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Med 1 > Endocrine/Metabolic > Flashcards

Endocrine/Metabolic Flashcards

1
Q

Elderly w/ nervousness , insomnia, hyperactivity and weight loss?

A

hyperthyroidism

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2
Q

Graves disease?

people seen?

A

Autoimmune IgG binding to TSH receptors -> synthesis -> hyperthyroidism

young women w/ other immune disorders

diffuse uptake on scan

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3
Q

Plummer disease

A

mulinodular toxic goiter - hyperthyroidism

high T4 and T3 levels -> low TSH and atrophy of thyroid

patchy uptake on thyroid scan

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4
Q

Transient hyperthyroidism

A

hashimotos and subacute thyroiditis

post partum thyroiditis (rare)

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5
Q

Graves uniques signs (3)

A

exothalamos
periorbital myxedema
thyroid bruit

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6
Q

Factors that increase TBG and as a result T4(4)

A

pregnancy*, liver disease, OCP and ASA

increase in bound T4 and not necessarly free T4

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7
Q

Pharmacologic for hyperthyroid (4)

Monitor?

A

methimazole and propylthiouracil - inhibit synthesis (PTU inhibits conversion)
- Monito agranulocytosis

beta blockers for symotms

Sodium ipodate lowers serum levels

Radio iodide 121-> destruction of thyroid follicular cells

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8
Q

hypocalcemia peri neck surgery

A

took out parathyroids or have inflammation temporrarily

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9
Q

Hyperthyroid and pregnant

A

propylthiuracil

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10
Q

Thyroid storm

A

Rare and life threatening complication of thyrotoxicosis

Precipitant (infeciton, DKA, surgery. etc)

20% die.coma

FEVER, tachy, agitation, psychosis and GI

IV fluids, cooling, PTU q2hrs, w/ iodine, beta blockers

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11
Q

Causes of hypothyroidism (3)

A

primary
- Hashimotis - common
itaragenic - prior tx for hyperthyroidism

secondary (pituitary disease, low TSH)
tertiary(hypothalamic, low TRH)

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12
Q

LOW free T4 and TSH think of

A

seondary and tertiary hypothyroidsm

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13
Q

Sublclinical hypothyrpoidism

A

thyroid inadequate -> increased TSH to maintain normal T4

elv TSH — normal T4

nonspecific signs, Tx w. thyroxine if goiter develops, hypercholerolemia, or symotms

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14
Q

HIGH TSH should 1st think of

Also order?

A

hypothyroidism

not true in seconday and tertiary

Lipids and CBC

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15
Q

Increase antimicrosomal antibodies

A

Hashimotos thyroiditis

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16
Q

Subacute (viral) thyroiditis

features

Dx

TX

A

prodromal period, transient hyperthyroidism -> decrease

PAINFUL, tender thyrod

Radioiodine uptake is low, damaged follicles

NSAIDs, ASA, steriods

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17
Q

Subacute lymphocytyc thyroiditis

A

PAINLESS (vs subacute viral)

transient thyrotoxic-> hypothyroid

low uptake (vs graves)

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18
Q

Chonic lymphocytic thyroiditis - hashimotos ot lymphocytic

See?

A

most common

antithyroid and antiperoxidase antibodies, goiter common,

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19
Q

Fibrous/Riedels thyroditis

A

fiberous tissue replaces -> thyroid firm

Surger

maybe hypothyroid

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20
Q

Detectable thyroid nodules by exam are ?

Malignancy suggested by?(7(

A

> 1cm

nodule fixed/no movement w/swallow; firm consistency; solitary; Hx of neck radiation; rapid development; vocal cord paralysis; cervical adenopathy

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21
Q

Cold thyroid nodules get what?

A

surgery

hot observe

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22
Q

FNA is reliable for all CA exceot?

