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Acute Care II > Endocrine > Flashcards

Endocrine Flashcards

1
Q

The Hypothalamus secretes what hormones to the anterior pituitary?

A

GHRH (growth hormone-releasing hormone)
CRH (corticotropin-releasing hormone)
GnRH (gonadotropin releasing hormone)
TRH (thyrotropin-releasing hormone)

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2
Q

GHRH stimulates the anterior pituitary to secrete what?

A

GH (growth hormone)

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3
Q

CRH stimulates the anterior pituitary to secrete what?

A

ACTH (adrenocorticotropin hormone)

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4
Q

GHRH stimulates the anterior pituitary to secrete what?

A

GH (growth hormone)

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5
Q

GnRH stimulates the anterior pituitary to secrete what?

A

FSH (follicle-stimulating hormone)
LH (luteinizing hormone)

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6
Q

TRH stimulates the anterior pituitary to secrete what?

A

TSH (thyroid stimulating hormone)

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7
Q

GH affects what organ?
ACTH affects what organ?
FSH and LH affect what organ?
TSH affects what organ?

A

muscles
adrenals
ovaries
thyroid

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8
Q

ACTH stimulates the adrenals to secrete what?
FSH and LH stimulates the ovaries to secrete what?
TSH stimulates the thyroid to secrete what?

A

Cortisol DHEA
Estrogens
T4 –> T3

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9
Q

Adrenal Cortex - 3 zones
Zona Glomerulosa
Located where?
Produces what?
Aldosterone production stimulated by what?
Aldosterone targets what?

A

outermost region
Mineralocorticoids (primarily aldosterone
hypotension & hyponatremia > triggers RAAS
kidneys (distal nephrons) causing retention of Na & H2O, K excretion

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10
Q

Adrenal Cortex - 3 zones
Zona Fasciculata
Produces what?
Production stimulated by what?
Levels are highest when? and falls to nadir when?

A

glucocorticoids (primarily cortisol)
ACTH from anterior pituitary; ACTH is secreted from ant. pituitary in circadian rhythm in response to CRH
highest in am, lowest at midnight

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11
Q

Adrenal Cortex - 3 zones
Zona Reticularis
Secretes what?

A

androgens (dehydroepiandrosterone sulfate & androstenedione- precursors to estrogen & testosterone)

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12
Q

Adrenal Insufficiency
Primary is the…
Inability of what?
Failure of what?
Resulting in what deficiency?

A

inability of adrenal gland to produce steroid hormones
Failure of adrenal gland itself
corticosteroid & mineralocorticoid

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13
Q

Adrenal Insufficiency
Secondary is the…
Inability of what?
Decreased ACTH secretion causes what?
What deficiency?

A

hypothalamic-pituitary unit to deliver CRH or ACTH
hypofunction of adrenal glands
corticosteroids only

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14
Q

Adrenal insufficiency
Tertiary is caused by

A

Decreased CRH secretion in hypothalamus

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15
Q

Adrenal Insufficiency - Etiology
Primary is ?

A

Autoimmune destruction (Addison’s disease)
AIDS, CMV< mycobacterial infection
Malignancy
Adrenal hemorrhage d/t anticoagulation, HTN sepsis trauma
Drugs (ketoconazole)
Granulomatous disorders (TB, histo)
Familial glucocorticoid deficiency

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16
Q

Adrenal Insufficiency - Etiology
Secondary is?

A

Exogenous/endogenous glucocorticoids
Hypothalamus or pituitary tumors
Surgery or XRT
Head Trauma

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17
Q

Acute Clinical Manifestations of AI include

A

Nausea
Vomiting
Agitation/confusion
fever
abdominal pain
dehydration
tachycardia
hypotension
shock
hypoglycemia
Hyponatremia
Hyperkalemia
Hypercalcemia
Eosinophila

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18
Q

Chronic Clinical Manifestations of AI

A

Weakness/fatigue
Loss of appetite/weight loss
Orthostatic Hypotension
Hyperpigmentation
Salt Cravings; unusual food preferences
Nonspecific GI symptoms
Myalgia/arthralgia
Headache
Hyponatremia
Hyperkalemia
Hypercalcemia
Eosinophila

