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Endocrine ABIM Flashcards

1
Q

Hypopituitarism causes (3 most common)

A

Pituitary Tumor, Pituitary surgery, Cranial irradiation

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2
Q

Hypopituitarism: Pituitary Apoplexy: cause, symptoms, treatment

A

Cause: Pituitary hemorrhage or infarction; Sx: sudden headache, visual change, opthalmoplegia, AMS; Tx: Acute admin of glucocorticoids until adrenal insuffiency r/o; May also require neurosurgical decompression

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3
Q

Hypopituitarism: Postpartum pituitary necrosis (Sheehan syndrome): cause, symptoms

A

Cause: silent pituitary infarction usually associated with obstetric hemorrhage and hypotension. Sx: Acutely, vascular collapse. More commonly, amenorrhea, inability to lactate, fatigue.

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4
Q

Hypopituitarism: Lymphocytic hypophysitis: what is it?

A

It causes hypopituitarism, and possibly sx of mass lesion. most cases occur during or after pregnancy.

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5
Q

Hypopituitarism: Signs of pituitary mass effect

A

Headache & Loss of peripheral vision

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6
Q

Hypopituitarism: Symptoms of anterior hypopituitarism: FSH/LH deficiency - symptoms/testing/findings

A

FSH/LH: amenorrhea, loss of libido, ED Test: depressed FSH, LH, estradiol or testosterone

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7
Q

Hypopituitarism: Symptoms of anterior hypopituitarism: ACTH deficiency -symptoms/tests/findings

A

ACTH: fatigue, N/V, Wt loss, Abd pain Tests: Low cortisol/depressed ACTH; depressed response of 11-deoxycortisol and cortisol to metyrapone, positive cortisol response to ACTH

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8
Q

Hypopituitarism: Symptoms of anterior hypopituitarism: TSH deficiency - symptoms/tests/findings

A

TSH: cold intolerance, weight gain, constipation Tests: depressed free T4 and TSH

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9
Q

Hypopituitarism: Symptoms of anterior hypopituitarism: GH deficiency - symptoms/tests/findings

A

GH: loss of muscle mass Tests: depressed IGF-1 (serum marker of GH); diminished response to insulin tolerance test ~ insulin induced hypoglycemia

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10
Q

Hypopituitarism: Symptoms of anterior hypopituitarism: DI secondary to ADH deficiency

A

ADH/DI: polyuria, polydypsia, nocturia Tests: Urine osmo < 200 does not increase with water deprivation test; Positive desmopressin challenge (urine concentrates); MRI or pituitary

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11
Q

Hypopituitarism: Symptoms of anterior hypopituitarism: visual changes

A

Bitemporal loss of vision (mass effect on optic chiasm)

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12
Q

Hypopituitarism: Symptoms of anterior hypopituitarism: prolactin level

A

Level may be elevated from loss of tonic inhibition ~ hyperprolactinemia

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13
Q

Hypopituitarism Treatment

A

Replace hormone deficiency appropriately * Hydrocortisone for adrenal insufficiency

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14
Q

Hypopituitarism Treatment: Central Hypothyroid Tx

A

Thyroxine dosing based on serum T4 rather than TSH level; T4 replacement only after hypoadrenalism r/o or treated

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15
Q

Pituitary Adenoma: micro vs macro

A

benign tumors; microadenoma < 10mm; macroadenoma > 10mm

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16
Q

Pituitary Adenoma: 2 ways they become symptomatic

A

1: mass effect causing hypopituitarism ~ ant pit hormone deficiencies + headaches/visual field disturbances, CN dysfn. 2: endocrine hyperfunction caused by excess secretion by the tumor

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17
Q

Pituitary gland is diffusely enlarged in these 2 situations

A

Normal Pregnancy & Untreated Primary Hypothyroidism

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18
Q

Pituitary Adenoma: Galactorrhea/Amenorrhea - think this/order this…

A

Think this: Prolactinoma; Order this: Serum Prolactin Level

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19
Q

Pituitary Adenoma: Enlargement of hands, feet, nose, lips, or tongue; increased spacing between teeth - think this/order this…

A

Think this: Acromegaly; Order this: Serum IGF-1, OGTT (fails to suppress GH)

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20
Q

Pituitary Adenoma: Proximal muscle weakness, facial rounding, centripetal obesity, purple striae, diabetes mellitus, and hypertension - think this/order this…

A

Think this: Cushing Disease; Order this: 24-hour urine cortisol excretion, dexamethasone suppression test (suppresses) or late night salivary cortisol level (elevated); serum ACTH level (elevated or inappropriately normal)