A

Follicular

good for: papillary, medullary, anapestic

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23
Q

Hurthle cell tumor

A

Variant of follicular CA but more aggressive

spread by lymphatics and does not take up iodine

Tx: total thyroidectomy

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24
Q

Papillary CA

A

70-80% of Ca
least aggressive

risk w/ neck radiation

spreads via lymphatics; + iodine uptake

only one you may get away w/ a partial thyroidectomy, >3cm all comes out

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25
Q

Follicular carcinoma

A

15% CA
Absords iodine

Spreads hematogenously and early (brain, lung, bone, liver)

Extension through tumor capsule differentiates from benign

NEED a biopsy

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26
Q

Medullary carcinoma

A

2%
1/3 sporadic, 1/3 familal, 1/3 MEN II (pheo)

Parafollicular cells -> calcitonin

malignant w/ 10 yr survival

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27
Q

Anaplastic carcinoma

A

5% and seen in elderly

highly malignant

arise from follicular/papillary thyroid carcinoma

months prognosis

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28
Q

Calctonin levels if concerned w/ what thyroid CA

A

medullary

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29
Q

Thyroid CA Tx

A

thyrodectomy (partial in papillary if <3cm)

radioiodine therapy
(unsuccesful in medullary)

Chemo and radiation in anaplastic

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30
Q

pituitary adenoma

A

usually benign but may have hormonal effects

Either hyper secretion:
Prolactin -> 
GH ->acromegaly
ACTCh -> cushings
TSH -> hyperthyroidism

hypo w/crushed**

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31
Q

HA and vision defects - tunnel vision

Get what test ?

A

Parasellar signs->
bitemporal hemianopsia in pituitary adenoma

MRI and pituitary hromone levels

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32
Q

hypogonadism, decreased labido infertility, galactorrhea/gynecomastia in men think of

A

hyperprolactinemia 2/2 prolactinoma

can also be MEDs, pregnancy, renal failure, hypothyroidism

parasellar signs more common

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33
Q

High prolactin levels inhibit what hormone

A

GnRHH -> decreased LH and FSH and low estrogen and testosterone

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34
Q

Premenopausal (oligomenorrhagia irregular) decreased labido, dyspareunia, vaginal dryness, glactorrhea in women be concerned of?

A

hyperprolactinemia 2/2 prolactinoma

can also be MEDs, pregnancy, renal failure, hypothyroidism

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35
Q

Tests for prolcatinoma? (4)

A

elv serum prolactin

pregnancy and TSH for r/o

CT/MRI

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36
Q

Prolactinoma Tx

A

bromocriptine (dopamine agonist) ddecreases production

Tx for 2 yrs before stopping
Cabergoline (dopamine agonist) maybe better tolerated

Surgery if persist

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37
Q

Prolactinoma Tx

A

bromocriptine (dopamine agonist) ddecreases production

Tx for 2 yrs before stopping
Cabergoline (dopamine agonist) maybe better tolerated

Surgery if persist

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38
Q

Common cause of death w/ acromegaly

A

CV disease

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39
Q

Acromegaly vs gigantism

A

excess pituitary GH after epiphyseal closure

10% of pituitary adenomas

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40
Q

Features of acromegaly

- 3 classes

A

Growth - soft tissue skeletal/ coarse face/ hands + feet/ organomegaly/arthralgia w/ joint tissue, hypertrophy cardiomyopathy, macrgnathia

Metabolically
-glucose intolerance and hyperhidrosis

Parasellula manifestations
-HA, vision change, HTN, sleep apnea

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41
Q

IGF 1 - somatomedin C elvated in?

Confirm w?

A

Acromegaly

Oral glucose suppression- failure confirms

MRI pf pituitary

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42
Q

Tx of acromegaly -

A

Surgery - transphenoidal ressection

Radiation if elv after

Octreotide to suppress?

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43
Q

Calcification of suprasellar region seen in the brain imaging is?

origin?

A

craniopharyngioma

remnants of Rathke’s pouch

usually visual field defects, maybe hyperprolacinemia, DI, panhypopituitarism

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44
Q

Panhypopituitarism casues

A

hypothalamic or pituitary tumor most common

Also - radiation, sheehans, infiltrative, head trauma, cavernous sis thrombosis

LH, FSH and GH lost first

Then TSH and ACTH

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45
Q

Central DI vs Nephrogenic DI

Risk factors

A

Central - more common 2/2 low ADH production from posterior pituitary
- trauma/surgery, idiopathuc*, other destructive processes

Nephrogenic is lack of response to ADH
- Lithium use**, hypercalcemia, pyelonephritis,

