[…]</span> for <span>[…]</span>. Pts are educated in regards to steroids during <span>[…]</span>. Genetic counseling is recommonened for <span>[…]</span>
Adults with adrenal insufficiency are monitered <span>every month</span> and ped every <span>6-12 months</span> by endo. They are screened <span>annually</span> for <span>thyroid, DM, premature ovarian failure, celiac disease, and vit B12 def</span>. Pts are educated in regards to steroids during <span>illness, fever and stress</span>. Genetic counseling is recommonened for <span>1º</span><br></br>
the three 1st line test to diagnose hypersortisolism are <span>[…]</span>, st<span>[…]</span>, and <span>[…]</span>
the three 1st line test to diagnose hypersortisolism are <span>urine(24hr)</span>, st<span>eroid supression(overnight LDDST)</span>, and <span>saliva(11pm-12pm, ↑ if cushings)</span><br></br>
a standard 2 day low dose <span>[…]</span> test consist of dexamethasone admin <span>[…]</span> x <span>[…]</span>. A <span>[…]</span> is obtained and repeated <span>[…]</span> of test. If <span>[…]</span>, <span>[…]</span> with <span>[…]</span>
a standard 2 day low dose <span>dexamethasone</span> test consist of dexamethasone admin <span>every 6 hrs</span> x <span>8 doses</span>. A <span>24 hr UFC baseline</span> is obtained and repeated <span>2nd day</span> of test. If <span>abnormal</span>, <span>cortisol is not suppressed by dexamethasone</span> with <span>cushings</span><br></br>
When diagnosis Cushings, if there is an <span>[…]</span> cause, the next test after labs and suppression test is <span>[…]</span> with <span>[…]</span>, <span>[…]</span>, or <span>[…]</span>
When diagnosis Cushings, if there is an <span>endogenous</span> cause, the next test after labs and suppression test is <span>imaging</span> with <span>CT of adrenals</span>, <span>MRI of pituitary</span>, or <span>CT/MRI of thorax and abdomen(ectopic ACTH producing tumor)</span><br></br>
the treatment for cushing’s syndrome is to <span>[…]</span>. <br></br>In order to reverse clinical manifestations, <span>[…]</span> <br></br>If there is a tumor → <span>[…]</span><br></br><br></br>When treating, <span>[…]</span> should be conidered
the treatment for cushing’s syndrome is to <span>treat the 1º cause</span>. <br></br>In order to reverse clinical manifestations, <span>steroid taperring is used.</span> <br></br>If there is a tumor → <span>surgery</span><br></br><br></br>When treating, <span>avoiding permenent med/ hormone dependence</span> should be conidered<br></br>
A trans-spehnoidal/pituitary endoscopic surgery is approached through <span>[…]</span> or <span>[…]</span>. The potential risks of the surgery are <span>[…]</span>. The most direct approach is a <span>[…]</span>.
A trans-spehnoidal/pituitary endoscopic surgery is approached through <span>upper lip</span> or <span>endonasally</span>. The potential risks of the surgery are <span>CSF leak</span>. The most direct approach is a <span>craniotomy</span>.<br></br>
<div> <div> <div> <div> <div>When tumor is not found or not cured by trans- sphenoidal resection, <span>[...]</span> and/or <span>[...]</span> is used.</div><div> <div> <div> <div> <div><br></br> </div> </div> </div> </div></div> </div> </div> </div></div>
