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Adult Health II > Endocrine Disorders > Flashcards

Endocrine Disorders Flashcards

1
Q

What is thyroid crisis (storm)?

A
  • Book calls it Thyrotoxicosis
  • An acute, severe, and rare condition that occurs when excessive amts. of thyroid hormones are released into circulation.
  • Severe form of hyperthyroidism
    • Physical or psychological stressors (possible cause)
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2
Q

Thyroid Crisis Etiology

A
  • Thought to result from stressors (e.g., infection, trauma, surgery) in a patient w/ pre-existing hyperthyroidism (diagnosed or undiagnosed)
    • Patients prone to thyroid crisis = those having thyroidectomy
      • manipulation of hyperactive gland = increase in hormones released.
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3
Q

Pathophysiology of Thyroid Crisis

A
  • Unsure
  • Massive release of Thyroid Hormone
    • Low tissue tolerance to triiodothyronine (T3) and thyroxine (T4)
    • Release leads to hypermetabolic state – stimulation of the sympathetic nervous system
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4
Q

Clinical Manifestation of Thyroid Crisis

A
  • Sweating
  • Heat intolerance
  • Nervousness
  • Tachycardia
  • Wide Pulse Pressure
  • Body Temp > 104o F without infection
  • Seizure, Tremors
  • Coma
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5
Q

Previous medical Hx most often associated w/ thyroid crisis

A

Grave’s Disease

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6
Q

Lab studies showing patient is in Thyroid Crisis?

A
  • Elevated Total T4 and free T3 and T4
  • Very low TSH
    • Due to the elevated levels of thyroid hormoneo Decreased K+ and Mg+o Elevated Ca++
  • LFTs (liver function test) may be elevated
  • Hyperglycemia
    • Insulin resistance and breakdown of stored glucose
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7
Q

Management of thyroid crisis

A

4 Fold:

  • Precipitating Factors
    • Stress, Trauma, MI, Shock
  • Controlling Excessive Thyroid Hormone release
  • Inhibiting Thyroid Biosynsthesis
    • Conversion of TH to T3 and T4
  • Treat peripheral effects
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8
Q

Drugs that Block Thyroid Synthesis

A
  • Propyithiouracil (PTU)
  • Methimazole
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9
Q

Drugs that Suppress release of TH

A
  • Sodium Iodide
  • Potassium iodide
  • Saturated solution of potassium iodine (SSKI)
  • Dexamethasone (Glucocorticoid Steroid)
    • Inhibit thyroid hormone release
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10
Q

Beta Blocker used to treat Thyroid Crisis? How does it work?

A
  • Propranolol (Inderal)
    • Restore cardiac function
    • Decreases catecholamine-mediated symptoms
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11
Q

Other drugs used in the treatment of Thyroid Crisis?

A
  • Digoxin
  • Dilitazem
  • Lasix
    • Tx’s CHF, tachydysrhythmias
      • Decrease myocardial O2 consumption and heart rate
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12
Q

Emergency removal of excess circulation or hormone - How is it done?

A
  • Plasmapherisis
  • Dialysis
  • Cholestyramine – oral
    • Absorbs excessive hormone
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13
Q

Management goals of Thyroid Crisis?

A
  • Reducing circulating thyroid hormone levels and clinical manifestations w/ appropriate drug therapy
  • The ultimate goal is to avoid reoccurrence
    • Identify triggers
    • Life long medications to suppress thyroid hormone
    • Thyroid Ablation
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14
Q

Thyroid Crisis Supportive Therapy

A
  • Manage respiratory distress
  • manage multi-system effect and responses to treatment -hourly!!
    • Reduce fever
    • Replace fluid
    • Eliminate/manage initiating stressor
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15
Q

Thyroid Crisis - Managing Cardiovascular status

A
  • HR – Rhythm – Heart sounds – BP
  • D5NS to treat hypovolemia
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16
Q

Thyroid Crisis - managing body temperature

A
  • Antipyretics
    • Acetaminophen – Not ASA
    • Increases free T3 and T4
  • Tepid Baths
    • Do not bring to shiver - ↑ Body temperature
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17
Q

Thyroid crisis- neurologic status

A
  • Seizure precaution
  • ↓ LOC may lead to obstructed airway
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18
Q

Thyroid Crisis - Radioiodine/RAI Therapy

A
  • RAI therapy
    • Definitive therapy
      • Will make patient Hypothyroid
    • Excreted in the urine - saliva
      • Over a few dayso
      • Do not share foods, drinkso
      • Do not get close to children
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19
Q

How long does the acute phase of thyroid crisis last?

A

24-48 hours

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20
Q

HYPOthyroidism Etiology

A
  • Low levels of thyroid hormone
  • Congenital – cretinism
    • Detected at birth
  • Primary thyroid failure
    • Hashimoto’s disease
    • Thyroiditis
  • Low basal metabolic rate
21
Q

What is Myxedema Coma?

