Endocrine Flashcards
a 25-year-old man concerned about some “bizarre symptoms” that he has been. He tells you that approximately 6 months ago, he began to experience the following symptoms: headaches, visual defects, weight gain, an appearance of his forehead growing, enlarging hands and feet (he could no longer get his gloves and shoes on), and increased sweating. On examination, mental status is normal, and the apical impulse is felt in the fifth intercostal space, midclavicular line. His blood pressure is 170/ 105 mm Hg. He does have a protruding brow, and three discrete visual field defects are noted (two in the left eye and one in the right eye). His tongue appears enlarged, and he is sweating profusely. What is the likely diagnosis
Acromegaly
What is the different between acromegaly and gigantism
igantism occurs if growth hormone (GH) hypersecretion begins in childhood, before the closure of the epiphyses
Acromegaly involves growth hormone GH hypersecretion beginning in adulthood; a variety of bony and soft tissue abnormalities develop
What is the main cause of both gigantism and acromegaly q
a pituitary adenoma that secretes excessive amounts of Growth Hormone; rarely, they are caused by non-pituitary tumors that secrete GHRH
What are the diagnostic tests for gigantism and acromegaly
GH test 2 hour after glucose load
Increased IGF-1
MRI/CT shows a pituitary tumor
What is the treatment of gigantism and acromegaly
Removal of pituitary tumor
a 25-year-old male presents complaining of fatigue, weight loss, and recurrent nausea and vomiting. On physical exam, he appears weak and has skin that appears abnormally tan. Her blood pressure is 90/70. A basic metabolic panel reveals hyponatremia and hyperkalemia. What is the likely diagnosis
Addisons disease
What causes Addisons disease
Typically autoimmune. May be due to Tuberculosis in endemic areas
What is Addison’s disease
Destruction of the adrenal cortex resulting in loss of cortisol production (↓ cortisol)
What are the typical lab findings with Addisons disease
↓ sodium, ↓ 8 AM cortisol, ↑ ACTH (primary), ↑ potassium (primary), low DHEA
What is the role of DHEA and where is it produced
It is produced in the adrenal gland and helps with the production of testosterone and estrogen
How do you diagnose Addison’s disease
High dose cosyntropin (synthetic ACTH) stimulation test
-Blood or urine cortisol is measured after an IM injection of cosyntropin (synthetic ACTH)
*The normal response is a rise in blood and urine cortisol levels after synthetic ACTH is given
Primary adrenal insufficiency results in little or no increase in cortisol levels (< 20 mcg/dL) after ACTH is given
How do you treat Addison’s disease
Hydrocortisone/prednisone PO daily
If someone is experiencing an Addisonian crisis, what will their presenting symptoms be and how would you treat it.
Hypotension, altered mental status
treatment: emergent IV saline, glucose, steroids
a 32-year-old woman who comes to the clinic because of new skin markings on her abdomen. Physical exam shows a round face, large purple striae over the abdomen, and several ecchymoses over her trunk, arms, and legs. She describes easy bruising, as well as a significant weakness when she tries to stand up from sitting on the ground. Her 24-hour urine free cortisol is 3 x the upper limit, her late-night serum cortisol is elevated and her plasma ACTH level is < 5 pg/mL. What is the likely diagnosis
Cushings disease
What is cushings disease
Cushing’s syndrome is a collection of signs and symptoms due to prolonged exposure to excess cortisol
-ACTH secreting pituitary microadenoma usually very small on anterior pituitary
Which gender is more susceptible to cushings disease
Females (3x)
What are common symptoms seen with cushings disease
buffalo hump, moon facies, supraclavicular pads, HTN, thirst, polyuria, hypokalemia, Proximal muscle weakness, pigmented striae; backache, headache, oligomenorrhea/amenorrhea emotional lability/psychosis
How do you diagnose cushings disease
Confirming high cortisol with a 24 hr urine free cortisol, late-night serum cortisol, and/or low-dose dexamethasone suppression test
What is the most reliable index of cortisol secretion