<div> <div> <div> <div> <div>When tumor is not found or not cured by trans- sphenoidal resection, <span>pituitary irradiation</span> and/or <span>cytotoxic chemotherapy</span> is used.</div><div> <div> <div> <div> <div><br></br> </div> </div> </div> </div></div> </div> </div> </div></div>
<br></br>
<div> <div> <div> <div> <div>If irradiation fails to normalize cortisol secretion, a <span>[...]</span> is performed. It will be followed by l<span>[...]</span></div> </div> </div> </div></div>
<div> <div> <div> <div> <div>If irradiation fails to normalize cortisol secretion, a <span>surgical bilateral total adrenalectomy</span> is performed. It will be followed by l<span>ifelong glucocorticoid & mineralocorticoid replacement</span></div> </div> </div> </div></div>
<br></br>
the treatment for exogenous Cushing’s syndrome is to <span>[…]</span> with <span>[…]</span>. Be cautious with <span>[…]</span> and <span>[…]</span> when steroids are stopped<div> <div> <div> <div> <div><br></br> </div> </div> </div> </div></div>
the treatment for exogenous Cushing’s syndrome is to <span>stop glucocorticoid administration</span> with <span>gradual withdrawl</span>. Be cautious with <span>withdrawl</span> and <span>peroid insufficiency</span> when steroids are stopped<div> <div> <div> <div> <div><br></br> </div> </div> </div> </div></div><br></br>
The improvements that occur with effective therapy for Cushing’s syndrome are the <span>[…]</span>, <span>[…]</span> and <span>[…]</span>
The improvements that occur with effective therapy for Cushing’s syndrome are the <span>manifestations disappear over 2-12 months</span>, <span>HTN and glucose intolerance improve</span> and <span>osteoporosis improves over 6 mos</span><br></br>
Untreated Cushing’s is <span>[…]</span> becuase of C<span>[…]</span>. <span>[…]</span> or <span>[…]</span> have <span>[…]</span> prognosis
Untreated Cushing’s is <span>fatal</span> becuase of C<span>V, clots, HTN complications or bacterial infections</span>. <span>Ectopic ACTH seretion</span> or <span>adrenocortical carcinoma</span> have <span>poor</span> prognosis<br></br>
<span>[…]</span> is the appearance of <span>[…]</span> and have some <span>[…]</span> but with a different <span>[…]</span>.
<span>Psueod-Cushing syndrome</span> is the appearance of <span>cushingoid</span> and have some <span>silimar biochemical abnormailites</span> but with a different <span>etiology</span>.<br></br>
Etiologies of Pseudo-Cushing’s Syndrome<span></span>are severe <span>[…]</span>, <span>[…]</span>, <span>[…]</span>, <span>[…]</span> or <span>[…]</span>
Etiologies of Pseudo-Cushing’s Syndrome<span></span>are severe <span>major depression</span>, <span>alcoholism</span>, <span>PCOS</span>, <span>morbid obesity</span> or <span>ESRD</span><br></br>
<div> <div> <div> <div>Pseudo-Cushing’s syndrome is also called <span>[...]</span> and is defined as a <span>[...]</span> that is not related to a <span>[...]</span></div> </div> </div> </div>
<div> <div> <div> <div>Pseudo-Cushing’s syndrome is also called <span>non-neoplastic hypercortisolism (NNH)</span> and is defined as a <span>mild to moderate hypercortisolism</span> that is not related to a <span>ACTH tumor</span></div> </div> </div> </div>
<br></br>
what are the transient 5 P’s of the clinical manifestations of phenochromocytoma?
<ul><li>pressure</li><li>palpatations</li><li>perspiration</li><li>pain</li><li>pallow</li></ul>
What are the other non-speficic clinical manifestations of phenochromocytoma?
