ENDOCRINE Flashcards
rapid onset hirsutism suggests…
hirsutism in general should make you think…
high androgen levels due to androgen secreting neoplasm
pcos
tumor in kids that causes precocious puberty with estrogen secretion
granulosa cell tumors
botulism vs GBS
botulism is descending paralysis with early cranial involvement and pupillary changes
GBS is ascending symmetrical paralysis over days
what level do you treat hypercalcemia?
> 14 mg/dL
treat with NS hydration plus calcitonin
niacin deficiency
sx?
tx?
B3 deficiency
PELLAGRA ( dementia, dermatitis, diarrhea)
niacin replacement
thiamine (B1) deficiency
beri beri or wenicke-korsakoff
ass with alcoholics or weight loss surgery
riboflavin deficiency
B2 deficiency
cheilosis, glossitis, seborrheic dermatitis
pyridoxine deficiency
B6
irritability, depression, dermatitis, stomatitis
B12 deficiency
cyanocobalamin deficiency
macrocytic anemia and peripheral neuropathy
what can be elevated in a patient with B12 deficiency?
methylmalonic acid
kallman syndrome
decreased GnRH and decreased FSH/LH
anosmia +/- renal agenesis
ADH deficiency is known as…
central diabetes insipidus
2 hormones of the posterior pituitary
ADH and oxytocin
central DI vs nephrogenic DI
presentation of DI?
central is decreased ADH production
nephrogenic is decreased response to ADH in kidneys
high volume urine output and excessive thirst resulting in volume depletion and hypernatremia -> can lead to confusion, lethargy
classically what medication can cause nephrogenic DI?
lithium
best diagnostic test to determine central vs nephrogenic DI
vasopressin (desmopression) stimulation test
central = urine V will decrease and urine osmolality will increase
nephro = no effect
treatment for central and nephro DI?
central = vasopressin
nephro = tx underlying cause + HCTZ, amiloride, and NSAIDs
acromegaly
usually caused by?
presentation?
dx?
tx?
overproduction of GH
usually d/t pituitary adenoma
enlarging soft tissue = increased hat, ring sizes, carpal tunnel, OSA, body odor, coarsening of facial features, deep voice, big tongue
best initial test is IGF-1
most accurate test is glucose suppression test (glucose should suppress GH)
tx: transphenoid resection of the pituitary
or meds
-ocreotide (somatostatin will suppress GH)
-pegvisomant (GH receptor antagonist)
should a head MRI ever be an initial diagnostic test?
NO!! never first test for endocrine disorders
if prolactin is elevated, next tests?
pregnancy test
thyroid function tests
BUN/Cr (kidney disease can elevate prolactin)
best first initial test for thyroid issues
TSH
findings and tx for hyperthyroid dz: 1 graves dz 2 subacute thyroiditis 3 painless silent thyroiditis 4 exogenous thyroid hormone use 5 pituitary adenoma
1 proptosis, TSH receptor abs, low TSH, high RAIU –> tx with radioactive iodine (ablation)
2 tender thyroid, low TSH, decreased RAIU –> tx with aspirin
3 normal exam, low TSH, decreased RAIU –> no tx
4 involuted/nonpalpable gland, low TSH, decreased RAIU –> stop exogenous use!
5 HIGH TSH, MRI of head –> surgery
thyroid nodules must be biopsied when?
must FNA nodule if it is >1 cm if they have normal thyroid function
cardiac sx of hypercalcemia?
short QT and htn
tx for acute hypercalcemia
saline hydration at high volume
and
bisphosphonates (aledronate, pamidronate, zeledronic acid)
if that doesnt bring ca down, you can use calcitonin
labs seen in primary hyperparathyroidism
high PTH high serum Ca low phosphate ekg with short QT alk phos may be elevated due to bone effects
tx for primary hyperparathyroidism
surgical removal of parathyroid glands
or
cinacalcet if nonoperable
labs seen in hypocalcemia due to low albumin
low albumin causes a decrease in total calcium
but free calcium is normal
= no sx
signs of hypocalcemia
chvosek sign (facial nerve hyperexcitable) carpopedal spasm perioral numbness mental irritability seizures tetany (treausseau sign) prolonged QT
tx for hypocalcemia
replace ca and vit D
orally if mild sx
IV if severe
HPA axis
hypothalamus –> CRH –> pituitary gland —> ACTH —> adrenal glands —> cortisol
cushings syndrome
4 main causes
hypercortisolism!