A
  • Severe form of hypothyroidism
    • Untreated hypothyroidism
22
Q

Precipitation factors of Myxedema Coma?

A
  • Drugs (esp. opioids, tranquilizers, & barbiturates)
  • Extreme cold
  • Sedatives
  • Surgery
  • Opioids
  • Infection
  • Trauma
23
Q

Signs and Symptoms of Myxedema Coma

A
  • Comatose
  • Hypothermic
  • Respiratory failure
    • R/T muscle weakness
    • Sleep apnea
  • Cardiac failure
    • R/T bradycardia
    • Decreased stroke volume
24
Q

Significance of slowed drug metabolism and Myxedema Coma?

A
  • Potential drug toxicity
    • Digoxin
25
Q

Myxedema Coma Treatment

A
  • Supportive
    • Ventilator
    • Fluids
    • Warming blankets – slowly
    • Thyroid Hormones
  • T3 and T4
  • Hydrocortisone – IV
    • If patient also has adrenal insufficiency
26
Q

Adrenal Gland - Medullary hormones

A
  • Dopamine
    • Precursor of Norepinephrine (increase BP)
  • Norepinephrine
    • ↑ PVR ( peripheral vascular resistance)
  • Epinephrine
    • Fight of Flight (HR Increase, dilates eyes, gets body ready to go)
  • Opioid peptides
    • Not exactly to sure how they work.
27
Q

Cortical hormones

A
  • Mineralocorticoids
    • Kidney
  • Glucocorticoids
    • Metab of fat, charbohydrates, protein
28
Q

Cushing’s Sydrome

A
  • results from chronic exposure to excess corticosteroids, particularly glucocorticoids.
  • Conditions causing CS: most common = iatrogenic adminstration of exogenous corticosteroids (e.g., prednisone)
  • Excess circulation of glucocorticoids
  • Pituitary tumor 60%
    • increased Adrenocorticotropic hormone (ACTH)
  • Primary Adrenal neoplasm/hyperplasisa 25%
  • Ectopic ACTH or CRH (corticotropin-releasing hormone) 15%
    • Pulmonary tumors
  • Women > Men
29
Q

Iatrogenic

A

of or relating to illness caused by medical examination or treatment.

30
Q

Cushing’s Sydrome Diagnostic Tests

A
  • 24 hour urine free cortisol
    • Best for dx Cushing’s syndrome
    • Day 1 collect second void and remaining voids
    • Day 2 collect just AM void
    • Normal: 10-100 mcg/24 hours
      • Increased levels – Cushing’s
      • Decreased levels – Addison’s
  • 8 mg overnight dexamethasone (for borderline levels) suppression test
    • Day 1 – 8 am cortisol level
    • Take 8 mg dexamethasone at 11 pm
    • Day 2 – Collect blood at 8 am for cortisol level
      • Pituitary Cushing’s 50% reduction of morning serum cortisol
31
Q

Medications for Cushing’s Syndrome

A
  • If patient fail surgical treatmen
    • Inhibit cortisol production in the adrenal glands
      • Ketoconazole
      • Metyrapone
      • Aminoglutethemide
      • Mitotane
    • Must identify the cause first:
      • Pituitary Cushing’s
        • Transsphenoidal surgery
        • Irradiation
        • Gamma Knife
      • Adrenal Tumor
        • Adrenalectomy - increased risk for adrenal crisis
      • Ectopic
        • Surgery/radiation
32
Q

Adrenal Insufficiency

A

hypodisfunction of adrenal cortex

33
Q

Adrenal Insufficency - Primary vs. Secondary cause

A

Addison’s Disease

  • West – autoimmune causes -adrenal tissue destroyed by abs agains pt’s own adrenal cortex
  • All three classes of adrenal corticosteroids are reduced (gluco-, mineral-corticoids, and androgens)
  • Gradual destruction of the adrenal glan
  • World wide
    • TB
  • Destruction of the Adrenal gland

Secondary adrenal insufficiency

  • Lack of ACTH secretion (corticosteroids and androgens are deficient, but mineral corticosteroids rarely are)
    • Alteration in any step of the hypothalamic-pituitary-adrenal axis
    • Can be temporary or permanent
34
Q

Secondary causes of Adrenal Insufficiency

A
  • Iatrogenic (induced by physician)
    • Abrupt withdrawal of exogenous adrenocorticotropic hormones (ATCH)… or
  • Complications of cortisol therapy
  • qCortisol therapy → ↓ATCH secretion by disrupting the natural feedback loop → acute adrenal insufficiency.
  • Other secondary causes
    • Metastatic carcinomas
      • Lung
      • Breast
    • Pituitary infarct
    • Surgery
    • CNS Disturbances
      • Basilar Skull Fracture
      • Meningitis
35
Q