<ul><li>weight loss</li><li>anxiety/ tremors</li><li>flank pain</li><li>cardiac arrythmia/cardiomyopathy</li><li>nausea/weakness</li></ul>
a phenochromocytoma is a <span>[…]</span> but <span>[…]</span> tumor on the <span>[…]</span> and causes <span>[…]</span> hormone secretion
a phenochromocytoma is a <span>rare</span> but <span>benign</span> tumor on the <span>adrenal medulla(epi and norepi secretion)</span> and causes <span>paroxysmal/continuous</span> hormone secretion<br></br>
A phenochromocytoma is diagnosed with <span>[…]</span> and labs via <span>[…]</span>
A phenochromocytoma is diagnosed with <span>CT/MRI</span> and labs via <span>catecholamine urine and plasma levels</span><br></br>
A phenochromocytoma is managed with <span>[…]</span> or <span>[…]</span>
A phenochromocytoma is managed with <span>⍺/𝛃 blockers</span> or <span>surgical resection</span><br></br>
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Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
<div></div>
// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
<div></div>
// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
<div></div>
// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
<div></div>
// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
<div></div>
// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
<div></div>
// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
<div></div>
// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
<div></div>
// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
<div></div>
// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
<div></div>
// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
<div></div>
// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
<div></div>
// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
<div></div>
// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
<div></div>
// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
<div></div>
// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
<div></div>
// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
<div></div>
// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
<div></div>
// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
<div></div>
// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
<div></div>
// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
<div></div>
// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
<div></div>
// Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
<div></div>
<div> <div><img></img></div> <div><img></img></div> </div>
Toggle Masks <div> <div> </div> </div> // Toggle answer mask on clicking the image var toggle = function() { var amask = document.getElementById(‘io-overlay’); if (amask.style.display === ‘block’ || amask.style.display === ‘’) amask.style.display = ‘none’; else amask.style.display = ‘block’ } // Prevent original image from loading before mask aFade = 50, qFade = 0; var mask = document.querySelector(‘#io-overlay>img’); function loaded() { var original = document.querySelector(‘#io-original’); original.style.visibility = “visible”; } if (mask === null || mask.complete) { loaded(); } else { mask.addEventListener(‘load’, loaded); }
Hyperthyroidism is an <span>[…]</span> that can present with <span>[…]</span> and <span>[…]</span>
Hyperthyroidism is an <span>excess of thyroid hormone cirulating in the blood</span> that can present with <span>increased heat production</span> and <span>adrenergic sensitivity (tachy,tremor)</span><br></br>
What are the causes of hyperthyroidism?
<ul><li>graves</li><li>ectopic production</li><li>toxic multinodular goiter/adenoma</li><li>subacute thyroiditis</li><li>exogenous ingestion<br></br></li><li>TSH-mediated</li></ul>
the ophthamlmic manifestations of graves result from <span>[…]</span> causing <span>[…]</span> and the <span>[…]</span>
the ophthamlmic manifestations of graves result from <span>AI binding of IGF 1 receptors</span> causing <span>inflammation, edema, increased pressure in the orbit</span> and the <span>accumulation of glycoaminoglycans(GAG)</span><br></br>
the ophthalmic presentation of graves can consist of <span>[…]</span>
the ophthalmic presentation of graves can consist of <span>possible vision loss, corneal irritation and diplopia</span><br></br>
the most common skin site affected by graves is the <span>[…]</span> and presents as a <span>[…]</span> of <span>[…]</span>
the most common skin site affected by graves is the <span>shin</span> and presents as a <span>raised, hyperpigmented, orange peel texture</span> of <span>papules</span><br></br>
Other common skin signs of graves are <span>[…]</span>. The only symptom that is indicitive of graves is <span>[…]</span>
Other common skin signs of graves are <span>sweating, onycholysis, pruritis, and thin hair</span>. The only symptom that is indicitive of graves is <span>infiltrative dermopathy</span><br></br>
Myxedema is <span>[…]</span> caused by <span>[…]</span> seen in <span>[…]</span>.
Myxedema is <span>skin changes from edema</span> caused by <span>severe hypothyroidism</span> seen in <span>myxedema coma</span>.<br></br>
Myxedema coma can present with <span>[…]</span> and <span>[…]</span> → <span>[…]</span>
Myxedema coma can present with <span>edema, mental change, hypotension/brady</span> and <span>low temp</span> → <span>death</span><br></br> <br></br>graves/hyperthyroidism → pretibial myxedema<img></img>
the cardio effects of graves → <span>[…]</span>, <span>[…]</span> and <span>[…]</span>. Another finding more commonly found in eldery is <span>[…]</span>
the cardio effects of graves → <span>increased CO + HR</span>, <span>wide pulse pressure</span> and <span>↓ perph vasc resistance</span>. Another finding more commonly found in eldery is <span>AFib</span><br></br>
Respiratory sypmtoms of graves can present as <span>[…]</span> or <span>[…]</span> due to the <span>[…]</span>
Respiratory sypmtoms of graves can present as <span>dyspnea</span> or <span>dyspnea on exertion</span> due to the <span>trachial obstruction of a goiter</span><br></br>
GI symptoms of graves presents as <span>[…]</span>, <span>[…]</span> and <span>[…]</span>
GI symptoms of graves presents as <span>weight loss</span>, <span>↑ gut motility</span> and <span>diarrhea/malabsorption</span><br></br>