24-hour urinary free cortisol
How do you confirm the source of the high cortisol
ACTH level
*If it is an ACTH dependent cause, an MRI of the brain should be done to look for a pituitary adenoma (Cushing disease). If it is an ACTH independent cause, a CT of adrenals should be done to look for an adrenal mass such as an adenoma
How does the dexamethasone suppression test work to diagnose cushings syndrome
Give a steroid (dexamethasone) ⇒ failure of steroid to decrease cortisol levels is diagnostic ⇒ proceed next to high dose dexamethasone suppression test ⇒ no suppression = Cushing’s syndrome
How do you treat cushings syndrome
Transsphenoidal selective resection of pituitary tumor cures 75-90%
a 25-year-old male complaining of an unabated thirst that began three weeks ago. He is constantly drinking and goes to the bathroom around five times a night. He has lost five pounds over the last few weeks. The patient is on lithium for bipolar disorder. His BP is 115/70. The patient’s labs are significant for serum Na of 145 mEq/L (normal: 135-145). Urine osmolality is 185 mOsm/kg, and urine specific gravity is 1.004 (normal: 1.012 to 1.030). What is the likely diagnosis
Diabetes insipidus
What is diabetes insipidus
Diabetes insipidus (DI) is caused by a deficiency of or resistance to vasopressin (ADH), which decreases the kidneys’ ability to reabsorb water, resulting in massive polyuria
What are the 2 different types of diabetes insipidus
Central
Nephrogenic
What is central diabetes insipidus
destruction of the posterior pituitary from either an autoimmune issue or some type of brain trauma
Results in no ADH production
What is nephrogenic diabetes insipidus
andwhat can cause it
There is a partial or complete insensitivity to ADH
Can be due to: drugs (Lithium, Amp B), hypercalcemia and hypokalemia affecting the kidney’s ability to concentrate urine, acute tubular necrosis
How do you diagnose diabetes insipidus
Serum osmolality (concentration) is high (unable to stop the secretion of water into the kidneys so blood becomes more concentrated) and urine osmolality is low because it is so dilute
- use a water deprivation test or desmopressin stimulation test
What will be seen with the Desmopressin stimulation test for DI
Central: reduction in urine output indicating a response to ADH
Nephrogenic: continued production of dilute urine (no response to ADH) because kidneys can’t respond
How do you treat central DI
DDAVP
How do you treat Nephrogenic DI
Sodium and protein restriction, HCTZ, indomethacin
an 11-y/o girl brought to you by her mother who reports weight loss along with increased thirst and urination. The patient has felt tired and nauseous. On examination her weight is below the 5th percentile, she looks thin, and her skin is pale. her blood pressure is 100/70 and her pulse is 104 bpm. Her respirations are deep at a rate of 28 breaths/minute. Her breath smells fruity. What is the likely diagnosis
T1DM
Which type of DM is due to islet cell antibodies
T1DM
What is the common presentation of T1DM
Children
Polyuria, polydipsia, polyphagia, fatigue, and weight loss
T1DM is often first recognized and DKA… how will the patient present and how will you treat them
Fruity breath, nausea, vomiting, dehydration
IV regular insulin
What is Dawn phenomenon
Normal glucose until 2-8 am when it rises. Results from decreased insulin sensitivity and a nightly surge of counter-regulatory hormones during nighttime fasting
How do you treat Dawn phenomenon
Treat with bedtime injection of NPH to blunt morning hyperglycemia, avoiding carbohydrate snack late at night
What is Somogyi effect
Nocturnal hypoglycemia followed by rebound hyperglycemia due to a surge in growth hormone
How do you treat Somogyi effect
Treat with decreased nighttime NPH dose or give bedtime snack
How do you treat DKA
TREAT WITH FLUIDS! Patients with DKA are always dehydrated and need large-volume IV fluid resuscitation, usually isotonic fluids such as normal saline. If the corrected serum sodium level is high, this can be reduced to half-normal saline. Insulin should always be administered by an IV pump to guard against accidental overdose.