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19
Q

Common Secondary & Tertiary AI Clinical Manifestations

A

Weakness
Myalgias/arthralgias
Hypoglycemia
Hyponatremia

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20
Q

Less Common Secondary & Tertiary AI Clinical Manifestations

A

Hyperpigmentation
Dehydration
Hypotension
GI complaints
Hyperkalemia

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21
Q

Differential Dx for AI includes

A

Adrenal Crisis
Hypotension
Shock
Acute Abdomen

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22
Q

AI diagnosis is done by performing what?

A

ACTH stimulation test
Check baseline cortisol level
Admin cosyntropin 250 mcg IV x1
Check cortisol level 60 min after admin
AI: peak cortisol level < 500 nmol/L (18 nanogram/dL)

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23
Q

ACTH level > 2 fold of upper limit is c/w what?

A

Primary AI

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24
Q

What test assess for destruction of adrenal glands?

A

21-hydroxylase antibodies

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25
Q

What imaging can assist in diagnosis?

A

CT scan of adrenals

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26
Q

AI Management - Acute

A

Glucocorticoid (Hydrocortisone 100mg IV x 1, then 200mg/d in 4 divided doses)
Fluid resuscitation
Treat underlying cause

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27
Q

AI Management - Chronic

A

Glucocorticoids (15-25mg in divided doses 2-3 x/d, highest dose in am)
Mineralocorticoid (primary AI) (Fludrocortisone (0.05 mg - 0.1mg qd)
Pt education; steroid emergency card, medical alert ID, steroid injection kit
Perioperative stress dose steroids

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28
Q

AI Management in Stress
Minor procedure: usual dose vs what?
Moderate procedure: give what? POD #1: give what?
Major Procedure: give what?
Mild Illness what rule?

A

hydrocortisone 25mg
hydrocortisone 50-75mg IV; usual dose
50-100mg hydrocortisone IV/q8hrs, taper over 48hrs

3x3 rule ( take 2-3 x glucocorticoid dose x 3 days)

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29
Q

Septic Shock CIRCI Management

A

Hydrocortisone 200mg IV per day (continuous infusion or divided doses q6h) w/ or w/o fludrocortisone 50 nanograms enteral daily for 7 days or until ICU d/c

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30
Q

Early ARDS CIRCI Management (w/n 24 hrs)

A

Dexamethasone 20mg IV daily for 5d, then 10mg daily for 5d until extubation

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31
Q

Early ARDS CIRCI Management (w/n 72hrs)
Days 1-14
Days 15-21
Dy=ays 22-25
Days 26-28
If extubated between days 1 and 15 then advance to what day of regimen?

A

Methylprednisolone 1mg/kg IV bolus then
1mg/kg/d continuous infusion
0.5mg/kg/d
0.25mg/kg/d
0.125mg/kg/d
day 15

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32
Q

Unresolving ARDS CIRCI Management (w/n 72hrs)
Days 1-14
Days 15-21
Days 22-28
Days 29-30
Days 31-32
If extubated before day 14 then advance to what day of regimen?

A

Methylprednisolone 2mg/kg/d IV bolus then
2mg/kg/d divided q6h
1mg/kg/d
0.5mg/kg/d
0.25mg/kg/d
0.125mg/kg/d
day 15

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33
Q

Severe CAP CIRCI Management
Hydrocortisone
7 day
8 or 14 day

A

200 mg IV once, then 10mg/hr IV infusion for 7d

200mg IV daily (for 4 or 8d based on clinical improvement), then taper (for a total of 8 or 14d)

D/c on ICU discharge

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34
Q

Severe CAP CIRCI Management
Methylprednisolone
w/ 36 hrs of hospital admission and CRP > 150mg/L

20 day:
bolus?
Days 1-7
Days 8-14
Days 15-17
Days 18-20
Admin while in ICU vs after ICU d/c

A

Methylprednisolone 0.5mg/kg IV every 12h for 7d

40mg IV bolus
40mg/d
20mg/d
12mg/d
4mg/d
via continuous infusion in ICU, then changed two divided doses BID, via IV or enteral, after ICU d/c

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35
Q

Cushing’s disease caused by?
Cushing’s Syndrome caused by?

