Endocrine Flashcards
Which “ast” does PTH stimulate?
osteoclast
What 2 places can absorb calcium?
bowel
kidney
MC cause of primary hyperparathyroidism?
benign parathyroid adenoma
causes of hypercalcemia?
hyperparathyroidism kidney failure malignancy milk-alkali TB sarcoidosis multiple myeloma meds (thiazides, lithium) prolonged bed rest adrenal insufficiency
What are the clinical manifestations of hypercalcemia?
stones (kidney)
bones (jaw fracture)
groans (psych)
moans (abd)
Dx to confirm primary hyperparathyroidism?
increased PTH and ca
phosphorus is normal
what can cause secondary hyperparathyroidism?
decreased vit D/ca
hyperphosphatemia
renal failure
hypercalcemia can cause what heart changes?
prolonged PR (contraction) shortened QT (repolarization) asystole bradycardia heart block
what is a congenital cause of hypothyroidism
digeorge
what is cvhostek sign?
tap on the facial nerve => eye, nose, mouth spasm
what sort of reflexia does hypocalcemia cause
hyperreflexia
troussea sign?
spasm of the hand/wrist with compression of the forearm from hypocalcemia
what are symptoms of hypocalcemia?
lethargy anxiety parkinsoniansim mental R personality change blurred vision
EKG change of hypocalcemia
prolonged qt
t wave changes
tx of tetany?
airway
slow IV of calcium gluconate
what is PTH used to tx?
osteoporosis
not for hypoparathyroidism
level of TSH in primary hypothyroid?
high
causes of hyperthyroid
graves #1 toxic multinodular goiter #2 hashimoto amiodarone excess I pituitary tumor pregnancy exogenous thyroid hormone
what antibodies are in graves?
peroxidase
thyroglobulin
can radio-iodine therapy be done in pregnancy
no
initial tx for hyperthyroid symptoms
bb
PTU or methimazole is used in pregnancy? which is generally preferred
PTU
methimazole
tx afibb in hyperthyroid?
need to be euthyroid to be able to fix it
digoxin
bb with caution
need to anticoagulate
what is a thyroid storm?
hyperthyroidism triggered by stress
ie pregnancy, illness, surgery, trauma
what antibodies are in hypothyroidism
anti-tsh
30% of what pts have hypothyroidism?
down
best screening test for hypothyroidism?
tsh
before init levothyroxine what should you check for?
angina and adrenal insufficiency
mc cause of thyroiditis? (infection)
staph aureus
what is subacute painful thyroiditis?
peaks in summer
young, middle aged F
course of subacute painful thyroiditis?
thyrotoxicosis => hypothyroid => euthyroid in <12 months
tx for subacute painful thyroiditis?
aspirin
drug => thyroiditis in 20% of patients
amiodarone
an asymptomatic, hard woody thyroid?
fibrous thyroiditis
which thyroid cysts are painful?
suppurative ie staph
how common are thyroid nodules?
1/12-15 of young women have them
ant pituitary releases what?
TSH ACTH prolactin GH LH TSH
post pituitary releases what?
oxytocin
ADH
what inhibits prolactin?
dopamine
what inhibitis TSH and GH?
somatostatin
what does TRH release?
TSH
prolactin
screen test for GH excess?
serum IGF-1
imaging choice for increased GH?
MRI
looking for pituitary adenoma
if you are checking IGF-1 for excess GH what are you also checking for?
prolactin
common for a pituitary adenoma to secrete both GH and prolactin
tx of increased GH?
somatostatin analog
what is pegvisomat?
GH receptor antagonist
what causes diabetes insipidus?
loss of ADH or insensitivity to it
central DI responds to what?
desmopressin
vasopressin ie ADH analog
what is osmolality in DI?
serum is high
urine is low
tx of nephrogenic DI
indomethacin alone or with
HCTZ, desmopressin analog, amiloride
what criteria are a part of metabolic syndrome?
low HDL high trigs increased waist insulin resistance BP
% of diabetics that have retinopathy
30%
complications of DM
retinopathy neuropathy nephropathy CAD poor healing (more)
1 unit of insulin is roughly how many carbs
15 grams
where is regular insulin most rapidly absorbed
abdomen
how long does regular insulin
last 5-8 hours
at what Cr is metformin CI?
