Endocrine Flashcards
USPSTF recommends screening for colon cancer using three different methods for which age groups?
Annual high sensitivity fecal occult blood testing
Sigmoidoscopy every 5 years
Colonoscopy every 10 years
Screen persons 50-75years old
The USPSTF guidelines recommend that asymptomatic adults with sustained blood pressure greater than 135/80mmHg be tested for
Type 2 diabetes using fasting plasma glucose
2-hour glucose Toler test
Or hemoglobin A1c
First test to be performed on a patient who presents with a palpable thyroid nodule
Thyroid ultrasound
TSH
Ultrasound can help detect clinically inapparent nodules and characteristics of cancer. What are high risk characteristics
Microcalcifications, hypoechogenicity, a solid nodule, a nodule more tall than wide, chaotic intranodular vasculature. fNA indicated two in a nonpalpable nodule
If a TSH is depressed and the ultrasound shows a solitary nodule or multinodular what test can be performed to make the diagnosis
Radioactive iodine uptake
If the nodule is hot it confirms the presence of
Hyperfunctioning adenoma benign no FNA
Increased uptake on RAIU in a diffuse heterogeneous pattern is indicative of
Toxic multinodular toxic goiter
If the TSH is normal or elevated in patient with palpable nodule what test to make diagnosis
Fine needle aspiration
An FNA positive nodule is malignant management?
Refer
A FNA negative nodule is benign, management?
Observe with yearly clinical and sonographic examinations
FNA suspicious nodule management?
REFER
Nondiagnostic FNA nodule
REFER
Thyroid nodule palpated first test to perform
Thyroid ultrasound
Thyroid ultrasound performed reveals single nodule if TSH suppressed what test makes the diagnosis
Radioactive iodine scan
Nodule with cold uptake on RAIU. Management?
perform FNA
Pt has palpable nodule. You perform thyroid ultrasound identify single nodule TSH is elevated or normal management?
Perform FNA
Palpable nodule thyroid ultrasound performed reveals multinodular goiter. TSH SUPPRESSED management?
Perform radioactive iodine scan -diffuse heterogeneous uptake BENIGN. FNA unnecessary
Patient presents with history of viral illness a few weeks prior to visit complains feeling better but then anterior neck pain/sore throat profuse sweating palpitations now exhausted and constipated. DX?
Subacute granulomatous thyroiditis
Treatment of subacute thyroiditis?
Thyroid is firm nodular and tender RAIU decreased ⬆️thyroglobulin ⬆️esr
Treat and reassure patient thyroid function will normalize in a few weeks
In hypothyroidism systemic vascular resistance increase causing ?
Rise in diastolic blood pressure
Other signs- ⬆️LDL cholesterol, reduced exercise tolerance
What is starting dose replacement once hypothyroidism is diagnosed
Synthetic thyroxine 1.6 mcg/kg per day
When should TSH be rechecked after initiating therapy
4-6 weeks
Elderly patients with diagnosis hypothyroidism should be treated at what starting dose?
25-50mcg/day
Hashimotos the most common cause of hypothyroidism is due to?
Antibody and cell mediated destruction of the thyroid gland
Patient presents slightly elevated TSH and normal T4. DX?
Subclinical hypothyroidism
Pt presents low TSH and elevated T4 scan: diffuse increased uptake most likely DX?
Graves’ disease
Female patient taking contraceptive meds presents c/o irregular menses TSH normal but total T4 elevated Why?
Elevated thyroid binding globulin (TBG)
TBG is elevated in persons with increased levels of?
Circulating estrogen
After hyperthyroidism is confirmed with TSH , what is next most appropriate test to deteriorate underlying etiology?
Radioactive iodine uptake scan
What is treatment of choice for adults with Graves’ disease?
Radioactive iodine ablation
What is treatment of choice children and adolescents with hyperthyroidism
Antithyroid drugs PTU, and methimazole
In elderly patient who becomes depressed consider?
Hypothyroidism CHECK TSH
Patients with fruity breath are ketotic and likely have DKA. These patients are usually dehydrated initial treatment?