A

pituitary adenoma resulting in excess ACTH production

glucocorticoid excess (including that from adenoma)

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36
Q

Cushing’s Etiology - ACTH Dependent
Hypersecretion of ACTH by?
Ectopic secretion of ACTH by?
Ectopic secretion of CRH by?

A

pituitary
nonpituitary tumors
nonhypothalamic tumors

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37
Q

Cushing’s Etiology - ACTH Independent
Exogenous admin of what?
Adrenocortical what?
Adrenal _________?

A

glucocorticoids
adenomas & carcinomas
macronodular hyperplasia

Most common

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38
Q

Cushing’s Clinical Manifestations

A

Truncal Obesity
Moon face
Buffalo Hump
Purple striae
Poor wound healing
HTN
Weakness
Thin Skin
Osteoporosis
Hirsutism
Amenorrhea
Easy bruising
Freq infections
Acne
Impotence
Headache

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39
Q

Differential Dx of Cushing’s includes

A

Polycystic ovarian syndrome
Metabolic syndrome
Obesity
Fibromyalgia
Psychiatric d/o

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40
Q

Cushing’s Diagnosis
Can be difficult b/c what?
Exclude exogenous glucocorticoids in what possible forms?

A

cortisol secretion is variable, may be intermittent

PO
Inhaled
Injected
Topical
Megestrol acetate
Skin lightening (bleach)

41
Q

Cushing’s Diagnosis
>/= 2 measurements of 24h urine free cortisol
if cortisol excretion normal x3, what?
Values 3-4 fold greater than Upper limit of normal is what?

A

Cushing’s unlikely

Diagnostic for Cushing’s

42
Q

Cushing’s Diagnosis
1mg overnight dexamethasone suppression (given at 11p)
Normal: AM cortisol suppresses to what?
C/w Cushing’s: serum cortisol > what?

A

<5.0 nanogram/dL
>1.8 nanogram/dL

43
Q

Cushing’s Diagnosis
2 measurements of 11pm salivary cortisol
Normal is what?
Abnormal is what?

A

<145 ng/dL
>145 ng/dL

44
Q

Cushing’s Management
Patient needs a?
Establish what?
Patient needs to be what?
Monitor/manage what?
Goals are what?
1st line treatment is what?
Post surgical replacement of what?

A

Endocrinologist
Cause
Educate
Cortisol dependent co-morbidities (DM, HTN, HL, Psych d/o, etc.)
Reduce cortisol levels to normal, Eradicate tumor if present, Avoid permanent hormone deficiency
surgical resection of primary lesion
glucocorticoid

45
Q

Thyrotoxicosis is what?

A

Systemic syndrome d/t exposure to excessive thyroid hormone

46
Q

Hyperthyroidism refers to those forms of thyrotoxicosis caused by what?

A

excessive production of thyroid hormone d/t stimulus or autonomous thyroid function

47
Q

Hyperthyroidism Etiology - Hyperthyroidism

A

Antibody mediated stimulation of thyroid tissue (graves disease - younger women)
Excessive secretion of TSH
Autonomously functioning Thyroid tissue (Toxic multinodular goiter, toxic adenoma, iodine exposure, struma ovarii, metastatic thyroid cancer)

48
Q

Nonhyperthyroid thyrotoxicosis - Etiology

A

Ingestion of exogenous thyroid hormone (meds, supplements, meat)
Inflammation (subacute thyroiditis, autoimmune thyroiditis)

49
Q

Graves Diseases is an autoimmune process

A

Thyroid stimulating immunoglobulins bind to/activate TSH receptor > thyroid hormone secretion, gland growth

50
Q

Graves Disease is characterized by what?

