Endocrine (8%) and Heme (5%) Flashcards
Thickened skin, insulin resistance, jaw protrusion, HA and vision problems is concerning for what condition, and how is it diagnosed?
Acromegaly
Start with IGF-1 levels
- If elevated –> do pituitary MRI
- If equivocal, do OGGT w/GH levels and if suppression is inadequate, get a pituitary MRI
What is the MC cause of acromegaly?
Somatotrophic (growth-hormone secreting) adnoma of anterior pituitary
Increases of IGF-1 are due to GH dependence
What is the treatment for acromegaly?
Transsphenoidal surgical removal or debulking of the adenoma
Fatigue, weight loss, salt cravings, GI complaints, diffuse myalgia/arthralgia, and decreased libido are concerning for what condition, and how is it diagnosed?
Concerning for adrenal insufficiency.
Primary adrenal insufficiency - Addison Disease:
Diagnosed when a patient has a reduced (<20ug/dL) rise in cortisol in response to cosyntropin – known as ACTH stimulation test. Cosyntropin is synthetic ACTH.
What is the MC etiology of primary adrenal insufficiency?
Autoimmune destruction of the adrenal cortex
How is Addison disease treated?
Steroids and PO mineralcorticoids
During adrenal crisis: aggressive IV saline, glucose, and glucocorticoids while addressing underlying cause
Obesity, hyperpigmented striae, HTN, thirst, and amenorrhea is concerning for what condition, and how is the diagnosis made?
Cushing disease or syndrome
- Disease is ACTH-secreting pituitary adenoma (secondary hypercortisolemia)
- Syndrome is an excess of cortisol
Dx via dexamethasone suppression test
- Should inhibit CRH and ACTH secretion
- AM cortisol level should be lower with dexamethasone
- If no suppression occurs, consider an adrenal tumor (primary hypercortisolemia)
A hypernatremic patient on lithium with low urine Na+ is suspect for what condition, and how is it treated?
Lithium is associated with nephrogenic diabetes insipidus – kidneys not responding to ADH. Treat with hydrochlorothiazide to induce transient hypovolemia –> increased Na+ reabsorption
How is neurogenic or central diabetes insipidus treated?
Desmopressin: synthetic ADH.
Central DI is a deficiency in ADH from posterior pituitary.
How is DMII diagnosed via fasting plasma glucose?
2 occasions when fasting 8+ hours:
- 126+ is diagnostic
- 110-125 is impaired insulin sensitivity, proceed to 2hr GTT
How is DMII diagnosed after fasting plasma glucose is 110-125?
Proceed to 2hr GTT:
- 200+ is diagnostic
- 140-199 is impaired insulin sensitivity
How is DMII diagnosed via A1C?
- 5+ is diagnostic
5. 7-6.4 indicates impaired insulin sensitivity
How is DMII diagnosed via random BSG?
200+ is diagnostic
What is the treatment for DKA?
IVF most important
Insulin + potassium unless K+ is >5.3
Potassium level will be artificially high, these patients are usually hypokalemic
What are the s/sx of hypercalcemia?
Stones, bones, abdominal groans, psych overtones
Shortened QT interval
Elevated PTH
Decreased Phosphate
Same s/sx as hyperparathyroidism!
What is the tx for hypercalcemia?
IV furosemide and denosumab
What are the s/sx of hypocalcemia?
- Tetany (perioral numbness, paresthesias, muscle cramps or spasms)
- Trousseau’s, Chvostek’s signs
May also see fatigue, hyperirritability, anxiety, depression
Prolonged QT interval
Heart failure
Arrythmiad
Decreased PTH
Increased Phosphate
What is the tx for hypocalcemia?
IV Ca gluconate or CaCl
What are the s/sx of hypernatremia?
Dehydration: poor skin turgor, dry mucous membranes, flat neck veins, hypotension
BUN:Cr >20
What is the tx for hypernatremia?
IV D5W corrected slowly to avoid cerebral edema/central pontine herniation
Goal ~10mEq/day rate decline of Na+
Consider possibility of DI
What are the s/sx of hyponatremia?
Signs of fluid overload: peripheral or presacral edema, JVD, HTN, decreased Hct, decreased serum protein
Decreased BUN:Cr <1
Muscle cramps, seizures may occur
What drugs are associated with hyponatremia?
SSRIs and SNRIs, especially in patients with reduced kidney function
Occurs via SIADH
What are some potential causes of hypervolemic hyponatremia?
CHF
Nephrotic syndrome
Renal failure
Cirrhosis
What are some causes of euvolemic hyponatremia?
SIADH, possibly 2/2 steroids, SSRI/SNRI use, or hypothyroidism
What are some causes of hypovolemic hyponatremia?
Sodium loss - renal vs non-renal
What are some s/sx of hyperparathyroidism?