> 1.5
pioglitazone is associated with what?
bladder cancer
is a thiazoliredione
GLP-1 SE?
pancreatitis
nausea
whipple triad?
hypoglycemia symptoms
(sweating, palp, anx, tremulousness)
immediate recovery with glucose
BS < 45
xanthelasma =
xanthoma affecting the eyelid
USPSTF recommends lipid screening at what age?
45
what do you monitor with statins?
liver enzymes
cushing disease is caused by what?
ACTH secreting adenoma (pituitary)
syndrome = signs of excess cortisol
most specific signs of cushing syndrome
proximal muscle wasting
pigmented striae
backache, HA
dx cushings
1) cortisol excess by dexamethasone test
<5 ug/dL excludes cushings
MC cause of addison’s
autoimmune destruction of gland
what infection can cause addison’s?
tb
does addisons or cushings cause hyperpigmentation
addisons
electrolytes in addisons?
hyperkalemia hyponatremia low glucose increased calcium decreased BUN
how would addisonian crisis present?
hypotensive
pain (abd/back)
v/d
altered mental status
dx addison’s
low 8 am cortisol < 3 ug/dL and increased ACTH
what is DHEA used to tx?
dehydroepiandrosterone
Addisons
tx of addisonian crisis?
IV saline
glucose
glucocorticoids
mc presentation of hyperparathyroidism is what
asymptomatic
klinefelter syndrome has what genetic abnormality?
extra x
symptoms of severe cramps, extremity parasthesias, lethargy- think what electrolyte which direction?
hypocalcemia
could be hypoparathyroidism
enlargement of the thyroid gland in graves looks like what?
diffuse enlargement
for a pt on a steroid for adrenal insufficiency…
how do you dose it during an illness?
how do you dose during a surgery?
illness = double surgery = 5-10 fold
tx for diabetes insipidis?
desmopressin
a tophus represents what?
underlying gout
what insulin do you give a diabetic in ketoacidosis?
regular insulin
what EKG waves are associated with hyperkalemia?
u waves
initial dx study for a thyroid nodule
FNA
tx of hyperkalemia
calcium
loop diuretic
In tertiary disorder which organ is the problem (endocrine)? Secondary? Primary?
3) hypothalamus
2) pituitary
1) target organ
best thyroid screening test?
TSH
which antibody is specific for graves?
thyroid stimulating antibody
in a pt with subclinical hypothyroidism when must you tx with levothyroxine?
if pt develops hyperlipidemia
if the TSH increases over 20
they have symptoms of hypthyroidism
what is cretinism and how do you manage it?
developmental hypothyroidsim
manage with levothyroxine
can be from mom hypothyroid or from infant hypopituitarism
what is a euthyroid?
abnormal thyroid levels but thyroid gland is normal
seen with illness, surgery, sepsis, cardiac disease
how does a person in a thyroid storm present?
hypermetabolic state:
palpitations, afibb, fever, nausea, vomiting, psychosis, tremors, tachy,
management of thyroid storm:
1) PTU IV or methimazole (PTU inh peripheral conversion)
2) beta blocker, iv sodium iodide (decreases coversion)
3) IV glucocorticoids (decreases conversion), fluids, cardiac monitoring, cooling blankets
what do you avoid giving in a thyroid storm for fever?
aspirin
because it increases 4-3 conversion
management of myxedema crisis:
levothyroxine IV
passive warming
normal saline
in adrenal insufficiency give steroids
what is commonly seen with older women with long standing hypothyroidism in the winter?
myxedema crisis
what does RAIU test show for graves?
diffuse uptake
If you see ophthalmopathy and a hyperthyroidism what is the cause of the hyperthyroidism?
graves
will see lid lag and proptosis
Besides opthalmopathy what manifestation is exclusive to graves?
pretibial myxedmea
ie nonpitting, edematous pink to brown plaques/nodeuls on the shin
tx of graves
radioactive iodine- will need hormone replacement
if pregnant- PTU (iodine ablation CI)
bb for symptoms
if unresponsive thyroidectomy
why can a toxic adenoma cause dyspnea, dysphagia, stridor and hoarseness?