A

Diffusely enlarged thyroid, ophthalmopathy
Exophthalmos, EOM involvement, vision loss
Dry, gritty eyes, pain, diplopia

51
Q

Hyperthyroidism Clinical Manifestations

A

Anxiety
Emotional lability
Weakness
Tremor
Palpitations
Tachycardia
Heat intolerance
Increase perspiration
Hyperreflexia
Increased appetite
Nervousness
Weight loss
Warm, moist skin
Thin, fine hair
Exophthalmos

52
Q

Hyperthyroidism in elderly may present differently with s/sx like

A

weight loss
tachycardia
constipation

53
Q

Hyperthyroidism Diagnosis
Physical Exam components

A

Thyroid (size, tenderness, symmetry, nodularity)
Pulmonary, Cardiac & Neuromuscular function
Peripheral edema
Optho signs
periorbital myxedema

54
Q

Hyperthyroidism Diagnosis
Ultrasound can show?

A

anatomy
lesions
nodules
goiters
masses
inflammation
flow

55
Q

Hyperthyroidism Diagnosis
TSH initial screening test
TSH will what? d/t what?
If TSH low check what?
Sometimes T4 is normal but T3 is what?

A

low; elevated levels of T3 & T4 inhibiting secretion of TRH by hypothalamus & TSH by pituitary
free T3&T4
elevated

56
Q

Hyperthyroidism Diagnosis
Additional Labs to help diagnosis

A

Thyrotropin receptor antibody (TRAb)
Radioactive iodine uptake (RAIU)
Thyroidal blood flow via US

57
Q

If TSH is low and Free T4 is High it is?

A

Thyrotoxicosis

58
Q

If TSH is low and Free T4 is normal is is?

A

T3-thyrotoxicosis
Subclinical thyrotoxicosis
Nonthyroidal illness

59
Q

If TSH is normal and Free T4 is elevated it can be?

A

TSH-secreting adenoma
Pituitary resistance to thyroid hormone
Generalized resistance to thyroid hormone
Familial dysalbuminemic hyperthroxinemia

60
Q

If TSH is normal and Free T4 is normal it is?

A

normal

61
Q

Hyperthyroidism Management
Beta blockers for who? why?

A

all (ameliorate symptoms of hyperthyroidism caused by increased beta-adrenergic tone

62
Q

Hyperthyroidism Management
In Graves disease possible treatments are?

A

Antithyroid drugs (Methimazole, Propylthiouracil (PTU)
Radioactive Iodine
Thyroidectomy

63
Q

Antithyroid drugs
Inhibit function of thyroid peroxidase which does what?
1st go to med? for how long?
What med is safer in pregnancy?
Side effects include?

A

reduces oxidation & organoification of iodine
methimazole (MMI) x 12-18 mo)
PTU (inhibits peripheral conversion of T4 > T3)
agranulocytosis, skin rash, elevated LFTs, vasculitis

64
Q

Thyroid Storm Clinical Manifestations

A

Tachycardia
CHF
Hyperthermia
Agitation
Delirium
Psychosis
Stupor
Severe N/V or diarrhea

65
Q

Thyroid Storm Precipitating Factors

A

Long Standing untreated hyperthyroidism
Infection
Trauma
Surgery
Acute Iodine Load

66
Q

Thyroid Storm Differential Dx

A

Sepsis
Cocaine use
PAID
Pheochromocytoma
Neuroleptic malignant syndrome
Hyperthermia

67
Q

Thyroid Scoring system results of >/=45 indicates?
25-44 is suggestive of?
< 25 is suggestive of?

A

highly suggestive of thyroid storm
impending storm
unlikely to represent thyroid storm

68
Q

Thyroid Storm Management
PTU dosing?
MMI dosing?
Propranolol dosing?
Iodine dosing?
Hydrocortisone dosing?

A

500-1000mg load, then 250mg q4h
60-80 mg/d
60-80mg q4h
5 drops PO q6h
300mg IV load, then 100mg q8h

69
Q

Subclinical hypothyroidism is characterized by what?

A

Elevated TSH & normal T4

70
Q

Overt Hypothyroidism is characterized by what?