How is DM diagnosed
random blood glucose level of > 200 mg/dL + diabetic symptoms
2 separate fasting (8 hours) glucose levels of > 126 mg/dL
2-hour plasma glucose of > 200 on an oral glucose tolerance test (3-hour GTT is the gold standard in GDM)
Hemoglobin A1c of > 6.5%
What are high fasting insulin and C-peptide levels suggestive of
T2DM
What is the treatment goal for HbA1C
<7
What is the treatment goal for finger stick glucose monitoring
< 130 mg/dL fasting
< 180 mg/dL peak postprandial
a 35-year-old Mexican American male complaining of increased thirst, frequent urination, hunger, fatigue, and blurred vision random finger stick blood glucose is 225. What is the likely diagnosis
T2DM
How do you diagnose T2DM
2 random glucose measurements of >200
OR
2 fasting glucose >126
What is the first line treatment for T2DM
How does it work
What class does it belong to
Metformin
decreases hepatic glucose production
Biguanides
At what creatinine level should metformin be stopped at
> 1.5
How do Sulfonylureas work
what are examples of sulfonylureas
What are some side effects
- stimulates pancreatic beta-cell insulin release
- Glipizide, glimipiride, Glyburide
- Hypoglycemia
*they are cheap and rapidly effective making them desirable
How do Thiazolidinediones work
What are examples
What are some contraindications
increases insulin sensitivity in peripheral receptor site adipose and muscle has no effect on pancreatic beta cells
Pioglitazone, Rosiglitazone
CHF, liver disease, fluid retention, weight gain, bladder cancer (pioglitazone), a potential increase in MI (rosiglitazone)
How do Alph-glucosidase inhibitors work
What are some examples
what are some side effects
Delays intestinal glucose absorption
Acarbose, miglitol
GI side effects, three times a day dosing
What do Meglitinides do
What are some examples
stimulates pancreatic beta-cell insulin release
Nateglinide, Repaglinide
How do GLP1 meds work
what are some examples
lowers blood sugar by mimicking incretin - causes insulin secretion and decreased glucagon and delays gastric emptying
Semaglutide, Dulaglutide, Exanatide, Liraglutide
*can cause gastroparesis but can help reduce CV mortality
How do DPP-4 inhibitors work
What are some examples
inhibits degradation of GLP-1 so more circulating GLP-1
Sitagliptan, saxagliptan
How do SGLT2 work
What are some examples
What are some side effects
inhibition lowers renal glucose threshold which results in increased urinary glucose excretion
Canagliflozin
Vulvovaginal candidiasis, urinary tract infections, bone fractures, lower limb amputations
When is insulin utilized in those with T2DM
When A1C >9
What is the most common complication of using insulin
Neuropathy
What is normal fasting glucose
70-100
What is the goal of post prandial glucose
<140
What is the serum total calcium to qualify for hypercalcemia
> 10.5
What are the signs of hypercalcemia
Bones, stones, groans, psychiatric overtones
*Shortened QT
What is hypercalcemia associated with
malignancy or hyperparathyroidism
How do you treat hypercalcemia
IV NS and furosemide
What sodium level is considered hypernatremia
> 145mmol
What are signs of hypernatremia
Poor skin turgor, dry mucous membranes, flat neck veins, hypotension, increased BUN/CR ratio > 20:1
What causes hypernatremia
diarrhea
Diabetes insipidus
diuretics
hyperglycemia
thirst deficit
How do you treat hypernatremia
D5W
What can occur if you correct hypernatremia too quickly
cerebral edema
pontine herniation
a 33-year-old woman presents to the emergency department due to diffuse pain and fatigue. The woman states that she feels like her bones and muscles diffusely hurt. She also has experienced some abdominal pain as well and states that she has trouble focusing. What is the likely diagnosis
Hyperparathyroidism
What is hyperparathyroidism
a condition in which one or more of the parathyroid glands become overactive and secrete too much parathyroid hormone (PTH). This causes the levels of calcium in the blood to rise
What is primary vs secondary hyperparathyroidism
Primary: ↑ PTH is usually caused by a PTH-secreting parathyroid ADENOMA
Secondary: ↑ PTH by a physiologic response to hypocalcemia or vitamin D deficiency
What is the most common cause of secondary hyperparathyroidism
CKD
What will be seen in the urine with hyperparathyroidism
hyperphosphaturia, hypercalciuria (all Ca and phosphorus go out through kidneys to urine)
How do you treat hyperparathyroidism