Similar to hyperCa+:
Stones, bones, abdominal groans, psych overtones
Shortened QT interval
Elevated Ca2+
Low phosphate
N/V, loss of appetite, weakness, fatigue, constipation, confusion, lethargy
What is the tx for hyperparathyroidism?
- If primary, remove parathyroid adenoma surgically, and then supplement with Ca2+ and vitamin D; may need to treat osteoporosis with bisphosphonates
- If Ca2+ is super high, tx with furosemide, calcitonin, IVF
Is nephrolithiasis associated with hyper- or hypoparathyroidism, and why?
Associated with hyperparathyroidism:
- Increased PTH and Ca2+ triggers renal loss of Ca2+ and phosphate, which form stones
What are some causes of secondary hyperparathyroidism?
CKD-related hypocalcemia or vitamin D deficiency
What are some s/sx of hypoparathyroidism?
The same s/sx as hypocalcemia:
- Tetany (perioral numbness, paresthesias, muscle cramps or spasms)
- Trousseau’s, Chvostek’s signs
May also see fatigue, hyperirritability, anxiety, depression
Prolonged QT interval
Heart failure
Arrythmia
Decreased Ca2+
Increased Phosphate
What is the MC thyroid malignancy?
Papillary
Follicular is second mc
If medullary, consider risk of MEN II
Describe the tremor associated with hyperthyroidism
High frequency
Low amplitude
Intentional tremor
Neck swelling with high frequency, low amplitude intentional tremor is concerning for what condition, and how is it diagnosed?
Grave’s disease - primary hyperthyroidism
- Labs will show low TSH and high T4
- Dx’d via scintigraphy, will show diffuse uptake of radioactive iodine
How is secondary hyperthyroidism diagnosed?
Secondary hyperthyroidism = excess TSH
- Labs will show high TSH and high T4
- MRI of the pituitary
What is the workup for a thyroid nodule?
US:
- High risk characteristics:
- – hypoechoic
- – irregular margins
- – microcalcifications
- – more tall than wide
- – rim calcifications
- – extrathyroid extensions
If high-risk via US, proceed to FNA
How does the diagnosis of papillary thyroid cancer differ from follicular?
Papillary thyroid nodules will show psammoma bodies on FNA
Follicular thyroid nodules are confirmed via core needle biopsy
What are some etiologies of hypothyroidism?
- Hashimoto’s is MC cause
- Drugs: lithium or iodine-containing drugs (amiodarone), methimazole, propylthiouracil, some biologics
- Hypothalamic or pituitary disease: pituitary tumor, Sheehan syndrome
- Infiltration: Scleroderma, leukemia, sarcoidosis
- Transient postpartum thyroiditis
What is the tx for hyperthyroidism?
Thionamide:
- Methimazole (1st line) vs
- Propylthiouracil (for pregnancy)
Ablation therapy (radioiodine vs surgery)
Bblocker for tremor
What antibodies are present in Hashimoto’s thyroiditis?
+ anti-thyroid peroxidase
+ anti-thyroidglobulin Ab
What are the s/sx associated with Paget’s disease of the bone?
*Usually asx and found via labs
- Bone pain with normal ROM, sensation, and no vascular compromise
- Fractures
- Elevated alk phos
- Lytic or sclerotic lesions
- Thickened cortices
- Normal PTH and vitamin D
AKA osteitis deformans
What is the treatment for a patient who presents with bone pain but normal ROM/sensation, elevated alk phos, lytic lesions and thickened cortices on imaging, and normal PTH and vitamin D?
Suspect Paget disease of the bone
- Bisphosphonates:
- risedronate
- alendronate
- zoledronic acid
- Calcitonin
With what syndromes is pheochromocytoma associated?
MEN II
von Hippel-Lindau
What is the tx for pheochromocytoma?
- ) a-blockade (phenoxybenzamine) + high salt diet to avoid volume contraction – never start B-blockade first!!!
- ) B-blockage (propranolol)
- )Surgical resection
For acute hypertensive crises, use phentolamine, sodium nitroprusside, and nicardipine
What drugs should be avoided in patients with suspected pheochromocytoma?
- *NO B-blocker without a-blocker!!!
- Glucagon
- Histamine
- Metoclopramide
- High dose steroids
What is the classic triad of symptoms ass’d with pheochromocytoma?
- Episodic HA
- Sweating
- Tachycardia
About 50% also have paroxysmal HTN, most have HTN of some sort but may be normotensive
What are the conditions associated with MEN2A?
Medullary thyroid cancer
Pheochromocytoma
Primary hyperparathyroidism
(also ass’d: cutaneous lichen amyloidosis, hirschsprung disease)
NO mucosal neuromas (MEN2B)
What are the conditions associated with MEN2B?
Medullary thyroid cancer
Pheochromocytoma
*Mucosal neuromas, esp lips and tongue
NO hyperparathyroidism (MEN2A)
What are the conditions associated with MEN1?