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21
Q

Pituitary Adenoma: Goiter & Hyperthyroidism - think this/order this…

A

Think this: TSH-secreting adenoma (rare); Order this: TSH normal or elevated; increased T4

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22
Q

Pituitary Adenoma: General Testing Rules

A
  1. Test all patients w/incidentally discovered pituitary adenoma for hormone hypersecretion 2. Order MRI if testing indicates hormonal hypersecretion from pituitary source 3. If mass effect is presenting sx, obtain MRI first, endocrine testing later (headache/visual) 4. Eval pts with at least 1 component of MEN1 and family hx of MEN1 for a pituitary adenoma (usually hyperparathyroidism)
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23
Q

Pituitary Adenoma: Nonprolactinoma causes of hyperprolactinemia

A

~ Usually level < 150ng/mL ~ Psychotropic agents, TCAs, Antiseizure meds, Metoclopramide, Domperidone, CCBs, Methyldopa, Opiates, Protease Inhibitors ~ Check TSH level (hypothyroidism can cause it)

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24
Q

Pituitary Adenoma: Tx for women with microprolactinoma/normal menses; Patients with nonfunctioning microadenomas (< 10mm)

A

Observation

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25
Pituitary Adenoma: Tx for symptomatic prolactinoma
Dopamine Agonist (cabergoline preferred to bromocriptine); consider w/d of RX if prolactin level normalized and mass no longer visible on imaging; Close follow up ~ recurrence rates up to 50%
26
Pituitary Adenoma: Tx for adenomas secreting GH, ACTH, TSH; Tx for adenomas w/mass effect, visual field disturbance, Tx for hypopituitarism and Tx for prolactinomas unresponsive to dopamine agonist
Surgery
27
DI: what is it? central vs nephrogenic
Inability to concentrate urine due to insufficient arginine vasopressin (AVP, ADH) release (central) or activity (nephrogenic)
28
DI: patient history includes...(6 likely scenarios)
1. recent head trauma 2. pituitary mass lesion 3. evidence of anterior hypopituitarism 4. h/o infiltrative disorder (such as sarcoidosis) 5. kidney disease (tubulointerstitial disease) 6. meds such as lithium
29
DI: symptoms/signs of central DI
cravings for water or cold liquids, urinary frequency, nocturia, and, depending on mass effect of pituitary tumor, visual field deficits
30
DI: initial testing/confirmation testing
Initial: 1. urine osmo \< 200 mOsm/kg 2. inability to concentrate urine during water deprivation test Confirmation: 1. desmopressin challenge test (+) urine concentrates = central, order MRI of pituitary; (-) urine does not concentrate = nephrogenic, order u/s kidneys
31
DI: Tx DI after neurosurgery or head trauma
If unable to drink, 5% dextrose in 0.45% sodium chloride IV; Add desmopressin if urine output high or hypernatremia develops
32
DI: Tx DI Chronic Central DI
Intranasal or oral desmopressin
33
DI: Lithium Induced nephrogenic DI
Stop lithium or add amiloride (diuretic)
34
DI: Non-drug induced nephrogenic DI
Thiazide diuretic and salt restriction
35
Empty Sella Syndrome: diagnosis
MRI: pituitary gland not visualized or is excessively small
36
Empty Sella Syndrome: causes
increased CSF entering and enlarging sella; tumor; previous pituitary surgery, radiation, infarction
37
Empty Sella Syndrome: testing in asymptomatic, testing in symptomatic
Asymptomatic: obtain cortisol, TSH, and free or total T4 Symptomatic: testing of all pituitary hormones
38
Hyperthyroidism: Thyrotoxicosis
any cause of hormone excess, including primary, secondary, destructive thyroiditis, excessive exogenous ingestion
39
Hyperthyroidism: destructive thyroiditis causes & testing
causes: subacute (de Quervain), silent (painless), postpartum ~ permanent hypothyroidism may follow all; testing: decreased TSH, normal T3 and T4, no symptoms, decreased or no RAIU uptake
40
Hyperthyroidism: Subacute (de Quervain): presentation, testing
nonautoimmune inflammation presents with firm and painful thyroid gland
41
Hyperthyroidism: Postpartum
painless autoimmune occurring within a few months of delivery
42
