Endocrine #4 Flashcards
Clinical manifestations of thyrotoxic crisis (thyroid storm)
- Cardiovascular dysfunction (palpitations, tachycardia, A-fib, CHF)
- High fever
- CNS dysfunction (agitation, delirium, psychosis, coma)
Labs for thyrotoxic crisis
Primary hyperthyroid profile: increased free T3 and T4, decreased TSH
Management of Thyrotoxic Crisis
-IVF + Propanolol + antithyroid medication (PTU) + IV Glucocorticoids
- Then, oral or IV sodium iodide
- Cooling blankets
- Avoid Aspirin because it can displace thyroid hormones off carrier proteins
MC thyroid cancer
Papillary thyroid carcinoma
Risk factors for papillary thyroid cancer
- Radiation exposure of head and neck
- Family history of thyroid cancer
Workup if you think the patient may have thyroid cancer
Fine needle aspiration
Treatment of papillary thyroid carcinoma
-Thyroidectomy followed by postoperative Levothyroxine
What is the unique thing about follicular thyroid carcinoma?
Distant METS are more common than local METS (hematogenous spread)
-Lung, liver, brain, bone
Medullary thyroid carcinoma pathophysiology
-Derived from Calcitonin-synthesizing parafollicular cells
What gene mutations are associated with medullary thyroid carcinoma?
MENIIa and MENIIb (associated with RET mutation)
What do labs show for medullary thyroid carcinoma?
Increased calcitonin
Anaplastic thyroid carcinoma is the most aggressive of all thyroid cancers. What are some symptoms of this type of cancer?
- Rapid growth, compressive symptoms
- Rock hard thyroid mass
What is the management of anaplastic thyroid carcinoma?
- Most not amenable to surgical resection
- Palliative tracheostomy may be needed to maintain airway
What is the most common type of benign thyroid nodule
-Follicular adenoma
What are some physical exam findings of a thyroid nodule that is malignant?
- Rapid growth
- Fixed in place
- No movement with swallowing
Workup for a thyroid nodule
- Thyroid function testing
- -If hyperthyroid, order radioactive iodine uptake scan (thyroid scintigraphy)
- -TSH normal or high, FNA with biopsy
- Thyroid US to determine if FNA with biopsy indicated
- FNA guided by US
With a radioactive iodine uptake scan, explain what cold or warm nodule means
Cold (no or low iodine uptake): rule out malignancy
Hot (normal) have lower malignancy potential
If thyroid cancer suspected, what is the treatment?
Surgical excision if cancer suspected, cold nodule, or indeterminate FNA
90% of cases of hypercalcemia are due to
primary hyperparathyroidism or malignancy
Other causes of hypercalcemia
- Thiazide diuretics
- Sarcoidosis
- Vitamin D and A intoxication
Symptoms of hypercalcemia
Stones (nephrolithiasis)
Bones (bone pain and fractures)
Abdominal Groans (ileus, constipation)
Psychiatric Moans (depression, anxiety)
Hypertension
Increased DTRs
What does an ECG on hypercalcemia show?
Shortened QT interval, prolonged PR interval, QRS widening
Management of mild hypercalcemia (< 12 mg/dL)
No immediate treatment needed
-Treat underlying cause and increase water intake (promotes calcium excretion)
Labs for hypercalcemia
- Ionized serum calcium more accurate than total serum calcium
- Intact PTH: once hypercalcemia is confirmed to rule out primary hyperPTH
- PTH-related protein: to rule out malignancy
Management of moderate (12-14 mg/dL) hypercalcemia
IVF initial management of choice
IV loop diuretics (Furosemide) to promote excretion
Bisphosphonates with Calcitonin in malignancy
MCC overall of hypocalcemia
Hypoparathyroidism: destruction or removal of parathyroid gland during neck surgery
Other etiologies of hypocalcemia
- Chronic renal disease
- Vitamin D deficiency (osteomalacia or Rickets)
- Hypomagnesemia
- Diuretics, Bisphosphonates
Symptoms of hypocalcemia
- Increased muscular contractions: decreases excitation threshold
- Muscle cramps, bronchospasm, circumoral paresthesias, Tetany
- Chvostek Sign: facial spasm with tapping of facial nerve
- Trousseau Sign: inflation of BP cuff above systolic causes carpal spasm
- Increased DTR and seizures
ECG for hypocalcemia shows
Prolonged QT interval
Treatment for hypocalcemia
- Mild: oral calcium + Vitamin D
- Severe or Symptomatic: IV calcium gluconate
Causes of primary hyperparathyroidism
- Parathyroid adenoma
- Lithium
- Men I and IIa
What triad is associated with primary hyperparathyroidism
Hypercalcemia + Increased intact PTH + decreased phosphate
-Also increased 24 hour urinary calcium excretion
Definitive management for primary hyperparathyroidism
Parathyroidectomy
-Vitamin D and calcium supplement afterwards
What medication inhibits release of PTH in patients that are not surgical candidates with primary hyperparathyroidism?
Cinacalcet
2 MCC of hypoparathyroidism
Post neck surgery
Autoimmune destruction of parathyroid gland
With hypoparathyroidism, what symptoms are present?
-Signs of hypocalcemia: increased muscle contractions
What triad is present in hypoparathyroidism?
-Hypocalcemia + decreased intact PTH + increased phosphate
Treatment for hypoparathyroidism
-Calcium supplementation + activated Vitamin D (Calcitriol)
Symptoms of growth hormone deficiency
Children or infants: short stature, dwarfism, fasting hypoglycemia
Adults: dyslipidemia, decreased CO, impaired concentration
Diagnostics for GH deficiency
-Arginine and sleep stimulation test: no change in GH release if hypopituitarism