it can cause laryngeal compression
SE of PTU and methimazole
agranulocytosis
hepatitis
what hyperthyroid disorder can cause bitemporal hemianopsia
pituitary adenoma
antibodies present in hashimoto’s?
thyroid antibody:
thyroglobulin ab
antimicrosomial
thyroid peroxidase ab
same antibodies present in silent lymphocytic thyroiditis, post-partum thyroiditis
treatment for lymphocytic thyroiditis
aspirin
lasts for 12-18 months whereas hashimoto’s is permanent
what is the cause of de quervain’s thyroiditis
mc post-viral
which hypothyroid disorders are painful
de quervain’s
acute (supportive) thyroiditis
pt with increased ESR, a painful thyroid, no thyroid ab, and hyperthyroid.
de quervain’s
what are three meds that can cause thyroiditis?
amiodarone
lithium
alpha interferon
tx of medication induced thyroiditis
stop med
can do steroids
mc cause of acute thyroiditis?
staph aureus
riedel’s thyroid is what kind of thyroid?
fibrous thyroid
what med may increase t4 requirements?
cholestyramine
prevents reabsorption of bile
best initial test for thyroid nodule
FNA
mc type of thyroid nodular?
follicular adenoma
follicular = frumpy
what % of thyroid nodules are benign?
90%
what do you do if a FNA of a thyroid nodule is undeterminate? (10% are)
benign?
malignant?
radioactive uptake scan
benign- prob needs meds in a couple years
malignant- excise
how often do you check a suspicious thyroid nodule?
q 6-12 months
mc type of thyroid cancer
papillary carcinoma
“papillary= popular”
put the 4 types off thyroid carcinomas in increasing order of worse prognosis
papillary
follicular
medullary
anaplastic
which thyroid cancer is associated with MEN2?
radiation? iodine deficiency?
MEN2- medullary
radiation- papillary
iodine- follicular
which thyroid cancer secretes calcitonin?
medullary
which thyroid cancer requires radiation and chemo and is not amenable to surgical resection?
anaplastic
mc cause of primary hyperparathyroidism? secondary?
parathyroid adenoma
secondary- kidney failure from lack of vit d=> ca
what are reflexes in hyperparathyroidism
decreased deep tendon
dx of 1 hyperparathyroidism?
hypercalcemia
increased PTH
decreased phosphate
calcium in urine (24 hour collection)
tx of hypercalcemia
iv fluids
furosemide
signs of hypoparathyroidism?
decreased calcium
decrease PTH
increased phosphate
increased deep tendon reflexes, tetany
carpopedal spasms
trousseau’s sign- flexed hand
chvostek’s sign- facial spasm with tapping
mc pathologic fracture of osteoporosis?
vertebral
what are the risks of tx osteoporosis with estrogen in women?
stroke CAD endometrial cancer breast cancer DVTs
blue-tinted sclerae and presenile deafness goes with what disease?
osteogenesis imperfecta
chronic renal disease causes what bone pathologies?
osteitis fibrosis cystica
osteomalacia
from lack of conversion of vit D
why does CKD cause bone pathologies?
kidney don’t convert vit D to active form, decreased ca absorption and ca levels, which increased PTH
PTH causes osteoclasts to release ca into the blood bone is weakened
what labs are off in CKD in relation to bones?
decreased Ca
increased phosphate P04 because it can’t excrete it
increased PTH
how do you manage renal osteodystrophy?
phosphate binders
Ca
active vit D
cinacalcet lowers PTH levels
how is osteomalacia different than osteoporosis?
osteomalacia= lack of vit D, corticol thinning (osteoid demineralization) “soft”
osteoporosis= bone breakdown > bone formation, mineral and matrix loss proportional “brittle”
tx of osteomalacia
vit D ergocalciferol
d2
MC of adrenocortical insufficiency overall? primary?
exogenous use
primary ie adrenal gland problem = addison’s = autoimmune
2ry and 3ry are uncommon
what infections causes adrenal insufficiency?
TB
HIV
(cause calcification)
there are others
in 2ry and 3ry adrenal insufficiency why is aldosterone normal but cortisol low?