Chronic Adrenal Insufficiency Treatment

A

Chronic Adrenal Insufficiency

  • Hydrocortisone
    • Usually 2/3 in AM
    • 1/3 in PM
    • Mimics the natural body
  • Mineralocorticoid
    • Fludrocortisone (Florinef)
36
Q

Adrenal crisis (aka addisonian crisis or acute adrenal insufficiency)

A
  • Rare – Life threatening emergency caused by insufficient adrencorticol hormone or a sudden sharp decrease in the hormones
    • Dysfunction of the adrenal cortex
    • Hypoadrenalism
    • Hypocorticism
  • Primary vs Secondary
    • Primary – involves the adrenal gland
    • Secondary – related to some other cause
      • Hypothalmic-pituitary disease
37
Q

Initial symptoms of Adrenal Crisis?

A
  • Initially
    • N/V/D
    • Weakness
    • Fatigue
    • Anorexia
    • Abdominal Pain
  • Initial Symptoms
    • Non-specific until linked with past history of AI or recent use of corticosteroid
    • > 20 mg hydrocortisone for 7 – 10 days
    • Suppression of hypothalmic-pituitary-adrenal feedback
38
Q

Signs of Adrenal Crisis

A

Severe Dehydration

  • Weight Loss
  • Orthostatic hypotension

Dehydration is related to nephrons inability to reabsorb sodium and water

39
Q

Other S/S of Adrenal crisis

A
  • Tachycardia
  • Orthostatic HTN
  • Headache
  • EKG changes associated with ↑K+
  • Hyperpigmentation
40
Q

Lab findings of Adrenal Crisis

A

Aldosterone Deficiency

  • Hyperkalemia
    • >5mEq/L
  • Hyponatremia
    • <130mEq/L
  • Hypovolemia
  • Elevated BUN/CR

Cortisol Deficiency (milder):

  • Hypoglycemia
  • Decreased gastric motility
  • Decreased vascular tone
  • Hypercalcemia

prim & sec? = anemia and leukocytosis - eosonophils?

41
Q

ATCH levels

A

Elevated -= primary adrenal insufficiency,

norm/low = secondary

42
Q

Other Tests - Adrenal Insufficiency

A

CT of Head & CT of Adrenals

43
Q

Adrenal Crisis Management Goals

A
  • Administer needed Hormones
  • Restore fluid and electrolyte balance
  • Hormone Replacement
    • Hydrocortisone
      • 100 mg IV q 6 – 8 hours for 24 hours
      • Glucocorticosteroids (prednisone & decadron) cause further loss of sodium….
        • DO NOT USE
  • Fluid Replacement
    • Normal Saline
    • Dextrose
  • Vasopressors
    • To use or not to use???
      • Are not effective until the patient is adequately hydrated.
44
Q

Pituitary Tumors

A
  • Also called adenomas
  • Hyperfunction
  • Anterior Pituitary Gland
    • May involve 1 or more hormones
45
Q

Pituitary Tumor Classification

A
  • Size
    • Macroadenomas - > 10 mm in diameter
    • Microadenomas - <10 mm in diameter
  • Hormone Production
    • Prolactin – 60%
    • Growth Hormone – 20%
    • ACTH – 10%
    • Others – 10%
46
Q

Prolactin Hypersecretion associated with Pituitary Tumors

A
  • Decreased testosterone
    • Loss of Libido; ED
    • decreased sperm count
    • Gynecomastia – rare galactorrhea
  • Decreased Estradiol -
    • Irregular menses
    • Infertility
    • Galctorrhea
  • Ectopic Causes
    • Dopamine antagonists
    • Chronic Renal Failure
      • Decreased clearance
    • Neurogenic secretion
      • Chest trauma, thoracotomy, herpes zoster
    • Hypothyroidism
    • Medications• Page 1062 Box 38-1
47
Q

Growth Hormone (Acromegaly)

A
  • Macroadenomas -> Ha = headaches
  • Facial Features
    • Coarsening of features
      • Increased size of nose, lips, and skin foldso
  • Increase size of hands and feet
  • Deepening voice
  • Increase vertebral bodies -> kyphosis
48
Q

Diagnosis –Prolactin Hypersecretion

A
  • Based on History
    • Galactorrhea
    • Irregular menstrual cycle
      • Infertility
    • Gonadal Dysfunction
  • Prolactin Levels
    • Normal – 20 ng/ml
    • Medication - <150 ng/ml
    • Tumor - >150 ng/ml
49
Q

Diagnosis of GH Hypersecretion

A

Clinically obvious

Confirmed by GH levels

Adult Health II (4 decks)

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