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46
Q

5-15L of urine daily that is colorless - think of?(4)

A

DI, DM, poly dypsia, Diuretics

hyponatreamia mild unless impaired thirst drive

Low specific gravity and low osmolarity
Normally Mosm 250-290

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47
Q

Test for Central DI vs Nephrogenic

A

water deprivation and measure urine Osm every Hr, when stable add 2g desmopressin subQ,

+ for central if concentrates in presence of desmopressin. no Change is normal(max adh response as is) or nephrogenic

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48
Q

Tx pf nephrogenic vs Central DI

A

Central gets desmopressin

Nephrogenic gets Na restriction and thiazide diuretics (depletes body of Na and leads to reabsorption of Na and pater in proximal tubule, less water reaches distal -> decrease urination)

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49
Q

Despite volume expansion what is not seen in SIADH

A

edema

due to naturesis, excretion of excess Na despite hyponatremia

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50
Q

SIADH pathophys and cuases (6)

A

excess ADH from ectopic source of posterior pituitary -> hyponatremia and volume expansion

Neoplasms(lung, pancreas, prostate, bladder), lymphoma, leukemia

CNS (stoke, trauma, infection)

Pulm (pneumonia, TB)

Ventilators (+ pressure)

Medication (vincristine, SSRIs, chlopropromide)

Post op

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51
Q

Hypovolemic hyponatremia

hypervolemic hyponatremia

SIADH

A

volume contracted

volume expanded w/ edema

volume expanded w/out edema

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52
Q

SIADN -> hyponatremaia

acutely causes?

Chronicially

A

Acute - lethargy, somnolence, weakness
-Seizures**, coma death

Chronic- asymptomatic, anorexia, N/V, CNS symptoms less common, brain edema decreased

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53
Q

Dx SIADH by?

A

by exclusion

r/o by nyponatremia an inappropriate concentration of urine; low uric acid level, low BUN and Cr, normal thyroid and adrenals, liver, cardiac, absence of hypovolemia

54
Q

Symptoms of SIADH(6)

A
  • hyponatremia,
  • volume expansion w/o edema
  • Naturesis
  • hypouricemia and low BUN
  • Normal/reduced serum Cr
  • Normal thyroid and renal function
55
Q

Tx SIADH

A

the underlying cause

water restrict, Normal saline w/ loop if faster desired

Lithium carbonate and demeclocycline both inhibit ADH

Symptoms -> hypertonic saline, slow though - central pontine myelinolysis (0.5mEq/L per hr)

56
Q

Features of hypoparathyroidism

A

LOW Ca

cardiac arrythmia; 
rickets/osteomalacia; 
neuromucular irritability
- numbness/tingling
-tetany/hyper reflexive
- chvosteks - facial nerve
- trousseau's BP cuff and spasms
Basal ganglia calcification

PROLONGED QT interval**

57
Q

Labs in hypophospahtemia

Ca
Phos
PTH
cAMP

A

LOW Ca
HIGH phos
LOW serum PTH
LOW urine cAMP

58
Q

Primary hyperparathyroidism

A

1+ glands gone crazy -> most common cause of hypercalcemia outpatient (NEED to r/o malignancy w/ high CA though)

Tx is surgery - adenoma easy, carcinoma remove thyroid lobe and lymph nodes.

59
Q

Primary hyperparathyroidism

A

1+ glands gone crazy -> most common cause of hypercalcemia outpatient (NEED to r/o malignancy w/ high CA though)

60
Q

Symptoms of hypercalcemia

A

STONES - nephrolithiasis, nephrocalcinosis

BONES - bone aches/pains; osteitis fibrous cystic (brown tumor)

GROANs- muscle pain, pancreatitis, PUD, gout, constipation

PSYCHIATRIC OVERTONES - depression, fatigue, anorexia, AMS,

Also polydypsia, polyuria, HTN, short QT**,

61
Q

osteitis fibrous cystic

A

brown tumor - seen w. hypercalcemia

predisposes to pathologic fxr

62
Q

Calcium levels relation to albumin

if Ca is high what would be an appropriate lab value

A

Ca + 0.8(4-alb)=

PTH should be elevated to cause if in need of Ca, HIGH Ca suppresses PTH

63
Q

Chloride to phos >33 diagnostic of what?