A

TSH > 10 mlU/L + subnormal T4

71
Q

Primary Hypothyroidism Etiology can be from?

A

Autoimmune disease (Hashimoto’s Thyroiditis)
Drugs (lithium, amiodarone, interferon)
Iatrogenic (post radiation, surgery)
Congenital (inborn error of hormone metabolism)
Iodine Deficiency (rare in US)

72
Q

Secondary Hypothyroidism Etiology can be from?

A

Pituitary tumor, pituitary surgery/ XRT
Craniopharyngiomas

73
Q

Hashimoto’s Thyroiditis pathophysiology

A

Infiltration of thyroid by sensitized T lymphocytes & serologically circulating thyroid autoantibodies

74
Q

Hashimoto’s Thyroiditis occurs with increased frequency among other autoimmune disorders such as?

A

DM I
RA
MG
primary adrenal failure
celiac disease
SLE

75
Q

What are the main Clinical Manifestations of Hypothyroidism

A

Intolerance of cold temperatures
Dry, thick skin
Delayed DTR
Carpal Tunnel Syndrome

76
Q

What are other Clinical Manifestations of Hypothyroidism?

A

Fatigue
Weight Gain
Coarse or thin hair
brittle nails
constipation
bradycardia
Puffy hands, face, feet (myxedema)
Menorrhagia/amenorrhea
+/- goiter

77
Q

Differential Dx for hypothyroidism

A

Anemia
Depression
Constipation
Hypothermia
Fibromyalgia

78
Q

Diagnosis of Hypothyroidism is done how?

A

TSH (elevated)
Free T4 (low)

79
Q

Hypothyroidism Management
Primary Hypothyroidism & TSH levels > 10 mlU/L

A

Start Levothyroxine 1.6mcg/kg/d

80
Q

In elderly w/ CAD how is hypothyroidism managed?

A

Start a lower dose & titrate gradually (20-25% less per kg/d; usually 12.5-25mcg/d)

81
Q

With pregnant patients who have hypothyroidism, what precaution must be made?

A

A need for transient increase in their dose.

82
Q

How often should dosage be titrated for hypothyroidism?

A

q4-8 wks (usually by increments of 12.5-25mcg)

83
Q

TSH goal is what?

A

between 0.45-4.12

84
Q

Myxedema is what?

A

thickened, nonpitting edema to soft tissues in markedly hypothyroid state

85
Q

Myxedema Coma is often precipitated by what?

A

infection
meds
environmental exposure
other metabolic-related stresses

86
Q

Management of Myxedema Coma
Hypothyroidism

Alternative?

A

Large inital IV dose of 300-500 mcg T4, if no response ad T3

Initial IV dose of 200-300mcg T4 plus 10-25mcg T3

87
Q

Management of Myxedema Coma
Hypocortisolism

A

IV hydrocortisone 200-400 mg daily (divided by 4 doses)

88
Q

Management of Myxedema Coma
Hypoventilation

A

Dont delay intubation and mechanical ventilation too long

89
Q

Management of Myxedema Coma
Hypothermia

A

Blankets, no active warming

90
Q

Management of Myxedema Coma
Hypotension

A

Cautious volume expansion with crystalloid or whole blood

91
Q

Management of Myxedema Coma
Hypoglycemia

A

Glucose admin

92
Q

Management of Myxedema Coma
Precipitating even

A

Identification and elimination by specific treatment, liberal use of abx

93
Q

Euthyroid
TSH
Free T4
Free T3

A

Normal
Normal
Normal

94
Q

Primary Hypothyroidism
TSH
Free T4
Free T3

A

High
Low
Normal or Low

95
Q

Hyperthyroidism
TSH
Free T4
Free T3

A

Low
High or normal
High

96
Q

Subclinical Hypothyroidism
TSH
Free T4
Free T3

A

High
Normal
Normal

97
Q

Subclinical Hyperthyroidism
TSH
Free T4
Free T3

A

Low
Normal
Normal

98
Q

TSH-mediated Hyperthyroidism
TSH
Free T4
Free T3

A

Normal or High
High
High

Acute Care II (5 decks)

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