RAAS system provides aldosterone and it’s just converted by the adrenal gland (which is still working because the problem is 2ry or 3ry)
so symptoms are due to lack of cortisol
remember aldosterone controls salt
in primary adrenal insufficiency what causes the symptoms?
lack of
aldosterone
sex hormones
increased ACTH
first line tx in established 2ry adrenal insufficiency?
hydrocortisone
interferes with testing so use prednisone/dexamethasone if not dx
aldosterone maintained by RAAS
tx for addisons?
glucocorticoid + mineralcorticoid
hydrocortisone + fludrocortisone
mc cause of cushing’s overall?
exogenous
mc endogenous cause of cushings?
pituitary adenoma
a low dose dexamethasone test does what?
dx cushings
ie there is no suppresion
a high dose dexamethasone test does what?
differentiates cushing’s from an adrenal/ectopic ACTH releasing tumor
cushing disease vs syndrome
disease = from pituitary increased ACTH ie 1 specific cause
syndrome = increased cortisol ie general
what are two common causes of hyperaldosteronism?
renal artery stenosis (from increased renin) adrenal aldosteronoma (conn's syndrome)
what are the 2 main clinical manifestations of hyperaldosteronism?
hypertension
hypokalemia
how to dx hyperaldosteronism?
- hypokalemia with metabolic alkalosis (losing K and H for Na)
- saline infusion test- will not suppress aldosterone = definitive test
- aldosterone to renin ration: if aldo> R is >20 its 1ry
if renin levels are high then its 2ry - CT/MRI to look for extra-adrenal mass
what are the symptoms of pheochromocytoma?
htn PHE palpiations headache excessive sweating
how do you dx pheochromocytoma?
24 hour urinary catecholamines
what do you give perioperatively when removing a pheochromocytoma?
phenoxybenzamine or phentolamine
ie alpha blockers
also “phe”
how often are pheochromocytoma’s benign?
90%
tsh deficiency in infancy is called what?
cretinism
mc type of anterior pituitary tumor
prolactinoma
study of choice to look for anterior pituitary tumors
MRI
primary tx for prolactinoma?
medical
bromocriptine or cabergoline (dopanie agonists inh prolactin)
name 2 dopamine agonists
cabergoline
bromocriptine
what does dopamine inhibit
prolactin
gynecomastia is due mainly to what hormones?
increased estrogen
decreased androgens
how do you dx gynecomastia
its clinical
medical tx of gynecomastia?
SERMs ie tamoxifen
or
aromatase inh
mc cause of end stage renal disease =
dm
tx for unconscious diabetic?
IV bolus D50
or
inject glucagon SQ
when do you start an ACE in DM?
if microabluminuria
rapid acting insulins: onset and duration
novolog
humalog
15-30 min
3-4 hours
short acting insulin: onset and duration
regular
30-1hr
4-6 hour
intermediate insulin: onset and duration
NPH
2-4 hours
16-20 hrs
long acting insulin: onset and duration
lantus, levemir
4 for lantus
6-8 for levemir
24-36 hours
dawn phenomenon
rise in glucose between 2-8 am
needs bedtime NPH and avoid carbs at night
somogyi effect
hypoclycemia at night followed by hyperglycemia from growth hormone surge
avoid NPH at night, have snack
management of DKA?
- fluid of NS .9% until hypotension resolves, then .45% normal saline, then D5 1/2 NS when blood glucose gets to 250
- regular insulin
- K replacement
MEN 1 has what tumors?
the P’s
pancreas, parathyroid, pituitary
what tumors are in MEN2?
parathyroid
medullary thyroid
pheochromocytoma
parathyroid is in 1 & 2
what drug is a common cause of nephrogenic diabetes insipidus?
lithium
Is central or nephrogenic Diabetes insipidus MC?
central
head trauma
decreased ADH production
what differentiates between central or nephrogenic DI?
desmopressin test
tx of nephrogenic DI?
hydrochlorothiazide
mc symptom of paget’s disease?
bone pain
what lab is elevated in paget’s disease?
ALP
tx for paget’s disease?
bisphosphonates
it inh osteoclast activity which stop bone remodeling
SE of bisphosphonates
esophagitis
femur fracture
what hormone primarily regulates water?
ADH