A

primary hyperparathyroidism; Cl is high secondarily to renal bicarb waisting (2/2 PTH)

64
Q

Surgery for priamry hyperparathyroidism (5)

A

Age 400mg in 24 hrs

65
Q

Secondary hyperparathyroidism is?

A

elv PTH due to low Ca

chronic renal failure (common cause)

Vit D deficiency

Tx w/ Vit D, calcitriol and oral Ca sup + phos restriciton

66
Q

What diuretic is contraindicated in medical Tx of primary hyperparathyroidism

A

Thizaide(retains Ca)

Fluids + loops instead

67
Q

Cushing syndrome vs Cushings Disease

A

Syndrome - results from excessive levels of glucocorticoid

Disease - Pituitary Cushing’s syndrome (pituitary adenoma)

68
Q

cortisol effects(4)

A

inpaired collagen production, enhanced catabolism

anti insulin effects-> glucose intolerance

impaired immunity

enhanced catecholane effects (HTN)

69
Q

Most common cause of cushing syndrome

A

iatogenic (exogenous)

acth secreting adenoma (disease) second

Ectopic ACTH - small cell carcinoma, bronchial carcinoid, thyoma

70
Q

Change in appearance, central obesity, rounding of the face, stare, langou hair, acne, bruising HTN, DM think of

A

Cushings

also lowered immunity, depression/mania/ proximal weakness

ACTH excess-> hyperpigmentism (addisons have pigment 2/2 low cortisol and feedback response)

71
Q

Screens of Cushings

A
  1. overnight low dose dexamethasone suppression screener- 1mgPM-> measure cortisol in am
    - serum 5 has Cushings

24hr cortisol?

  1. ACTH
    - low in high cortisol -> adrenal source
    - high in high cortisol then pituitary sources(suppresses) vs. ectopic(not suppress)

HIGH dose suppresses Cushing disease

72
Q

Pheos arise from

A

chromatin cells of adrenal medulla or sympathetic ganglia if extra adrenal

73
Q

hyperglycemia, hyperlipidemia an dhypokalemia w/ periodic tachycardia and HTN

A

Pheo

74
Q

Features of pheo(8)

A 
HTN - high and episodically super high
pounding HA
Severe sweating
Tachycardia
Palpitations
Anxiety
impending doom
Lab: hyperglycemia. hyperlipdemia, hypokalemia
75
Q

Urine screen for pheo?

A

Meanephrine

Vannillymandelic acid, homovanillic, normetanephrine

76
Q

rule of 10 w/ pheos?

A 
10% familial
10% biateral- MEN II
10% malignant
10% mtpl
10% kids
10% extrarenal
77
Q

Tx prior to surgical intervention w/ pheo

A

beta blockade(HR) and alpha blockade(BP) 2-3 days prior

78
Q

MEN Type I (3Ps)

A

parathyroid hyperplasia
pancreatic islet cells
pituitary tumors

79
Q

MEN IIA (MPP)

A

medullary thyroid CA
Pheochomocytoma
hyperParathyroidism

80
Q

MEN IIB (MMP)

A

Medullary thyroid CA
mucosa neuromas
pheochromocytoma

marfoid body

81
Q

Hyperaldosterone - Primary

electrolytes and acid/base

A

Conn syndrome(Adrenal adenoma); adrenal hyperplasia

excess mineralcorticoids -> increase Na/K pump -< Na retention and K loss

Metabolic alkalosis w/ loss of H w/ K

82
Q

HTN and low K think of?

Sep if not on diuretic

A

Conns- primary hyperaldosterone

83
Q

Adrenal incidentaloma

A

common, determine if functional if not

resect if >6cm

84
Q

Signs of Conn?(4)

A

HTN*
Ha/fatigue/weakness
polydypsia
Absence of peripheral edema

85
Q

Screener of conns

3

A

Ratio of plasma aldosterone: renin
>30 eval further

Saline infusion, decreases aldosterone in normal Pts, unchanged if not

Aldosterone r/o

86
Q

Dx of primary aldosteronism

and treatment- depends

A

adenoma/hyperplasia

  • Adrenal venous sampling
  • renin-aldosterone stim test
  • Imaging - CT/MRI differentiate for need to bilateral w/ hyperplasia(spiranolactone)
87
Q

Most common cause of addisons

adrenal insufficiency?