Large volume IV fluid with isotonic fluids like normal saline
To minimize risk of cerebral edema, lowering of blood glucose should be done no faster than what rate per hour
80 mg/dL
DM is associated with autoimmune disorders like
Hashimotos hypothyroidism, onset usually late adolescence or childhood
Islet cell antibodies are found in what percentage of cases of type 1 diabetes
90%
Goals to reduce macrovascular complications in diabetics
LDL40 men, >50 women, triglycerides
Fluid deficit in DKA is often
6 to 8 L
In DKA the initial fluid replacement should be
Normal (0.9%) saline unless severe hypernatremia
In DKA potassium levels should be monitored frequently during initial treatment phase how?
Every hour at first then every 2-4 hours
In at patient with acute DKA but otherwise organ function, serum potassium concentration is 4 to 5 mEq/L, ivf changes
Add 20-40mEq/L of potassium chloride to IVF
Sulfonylurea that increases insulin sensitivity in the peripheral tissues - causes hypoglycemia in the elderly
Glimepiride ( amaryl
Glyburide
Oral hypoglycemia agent that inhibits gluconeogenesis, decreases production of glucose, decrease rate of glucose absorption, and increases glucose uptake in the periphery
Biguanides (metformin,i.e. Glucophage
COMPLICATION lactic acidosis
Two advantages of metformin
1) should not induce
2) does not promote weight gain
Oral hypoglycemic agent decreases insulin resistance and inhibits liver gluconeogenesis
Thiazolidinediones like Avandia ( rosiglitazone, Actos (pioglitazone) assoc ⬆️liver enzymes, jaundice, contraindicated HF
Nonsulfnylureas benzoic acid derivative works by stimulating insulin release from the pancreas, very short half life
Meglitinides like Prandin (repaglinide ) and starlix (nateglinide
DPP-4 inhibitors like sitagliptin and saxagliptin work by
Increasing incretin which inhibits glucagon release thereby increasing insulin secretion through pancreatic alpha and beta cell stimulation main side effect headache, nausea
Potent antioxidant that enhances glucose uptake and prevents glycosylation of tissues 600mg daily improves diabetic neuropathy
Alpha lipoic acid
How much fish oil is required to lower triglycerides
4g omacor is a high quality and concentrated prescription source of omega 3 fatty acids
This supplement has been shown to reduce progression of macular degeneration
Lutein
Maximal dose of Vit A for retinal function
10,000 units per day
Average insulin doses
0.6-0.8 units/kg of body Weight per day
Glargine insulin is very long acting should be given
Once daily often in the evening or at bedtime
How to calculate starting dose of insulin
Morning 2/3 total daily dose
Evening 1/3 total daily dose
Morning 2/3 intermediate, 1/3 regular
Evening 2/3 intermediate 1/3 regular
Because of high rate recurrence initial treatment prolactinoma
Bromocriptine
This level serum prolactin is almost always the result of a pituitary adenoma in the abscence of pregnancy
300ng/mL
Imaging scan of pituitary gland to confirm confirm diagnosis
MRI with gadolinium
Combination symptoms of gallactorrhea amenorrhea decrease libido, infertility, bitemporal hemianopsia is indicative of
Prolactinoma
Acromegaly is almost always a result of growth hormone excess caused by
Pituitary adenoma
Treatment of acromegaly
Treatment of choice- transsphenoidal pituitary microsurgery
Cabergoline, growth hormone receptor blockers like pegvisomant
Symptoms of hyperpigmentation weakness weight loss and hypotension is indicative of
Addison’s disease
Lab findings of hyponatremia, hyperkalemia, hypercalcemia, increased plasma ACTH, decreased serum cortisol are indicative of
Addisons disease
Most common cause of Addison disease
Autoimmune destruction of the adrenal gland
Treatment of choice Addison disease
Dexamethasone sodium phosphate 4 mg every 12 hours or hydrocortisone 100mg IV every 6 hours
The chronic treatment of Addison disease
Combo fludrocortisone (0.05-0.3mg/day) and hydrocortisone 15-25mg/day)