Hyperthyroidism: defined (\* = most common)
disorders of increased thyroid hormone production and release ~ destructive thyroiditis, \*Graves disease, \*thyroid nodules, toxic multinoduar goiter
43
Hyperthyroidism: signs/symptoms
nervousness, emotional lability, increased sweating, heat intolerance, palpitations, increased defecation, weight loss, menstrual irregularity, tachycardia, lid lag, fine tremor, muscle wasting, proximal muscle weakness, hyperreflexia
44
Hyperthyroidism: Graves specific findings
goiter, opthalmopathy (proptosis, chemosis, extraocular muscle palsy) and pretibial myxedema; TSH receptor abs - do not need checked unless diagnosis unclear
45
Hyperthyroidism: Thyroid Storm - what? why? testing?
what? life threatening hyperthyroidism associated with cardiac decompensation, fever, delirium, and psychosis. why? following surgery, infection, iodine load (contrast), untreated grave's. diagnosis? clinical diagnosis; levels are not indicative
46
Hyperthyroidism: surreptitious use of thyroid hormone
Suppresses thyroglobulin levels (useful measurement to r/o this cause)
47
Hyperthyroidism: testing - what to order?
order TSH, Free T4 levels; it TSH suppressed but T4 is normal, order free T3 to diagnose T3 toxicosis (rare)
48
Hyperthyroidism: testing - 1: tsh low; free T4 high; 2: tsh low; T3 high; normal fT4 3: low TSH, normal T3 and free T4, w/o sx 4: high TSH, high T3, high free T4
1. Primary hyperthyroidism 2. Primary hyperthyroidism w/T3 toxicosis 3. Subclinical hyperthyroidism 4. Secondary hyperthyroidism from pituitary tumor
49
Hyperthyroidism testing - RAUI uptake: 1. diffuse homogenous increased uptake 2.patchy areas of increased uptake 3.focal increased uptake with decreased uptake elsewhere in gland 4.decreased or no uptake
1. Grave's 2.Toxic Multinodular Goiter 3.Solitary adenoma 4. Iodine load (IV contrast or Amiodarone), Thyroiditis (silent, subacute, postpartum, amiodorone induced), Serruptitious ingestion of excessive thyroid hormone
50
Hyperthyroidism: Treatment options (3)
1. Radioactive iodine therapy (may lead to painful radiation thyroidits and sialadenitis, not used during pregnancy or breastfeeding), frequently restores euthyroidism 2. Antithyroid drugs (may lead to drug free remission in 30-50% of Grave's or bridge to more definitive therapy), 3. Thyroidectomy (when definitive therapy required in patient with severe graves opthalmopathy or if RAI or antithyroid drugs can't be given or aren't tolerated or if large goiter causing local sx)
51
Hyperthyroidism: Antithyroid drugs ~ 1. Methimazole - used for/watch for 2. Propylthiouracil - used for/watch for
1. Methimazole: 1st line antithyroid for most pts; watch for agranulocytosis, drug rash, hepatotoxicity 2. PPU: 1st trimester, thyroid storm (inhibits T4 to T3 conversion); watch for: agranulocytosis, drug rash, frequent hepatotoxicity
52
Hyperthyroidism: Treatment 1. Sympathetic nervous system symptoms 2. Prep for thyroidectomy 3. Severe Graves opthalmopathy 4. Pregnancy 1st trimeser; 2nd/3rd trimester
1. SNS: Atenolol or Propanolol 2. Thyroidectomy Prep: Methimazole 3. Severe Graves optho: MMZ or Thyroidectomy \*Avoid RAI (may worsen unless pretreated with glucocorticoids) 4. Pregnancy: 1st trimester PPU; 2nd/3rd trimester: MMZ (RAI contraindicated)
53
Hyperthyroidism: Treatment 5. Subclinical Hyperthyroidism 6. Subacute Thyroiditis 7. Suspicious Nodule (malignancy) 8. Thyroid Storm
5. Methimazole if TSH \< 0.1 6. NSAIDS, glucocorticoids for pain mgmt; atenolol or propanolol for sx; levothyroxine for sx hypothyroidism; repeat thyroid studies 4-6 mos; 50% normalize without treatment
54
Hyperthyroidism: Treatment 7. Suspicious Nodule (malignancy) 8. Thyroid Storm
7. FNAB followed by thyroidectomy if malignant 8. PPU (preferred) or MMZ, idoine-potassium solutions, glucocorticoids and B blockers
55
Hyperthyroidism: PPU or MMZ + fever or sore throat?
Agranulocytosis until proven otherwise
56
Hypothyroidism: Signs/Symptoms
weakness, lethargy, fatigue, depression, poor concentration, myalgia, cold intolerance, constipation, weight gain, menstrual irregularity or menorrhagia, carpal tunnel syndrome