A

TB- wordwide(fungal, CMV, cryptococcus), toxo)
Autoimmune- western world
(primary)

rapid glucocorticoid withdrawal (secondary adrenal insufficiency)

88
Q

Clinical findings of: weight loss, weak, pigmentation, anorexia, nausea, postural hypotension, ab pain, hypoglycemia

A

Addisons

ACTH ramped up-> pigmentation

low aldosterone -> Na loss and hypotension, shock, hyperkalemia

89
Q

Dx of Addisons

A
  1. decreased plasma cortisol
  2. plasma ACTH level

ACTH synthetic given and measure response, (primary no response, secondary also no response initially)

MRI

90
Q

Tx of addisions

A

daily oral glucocorticoid, (hydrocortizone, prednisone and daily fludrocortizone) may need stress dosing

91
Q

Congenital adrenal hyperplasia - cause?

A

Auto recessive
90% 21 hydroxylase deficiency

2nd: 11 hydroxylase deficiency

92
Q

Features of congenital hyperplasia

A

lower cortisol and aldosterone- precursors shunted towards androgens -> viralization of females (ambiguous genitalia w/ normal ovaries/uterus)

Males NO change

hyponatremia an dhyperkalemia

93
Q

high levels of 17 hydroxyprogesterone is?

Tx?

A

congenital adrenal hyperplasia

medically w/ glucocorticoid and mineralcorticoid

surgically- genitalia correction for females

94
Q

HLA is associated w/ what DM

A

Type 1 HLA DQ/DR

95
Q

Ketosis is common in what DM?

A

Type 1

also has autoantibodies

96
Q

Dawn and somogyi effect in DM management

A

Growth hormone at night -> lowest sugars ~3am.

HYperglycemic at that time may need to increase Rx, more often lower at that time and need to lower evening meds

97
Q

Screens/tests for DM

A 
A1c ACEi/ARB
BUN/Cr check
eye screening yearly
feet check
Statin
ASA
pneumococcal
98
Q

DM diagnosed if

A

Hgb>6.5 (5.7-6.4)

FPG >126 2x (110-126)

oral glucose >200 2 hrs (140-200)

99
Q

Sulfonureas - glyburide

A

stimulates pancreas to secrete Insulin

effective, inexpensive,

concern w/ weight gain and hypoglycemia

100
Q

Metform

A

enhances sensitivity, blocks gluconeogenesis

mild weight old, no hypoglycemia

GI upset and lactic acidosis

101
Q

Acarbose

A

reduces glucose absorbtion-> low calories

Low risk

Gi upset/diarrhea

102
Q

thiasolidinedione - rosiglitazone and pioglitazone

A

reduce insulin resistance

reduces insulin levels

heptotoxicity, cardiac concerns

103
Q

initial dosing of insulin for a PT

A

0.5U/kg (to 1U/kg)

60% long acting, 40% short

104
Q

Macrovascular complication s of DM

A

Accelerated atherosclerosis-> stroke, MI, CHF

Peripheral vascular disease (60%)

105
Q

Microvascular complications of DM(3)

A 
Diabetic nephropathy -
 -nodular glomerular sclerosis (kimmelsteil wilson Syndrome) ->
 -hylane deposits in glomerulus
-Diffuse glomerular sclerosis
isolated glomerular BM thickening

Retinopathy- asymptomatic unless retinal edema or ischemia to central macula

neuropathy - ulcer formation w/ numbness (Charcots joints). Can by painful-sep at night

106
Q

Radiocontrast in DM Pts

A

generally a bad idea w/ AKI possible

give lots of fluid prior and hold metformin 48hrs after

107
Q

UA will not pick up microalbuminuria

A

need to order separate . Does not become + until 300

Mcroalbuminuria is 30-300

108
Q

CN complications w/ DM

A

CN III but also VI and IV

palsy of 3rd eye but pupils SPARED

109
Q

Autonomic neuropathy in DM

A

impotencein men, neurogenic bladder, gastroparesis, constipation, postural hypotenison

110
Q

Diabetic foot 2/2?