Primary ⇒ surgical correction to remove the overactive parathyroid gland ⇒ If all 4, remove 3.5 glands
Secondary ⇒ replace cause (vitamin D/Ca supplementation)
How to treat someone with severe hypercalcemia coupled with hyperparathyroidism
IV fluids, Lasix, calcitonin; treat osteoporosis with bisphosphonates
a 34-year-old female complaining of irritability and nervousness, heat intolerance with increased sweating, and weight loss despite an increase in appetite. What is the likely diagnosis
hyperthyroidism
What is the autoimmune disease that leads to hyperthyroidism
graves disease
How will someone present with hyperthyroidism
Heat intolerance, palpitations, sweating, weight loss, tremor, anxiety, tachycardia
How will someone with graves disease present in addition to the usual hyperthyroidism sign
Diffuse goiter with a bruit, exophthalmos, pretibial myxedema
What will be seen with someone experiencing a thyroid storm
Fever, tachycardia, delirium
What will be seen on labs with hyperthyroidism
Low TSH
High T4
What antibodies can be tested for in someone with Graves disease
Anti-thyrotropin antibodies
What is the treatment for hyperthyroidism
Methimazole/PTU
radioactive iodine
Thyroidectomy
How do you treat someone experiencing a thyroid storm
prompt beta-blockers, hydrocortisone, methimazole/propylthiouracil, iodine
What is the most common injury associated with a thyroidectomy
Injury to the laryngeal nerve leading to hoarseness
If someone has hyperthyroidism or graves disease and becomes pregnant, how do you treat them
PTU during the first trimester
Methimazole for the remainder of their pregnancy
What is Hashimotos thyroiditis
Diffusely enlarged, painless, nodular goiter
What is subacute thyroiditis and when does it present
Painful enlarged thyroid with dysphagia, mild fever
Young women after a viral infection
*treat with ASA
What is postpartum thyroiditis
1-2 months of hyperthyroidism after delivery
Completely resolves, give propranolol for cardiac symptoms
Which disease will lead to Trousseau’s sign and Chvostek’s sign
Hypocalcemia
How do you treat hypocalcemia
IV calcium gluconate
If suspicious of phosphorus or calcium imbalance what should you do
order a PTH level
**Always remember it is the effect on the EKG that counts the most, not the serum levels
What imbalance is occurring if peaked T waves is seen on EKG
Hyperkalemia
What defines hyponatremia
sodium of < 135 mmol/L
What are signs of hyponatremia
Peripheral and presacral edema, pulmonary edema, JVD, hypertension, decreased hematocrit, decreased serum protein, decreased BUN/CR
*presents with muscle cramps and seizures
what causes Hypervolemic hyponatremia
CHF, nephrotic syndrome, renal failure, cirrhosis
What causes Euvolemic hyponatremia
SIADH (Picmonic), steroids, hypothyroid
What causes Hypovolemic hyponatremia
sodium loss
How do you treat severe hyponatremia
Hypertonic saline
mannitol
Why should sodium concentration be corrected slowly
To avoid osmotic demyelination syndrome
a 33-year-old woman whose vision has been steadily declining over the past two years. She further complains that her lips and feet feel numb. Her medical history is notable for medullary thyroid cancer status post total thyroidectomy. What is the likely diagnosis
Hypoparathyroidism
What occurs in the body with hypoparathyroidism
Calcium levels in the blood will increase
How will someone with hypoparathyroidism present
Tingling
tetany
cataracts
Chvosteks & trousseaus sign
What is Chvosteks sign
tap facial nerve illicit cheek twitch
What is trousseaus sign
BP cuff inflation illicit carpal spasm
How do you treat someone with hypoparathyroidism
What if they are experiencing tetnany
Vitamin D and Calcium
secure airway, IV calcium gluconate
a 28-year-old woman with increased fatigue and a 10-lb weight gain over the last 2 months. She states that she “feels cold” all the time, has decreased energy, and is experiencing worsening constipation. Patient has a tender thyroid, increased TSH, elevated antimicrosomal antibodies, and increased antithyroglobulin antibodies. What is the likely diagnosis
Hypothyroidism
How will someone with hypothyroid present
Cold intolerance, fatigue, constipation, depression, weight gain, bradycardia
Congenital: round face, large tongue, hernia, delayed milestones, poor feeding
What will be seen on labs with hypothyroidism
High TSH
Low T4
How do you treat hypothyroidism
Levothyroxine