57
Hypothyroidism: Exam findings
Bradycardia, Hypothermia, diastolic hypertension, husky voice, goiter, cool dry skin, brittle hair, edema, delayed relaxation phase of DTRs
58
Hypothyroidism: Causes (6)
1. chronic lymphocytic thyroiditis (Hashimotos) 2.thyroidectomy 3.previous radioactive iodine ablation 4.history of external beam radiation to the neck 5.medication induced (lithium, interferon alfa, ILK2, amiodarone) 6.central (pituitary disease, previous surgery, radiation to sella)
59
Hypothyroidism: Myxedema coma - defined - caused by - precipitated by
defined: severe hypothyroidism leading to decreased mental status, hypothermia, hypotension, bradycardia, hyponatremia, hypoglycemia, hypoxemia, hypoventilation. occurs with: severe, long-standing, untreated hypothyroidism; may pre precipitated by: acute medical or surgical event or administration of opiates
60
Hypothyroidism: Testing
TSH, free T4; T3 usually not necessary; Antithyroid peroxidase associated w/hashimotos
61
Hypothyroidism: Non thyroidal illness
Low/Normal Free T4 Low TSH (initially) then elevated TSH (recovery phase) Normalization of levels 4-8 weeks after recovery No treatment required
62
Hypothyroidism: 1. High TSH; Low free T4 2. High TSH; Normal T4 3. Low TSH, Low free T4
1. Primary hypothyroidism 2. Subclinical hypothyroidism 3. Secondary (central) hypothyroidism; hypopituitarism
63
Hypothyroidism: How do you treat? Who do you treat?
Levothyroxine; treat subclinical w/serum TSH \> 10 or who are pregnant or are trying; Also thyroxine demand increases by 30-50% during pregnancy
64
Hypothyroidism: 4 causes of decreased levothyroxine absorption
1. Celiac disease 2. Calcium 3. Iron 4. PPIs
65
Hypothyroidism: Levothyroxine dosing 1. Age \< 60 2. Age \> 60 3. Heart disease
1. \< 60: Begin full dose 2. \> 60: Begin at 25 - 50; increase by 25 q6 weeks 3. \<3: Begin at 12.5 - 25
66
Hypothyroidism: Levothyroxine dosing 4. Myxedema coma 5. Pregnancy
4. Begin levothyroxine & hydrocortisone ~ give until adrenal insufficiency ruled out 5. increased by 30% initially; check levels frequently
67
Thyroid nodules: 1st step; what does normal mean? what does low mean? 2nd step; 3rd step
1st: TSH level; commonly normal aka not helpful 2nd: Low TSH level suggests benign 3rd: If low, order radioisotope scan to confirm diagnosis and r/o additional non functioning nodules w/i a multinodular goiter
68
Thyroid nodules: Eval MNGoiter for compressive symptoms (name 3) and further testing as needed (name 4)
1. Dysphagia 2. Hoarseness 3. Dyspnea (tracheal compression from substernal goiter) Testing: Barium Swallow; direct visual cord visualization, spirometry w/flow volume loops and/or CT chest
69
Thyroid nodules: FNAB is indicated for...
1. All thyroid nodules \> 1 cm with suspicious features & normal TSH 2. Nodules \< 1 cm with risk factors for thyroid cancer or suspicious u/s characteristics
70
Thyroid nodules: Management/Treatment 1. Observe who? how? 2. RAI or surgery for who? 3. Surgery for who?
1. Observation: periodic u/s for benign nodules 2. RAI or surgery: hyperfunctioning solitary thyroid nodules with RAI ablation or hemithyroidectomy 3. Surgery: continued nodule growth, malignant cytology, large MN goiters w/compressive sx
71
Hypercortisolism Syndrome: what is it? most common causes?
defined: Ongoing exposure to excessive glucocorticoids MCC: iatrogenic, endogenous (ACTH dependent or non)
72
Hypercortisolism: ACTH dependent -defined causes
defined by: inappropriately elevated or normal ACTH levels in relation to cortisol level 1. ACTH secreting pituitary adenoma (cushing disease) 2. ACTH secreting carcinomas and carcinoid tumors
73
Hypercortisolism: ACTH independent
defined by: low or normal ACTH levels in relation to cortisol level | 1. adrenal adenoma 2. adrenal carcinoma
74
Hypercortisolism: Clinical Findings highly specific for Cushing Syndrome
centripetal obesity facial plethora supraclavicular or dorsocervical (buffalo hump) fat pads wide \> 1 cm violaceous striae
75
Hypercortisolism: Testing Diagnostic Studies
76
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