3 P’s:
Primary hyperparathyroidism
Pituitary adenomas
Pancreatic islet cell/GI endocrine tumors (Zollinger-Ellison, insulinoma)
Other tumors: carcinoid, cutaneous, breast cancer)
NO pheochromocytoma (MEN2 a&b)
What changes can be seen on EKG with hyperkalemia?
Peaked T waves
Prolonged QRS
What is the treatment for hyperkalemia with EKG changes?
- ) Membrane stabilization: 10% Ca gluconate IV
- ) Redistribution: insulin + glucose, shifts K+ into cells
- ) Elimination: Lasix
What changes can be seen on EKG with hypokalemia?
Flattened/inverted T waves
How is hypokalemia treated?
- IV K+
- Must replete Mg if deficient
- Do not use anything containing dextrose: will cause insulin release and subsequent movement of K+ into cells
What are some potential causes of hypokalemia?
- GI loss: vomiting, diarrhea, laxatives
- Sweating, diuretics, polyuria
- Renal tubular acidosis
- Hypothermia
- Increased insulin availability (DKA – insulin present, can’t be used by insensitive cells)
What are some potential causes of hyperkalemia?
- Impaired secretion:
- – reduced aldosterone secretion or response 2/2 kidney disease
- Metaboblic acidosis (shifts K+ out)
- Insulin deficiency
- B-Blockers
What is the MC leukemia in adults?
CLL (chronic lymphocytic leukemia)
What is the MC leukemia in children?
ALL (Acute lymphocytic leukemia)
The Philidelphia chromosome is associated with what condition, and with what patient population?
Ass’d with CML which is rare in kids, affecting primarily adults 20-50 YO
Auer rods are associated with what condition and with what patient population?
Ass’d with AML, which is more common in adults than children
Smudge cells are associated with what condition and what patient population?
CLL - MC leukemia in adults
What is the tx for idiopathic thrombocytic purpura?
Prednisone
- Consider IV IG for short term treatment
If platelets remain low for 6+ weeks, consider splenectomy
- If refractory to splenectomy, use Danazol
What is the classic pentad of symptoms associated with thrombotic thrombocytopenic purpura?
- Fever
- Microangiopathic hemolytic anemia
- Thrombocytopenia (evidenced by petechiae)
- Renal dysfunction
- Neuro changes
A patient with fever, petechiae, renal dysfunction, anemia, schistocytes on blood smear plus a normal PT, INR, and PTT is concerning for what condition?
Thrombotic thrombocytopenic purpura
Fatigue + night sweats + painless lymphadenopathy is concerning for what condition, and how is the diagnosis made?
Lymphoma; dx via lymph node and bone marrow biopsy, with CT chest to stage
What are 6 s/sx of multiple myeloma?
- Lytic lesions
- Anemia
- Thrombocytopenia
- Hypercalcemia
- Renal insufficiency
- Bone pain
With what population is a-thalassemia associated?
Asian populations
With what population is B-thalassemia associated?
Mediterranean populations
Heinz bodies are associated with what conditions?
a-thalassemia and G6PD deficiency
What are the RBC morphologies commonly associated with B-thalassemia?
Target cells
Teardrop cells
Basophilic stippling
Nucleated RBCs
How do a-thalassemia and B-thalassemia differ in timing of onset?
a-thal present at birth
B-thal present around 6 months after fetal Hgb is gone
Name MC microcytic anemias
- Iron deficiency MC
- MC 2/2 blood loss
- a-thal
- B-thal
Name MC macrocytic anemias
- B12 deficiency
- Folate deficiency
Consider EtOH abuse
How can the MC macrocytic anemias be differentiated?
B12 deficiency occurs with symmetric paresthesia and high MMA
Folate deficiency has no neuro symptoms and normal MMA
How is pernicious anemia treated?
IM B12 q/month indefinitely
Describe PT/PTT times for hemophilia A and B
Prolonged PTT with normal PT
What is the MC inherited hypercoaguability disorder and what are the PTT/PT findings?
Factor V Leiden: normal PT/PTT
What is MC inherited bleeding disorder, and what are the PTT/PT findings?
von Willebrand disease
- PTT is prolonged
- PT is normal
In what bleeding disorders is desmopressin useful?
- Mild-mod von Willebrand disease
- Potentially useful as prophylaxis in hemophilia A
A child with recent diarrheal illness presents with hemolytic anemia evidenced by schistocytes and reticulocytes, plus evidence of renal dysfunction with increased BUN and Cr. This is suspicious for what condition, and what is the tx?
HUS
Generally self-limiting but avoid antibiotics and antimotility agents!
Prolonged PTT is associated with what hematologic disorders?
- vWD
- Hemophilia A or B
- Antiphospholipid antibody syndrome
- DIC
- Heparin use
Prolonged PT is associated with what conditions?
- Vitamin K deficiency
- DIC
- Warfarin use
How is autoimmune hemolytic anemia diagnosed?
Coombs test +
How is SSD diagnosed?
Hgb S on electrophoresis