A

Comnined artery disease and nerve

increased susceptibility to infection ( cellulitis, candidiasis, pneumonia, osteomyelitis,)

111
Q

DKA precipitating factors

A

Any stress - infectious, trauma, MI, stroke, surgery, sepsis, GI

Inadequate insulin

Have low insulin compounded by glucagon excess-> hyperglycemia and ketogenesis

112
Q

Signs of DKA (8)

A 
N/V
Kussmaul brealing
Ab pain
fruity breath
Dehydration -> orthostatic hypotension, tachy
Polydipsia, uria, phagia
Altered consciousness/drowzy
Occur w/in 24 hrs
113
Q

DDx for DKA (5)

A 
alcoholic ketoacidosis
hyperosmolar hyperglycemic nonketotic syndrome
hypoglycemia
sepsis
intoxification
114
Q

Dx of DKA(3)

A

glucose
- >450, shift
Low phosphate and magnesium

115
Q

Correction of Na w/ hyperglycemia

A

Na _ 1.6 (Glucose-100)

116
Q

DKA Tx (3)

A

IV fluids, AND insulin(0.1U/kg priming w/ 0.1/kg/hr after)

THEN potassium (1-2 hrs after)

insulin till gap is closed

117
Q

Hyperosmolar hyperglycemic nonketotic syndrome(3)

Pts?

A

hyperglycemia >900 and hyperosmolar >320, elv BUN

DEHYDRATED

no acidosis
no ketones b/c minimal insulin blunts counter reg

Seen in elderly Type II

118
Q

Features of HHNS(4)

A

thirst, pyorrhea,
hypotension/tachy
CNS** siezures,
Lethargy/confusion

Hyperosmolar hyperglycemic nonketotic syndrome

119
Q

TX w/Hyperosmolar hyperglycemic nonketotic syndrome(2)

A 
Fluids key (NS) 1L in 1hr, then 1 L/2hr,  
->glucose 250 ad 5% glucose D51/2 NS

worry of cerebral edema is too rapid

Insulin - bolus 5-10 U w/ 2-4 Udrip after

120
Q

Response to hypoglyemia

A

80s - insulin lowers

glucagon begins to increase

Epi and cortisol next

50s - > symptoms

121
Q

Organ at risk w/ hypoglycemia?

A

Brain - can’t use free fatty acids

122
Q

Measure what in hypoglycemia of unknown cause (4)

A

plasma nsulin
c peptid
anti insulin antibodies
plasma and urine sulfonureal levels

123
Q

causes of hypoglycemia

A

drug induced, factitious, insulinoma, ethanol ingestion, post op after gastric surgery, Adrenal insufficiency, liver failure, illness

124
Q

features of hypoglycemia -

A

Around 40-50

Elvated epinephrine levels-> sweating, tremors, BP and pulse, anxiety

Neuroglycopenic -> irritability, behavioral change, weakness, drowsiness, HA, convulsions death.

125
Q

Whipples triad

A

hypoglycemic by fasting
blood glucose <50 during symptomatic attack
glucsoe admin brings relief

126
Q

Insolinoma

what is it?

Test?

A

tumor of beta cells of pancreas (MEN I) usually benign

See hypoglycemia -> sympathetic activation and neuglycopenic symptoms

72 hr fast - hypoglycemic and should see the insulin drop, if not =insulinoma

See high c peptide as well

127
Q

ZOllinger ellison syndrome

A

gastinoma

pancreatic cells secrete gastrin -> ulcers

gastinomoma triangle - cystic duct, junction of 2nd and 3rd portions of duodenum

GI hemmorage/perforation, METS

Tx w. PPIs, maybe exploration w. curative resection

128
Q

Glucagonoma

A

clinically necrotizing migratory erythema - below the waist

glossitis, stomatitis, DM, hyperglycemia

Tx w/ surgery

129
Q

Somatostatinoma

A

rare

poor prognosis
Triad of gallstones, DM and steatorrhea

130
Q

VIPoma

A

rare pancreatic tumor

Water diarrhea!!-> dehydration and hypokalemia

achlorhydria - low gastric acid secretion

hyperglycemia and hypercalcemia

Surgical resetion

Med 1 (11 decks)

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