Nephrogenic ( the collecting tubules of the kidneys are unresponsive to ADH produced) diabetes insipidus is usually caused by
Drugs- lithium and amphotercin B
Treatment nephrogenic diabetes insipidus
Stop offending drug
Treatment central diabetes insipidus
Desmopressin either intranasally or orally
Clinical signs of Conns disease
Lab signs- metabolic alkalosis,low renin,
Weakness, hypertension, polydipsia, polyuria, hypokalemic, , increased urine potassium
Treatment of Conn syndrome ;primary hyperaldosteronism,is the result of excess mineralcorticoid production from a unilateral adenoma of the adrenal cortex
Laparoscopic removal adenoma
Or if result of bilateral hyperplasia adrenal glands- spironolactone
Most common cause of Cushing’s syndrome is corticosteroid therapy, if yo exclude steroids most common cause
Pituitary adenoma
Metastatic malignant disease is most likely to mimic
Hyperparathyroidism
Recommended treatment for Cushing’s
Surgery to remove pituitary adenoma
Best lab test Cushing’s
Serum cortisol, low dose dexamethasone suppression test ( in Cushing’s no suppression) 24h free urine cortisol
Confirm- high dose 8 mg dexamethasone suppression test ( suppresses pituitary adenoma but NOT adrenal Cushing’s)
Renal stones most common symptomatic presentation salt pepper skull personality changes
Hyperparathyroidism
Treatment of choice Graves’ disease
Radioactive iodine
Drugs of choice treatment Graves’ disease
PTU, methimazole, beta blockers
Methimazole much safer than PTU
PTU now second line treatment graves except
Pregnancy and lactation
Add 2 more pills per week
Keep below2.5
Treatment of choice Graves’ disease during pregnancy
1st trimester?
2nd-3rd trimester?
1sr trimester PTU
2nd trimester switch to methimazole
Treatment Graves’ disease if breastfeeding
PTU
Most common type of thyroid cancer
Papillary
For multinodular thyroid cancer more accurate test test than FNA
Dynamic contrast medium enhanced MRI (DCE-MRI)
Difference between primary nod secondary male hypogonadism
Gonadotropin elevated primary ⬆️ LH, FSH, low testosterone no sperm count
Secondary ⬇️ gonadotropin, sperm count, testosterone
Primary Hyperparathyroidism is most commonly caused by?
Treatment?
Adenoma of parathyroid
Treat with surgical parathyroidectomy
Current guidelines recommend screening patients with stage IV chronic kidney disease for
Serum calcium and phosphate levels every 3-6 months and bone specific alkaline phosphatase activity every 6-12 months
Half patients with a GFR
Hyperparathyroidism
Metformin is contraindicated in patients with a creatinine level
Stop metformin when creatinine >1.5
.”A 25-Year-Old Man with “Visual Problems- visual field defects,” Headaches, Weight Gain, Sweating, and “enlarging Hands and Feet
Gland?
Excerpt From: Alfred F. Tallia, Joseph E. Scherger & Nancy Dickey. “Swanson’s Family Medicine Review.” Saunders, 2013. iBooks.
This material may be protected by copyright.
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- Acromegaly a tumor in the pituitary that increases growth hormone
Pituitary
Tumor that leads to excess prolactin, the hormone that stimulates production of breast milk? Pt presents complaints abnormal lactation, infertility, headache, decreased sexual interest
Gland?
Prolactinoma
Pituitary gland
Patient with weight loss, fatigue, muscle weakness, low blood pressure
Gland?
Addison when the adrenal glands produce too little cortisol
Adrenal
Skinny Addison adrenal is low pressure low ?”cort “
Patient with fluid retention, high blood pressure weak, muscle spasms
Gland?
Hyperaldosteronism when the adrenal glands produce too much aldosterone
Adrenal
Hyper Aldo adrenal is high pressure and spasms cause he’s holding his pee
Patient presents with complaints of fatigue, and osteoporosis
Gland
Disorder
Parathyroid gland
Hyperparathyroidism is when parathyroid produces too much PTH
Possible disorders of the adrenal gland
1) Addison too lit tittle cortisol
2) hyperaldosteronism
3) Cushing’s