a 72-year-old man presents to the emergency department after a fall outside of church. He complains only of right hip pain, which has been progressively worsening for the past six months. He denies hitting his head during the fall, but according to his wife, he has been complaining of worsening headaches. His temperature is 98.6°F (37°C), blood pressure is 110/60 mmHg, pulse is 80/min, and respirations are 18/min. Examination of the right lower extremity reveals mild crepitus at the hip, appropriate range of motion, adequate distal sensation, and palpable posterior tibial and dorsalis pedis pulses. A review of his laboratories reveals a serum alkaline phosphatase level that is markedly elevated. An X-ray of the hips is ordered, demonstrating bone sclerosis, coarse cortical trabeculation, and cortical thickening. What is the likely diagnosis
Pagets
What is Paget’s disease
bone remodeling disorder that results in the formation of an unorganized mosaic of woven and lamellar bone that is less compact and weaker than the normal bone
Where does pages disease typically occur in the body
Pelvis
Spine
Skull
What may pagets disease lead to
osteosarcoma
An x-ray shows is preformed and shows lytic lesions and thickened bone cortices. A bone biopsy is preformed to exclude malignancies. What is the likely diagnosis
pagets
What will be seen on labs with Pagets disease
↑ alkaline phosphatase and bone-specific alkaline phosphatase; increased osteoclast activity and osteoblastic activity
How do you treat pagets disease
Bisphosphonates
a 43-year-old female with high blood pressure unresponsive to therapy. She complains of headaches, palpitations, and sweating. She has a history of neurofibromatosis type 1, though without any neurological deficits. She has multiple café-au-lait spots on her body. The ECG demonstrates sinus tachycardia. She is found to be hypertensive to 154/121 mmHg. Her 24-hour urine metanephrines and VMA come back elevated. Her abdominal CT demonstrates an adrenal mass. What is the likely diagnosis
Pheochromocytoma
What is a pheochromocytoma
a catecholamine-secreting adrenal tumor that secretes norepinephrine and epinephrine autonomously and intermittently
What is pheochromocytoma associated with
neurofibromatosis type 1, MEN 2A/B
What are the 5 P’s to look for with a pheochromocytoma
Pallor
Perspiration
Palpitations
pressure
Pain (H/A)
How do you diagnose a pheo
4-hour catecholamines including metabolites (metanephrine and vanillylmandelic acid)
MRI or CT of the abdomen to visualize the tumor
What is the pre-op treatment for someone with a pheochromocytoma
phenoxybenzamine or phentolamine 7-14 days followed by beta-blocker to control HTN
*For HTN crisis: Nicardipine or nitroprusside
a 31-year-old woman who complains of irregular, infrequent menstrual periods. On further questioning, she complains of headaches, fatigue, and breast discharge. She takes ibuprofen only occasionally. The serum prolactin level is 380 μg per L. (prolactinoma). What is the likely diagnosis
Pituitary adenoma
What is a pituitary adenoma
Noncancerous tumors in the pituitary gland that don’t spread beyond the skull
What are the types of pituitary adenomas
Most common tumors are microadenomas that are functional (hypersecretion of pituitary hormones), nonfunctional, or compressive
*If larger than 1cm–> Macroadenoma
What are the signs and symptoms of a pituitary adenoma
diminished temporal vision, or bitemporal hemianopsia = MC visual
What are the s/sx of a prolactinoma
menorrhea, galactorrhea, and headache
How are pituitary adenomas diagnosed
MRI to look at the sella turcica
+
Endocrine studies: Prolactin, GH, ACTH, TSH, FSH, LH
How do you treat a pituitary adenoma
dopamine agonists cabergoline and bromocriptine
*if unsuccessful at managing symptoms, transphenoidal resection will be preformed
What is the greatest risk factor for thyroid cancer
Radiation exposure
MC F 40-60 y/o
What is the most common type of thyroid cancer
Papillary carcinoma
How do you dx thyroid cancer
ultrasound – all lesions >1 cm should be biopsied; smaller lesions can be followed/reevaluated if they grow
On US, what characteristics are highly suggestive of a malignant thyroid lesion
microcalcifications, hypoechogenicity, a solid cold nodule, irregular nodule margins,
*to eval malignancy, a thyroid uptake scan will be preformed
*If uptake is cold… do an FNA of the nodule
What is the treatment for thyroid cancer
Always involves complete/partial thyroidectomy with chemo and radiation for anaplastic thyroid CA
Recommended TSH level for pt: 1-2.0