pituitary overproduction of ACTH (cushing disease)
adrenals
unknown source
extopic ACTH (cancer, carcinoid)
dx tests for hypercortisol/cushings
best initial test = 24 hr urine cortisol (second best option is overnight dexamethasone suppression)
if 24 hr urine is elevated = confirms hypercortisolism
if suppression on dexa test occurs, can rule out hypercortisolism
ACTH testing is best test to identify the SOURCE of hypercortisolism
- -low ACTH means adrenal source
- -high ACTH means either pituitary of ectopic
–> scan brain with MRI if high ACTH and nonsuppressible
addisons disease aka? presentation? dx? tx?
chronic hypoadrenalism
weakness, ams, n/v, hypoNa, HyperK, hyperpigmentation
hypoglycemia, hyperK, met. acidosis, hypoNa, high BUN, EOSINOPHILIA
if pituitary failure = ACTH is low
if primary adrenal failure = ACTH high
cosyntropin test (synthetic ACTH) –> if normal should cause a rise in cortisol
tx steroids
acute adrenal crisis
presentation?
first step?
profound hypotension, fever, confusion, coma
high eosinophils, hyperK, hypoNa, hypoglycemia
draw cortisol level and give HYDROCORTISONE
**hydrocortisone is more important than diagnosis in acute adrenal crisis
primary hyperaldosteronism main causes? presentation? dx? tx?
solitary adenoma or bilateral hyperplasia
high BP despite low renin and hypokalemia
best initial test is ratio of aldosterone to renin
only do a CT if testing shows: 1) low K, 2) high aldosterone, and 3) low renin
adenoma = surg laparotomy
bil, hyperplasia = tx w eplerenone or spironolactone
pheochromocytoma
presentation?
dx?
tx?
nonmalignant autonomous lesion of adrenal medulla that produces catecholamines despite high BP
episodic htn, headache, sweating, and palpitations
best initial test is free plasma metanephrines and 24 hr urine metanephrines
then do CT
tx phenoxybenzamine (alpha blocker) –> surg removal
DM diagnosis
2 fasting BG >125
single glucose >200 with symptoms
or
increased glucose on oral glucose tolerance testing
or hgA1c>6.5% (best test to follow therapy effect)
how does exercise help in DM
exercising muscle does not need insulin so it decreases insulin requirement/decreases insulin resistance by decreasing adipose tissue
best initial med for DM?
mech?
but it is contraindicated in?
metformin - it bocks gluconeogenesis (does not increase weight gain and does not cause hypoglycemia)
contraindicated in renal dysfunction (can accumulate and cause met acidosis)
sulfonylureas
not first line for DM since they increase insulin release from pancreas and increase weight gain
if oral agents are not controlling DM, start patient on…
insulin
insulin glargine = 1x/day long acting
NPH would be 2x/day long acting
+
lispro or aspart (short acting)
goal is hgba1c<7%
DKA tx
large volume saline and insulin
best indicator of severity of DKA?
serum bicarbonate
**if very low (big anion gap), there is risk of death
all DM patients should receive
pneumococcal vaccine yearly eye exam yearly foot exam statin if LDL>100 acei/arb if BP >140/90 or if urine + microalbuminuria aspirin if >30yo
tx for DM associated gastroparesis (decreased bowel mobility due to decreased stretch feedback)
metoclopromide and erythromycin (increase gastric mobility)
retinopathy seen w DM?
tx?
nonproliferative retinopathy –> tighter gluc control
proliferative retinopathy (vitreous hemorhage and neovascularizatuion) –> laser photocoagulation
to dx amyloidosis
abdominal fat pad biopsy
