Endocrine/Metabolic Flashcards
1
Q
Elderly w/ nervousness , insomnia, hyperactivity and weight loss?
A
hyperthyroidism
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
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
4
Q
Transient hyperthyroidism
A
hashimotos and subacute thyroiditis
post partum thyroiditis (rare)
5
Q
Graves uniques signs (3)
A
exothalamos
periorbital myxedema
thyroid bruit
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
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
8
Q
hypocalcemia peri neck surgery
A
took out parathyroids or have inflammation temporrarily
9
Q
Hyperthyroid and pregnant
A
propylthiuracil
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
11
Q
Causes of hypothyroidism (3)
A
primary
- Hashimotis - common
itaragenic - prior tx for hyperthyroidism
secondary (pituitary disease, low TSH)
tertiary(hypothalamic, low TRH)
12
Q
LOW free T4 and TSH think of
A
seondary and tertiary hypothyroidsm
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
14
Q
HIGH TSH should 1st think of
Also order?
A
hypothyroidism
not true in seconday and tertiary
Lipids and CBC
15
Q
Increase antimicrosomal antibodies
A
Hashimotos thyroiditis
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
17
Q
Subacute lymphocytyc thyroiditis
A
PAINLESS (vs subacute viral)
transient thyrotoxic-> hypothyroid
low uptake (vs graves)
18
Q
Chonic lymphocytic thyroiditis - hashimotos ot lymphocytic
See?
A
most common
antithyroid and antiperoxidase antibodies, goiter common,
19
Q
Fibrous/Riedels thyroditis
A
fiberous tissue replaces -> thyroid firm
Surger
maybe hypothyroid
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
21
Q
Cold thyroid nodules get what?
A
surgery
hot observe
22
Q
FNA is reliable for all CA exceot?
A
Follicular
good for: papillary, medullary, anapestic
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
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
25
Follicular carcinoma
15% CA
Absords iodine
Spreads hematogenously and early (brain, lung, bone, liver)
Extension through tumor capsule differentiates from benign
NEED a biopsy
26
Medullary carcinoma
2%
1/3 sporadic, 1/3 familal, 1/3 MEN II (pheo)
Parafollicular cells -> calcitonin
malignant w/ 10 yr survival
27
Anaplastic carcinoma
5% and seen in elderly
highly malignant
arise from follicular/papillary thyroid carcinoma
months prognosis
28
Calctonin levels if concerned w/ what thyroid CA
medullary
29
Thyroid CA Tx
thyrodectomy (partial in papillary if <3cm)
radioiodine therapy
(unsuccesful in medullary)
Chemo and radiation in anaplastic
30
pituitary adenoma
usually benign but may have hormonal effects
```
Either hyper secretion:
Prolactin ->
GH ->acromegaly
ACTCh -> cushings
TSH -> hyperthyroidism
```
hypo w/crushed**
31
HA and vision defects - tunnel vision
Get what test ?
Parasellar signs->
bitemporal hemianopsia in pituitary adenoma
MRI and pituitary hromone levels
32
hypogonadism, decreased labido infertility, galactorrhea/gynecomastia in men think of
hyperprolactinemia 2/2 prolactinoma
can also be MEDs, pregnancy, renal failure, hypothyroidism
parasellar signs more common
33
High prolactin levels inhibit what hormone
GnRHH -> decreased LH and FSH and low estrogen and testosterone
34
Premenopausal (oligomenorrhagia irregular) decreased labido, dyspareunia, vaginal dryness, glactorrhea in women be concerned of?
hyperprolactinemia 2/2 prolactinoma
can also be MEDs, pregnancy, renal failure, hypothyroidism
35
Tests for prolcatinoma? (4)
elv serum prolactin
pregnancy and TSH for r/o
CT/MRI
36
Prolactinoma Tx
bromocriptine (dopamine agonist) ddecreases production
Tx for 2 yrs before stopping
Cabergoline (dopamine agonist) maybe better tolerated
Surgery if persist
37
Prolactinoma Tx
bromocriptine (dopamine agonist) ddecreases production
Tx for 2 yrs before stopping
Cabergoline (dopamine agonist) maybe better tolerated
Surgery if persist
38
Common cause of death w/ acromegaly
CV disease
39
Acromegaly vs gigantism
excess pituitary GH after epiphyseal closure
10% of pituitary adenomas
40
Features of acromegaly
| - 3 classes
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
41
IGF 1 - somatomedin C elvated in?
Confirm w?
Acromegaly
Oral glucose suppression- failure confirms
MRI pf pituitary
42
Tx of acromegaly -
Surgery - transphenoidal ressection
Radiation if elv after
Octreotide to suppress?
43
Calcification of suprasellar region seen in the brain imaging is?
origin?
craniopharyngioma
remnants of Rathke's pouch
usually visual field defects, maybe hyperprolacinemia, DI, panhypopituitarism
44
Panhypopituitarism casues
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
45
Central DI vs Nephrogenic DI
Risk factors
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,
46
5-15L of urine daily that is colorless - think of?(4)
DI, DM, poly dypsia, Diuretics
hyponatreamia mild unless impaired thirst drive
Low specific gravity and low osmolarity
Normally Mosm 250-290
47
Test for Central DI vs Nephrogenic
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
48
Tx pf nephrogenic vs Central DI
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)
49
Despite volume expansion what is not seen in SIADH
edema
due to naturesis, excretion of excess Na despite hyponatremia
50
SIADH pathophys and cuases (6)
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
51
Hypovolemic hyponatremia
hypervolemic hyponatremia
SIADH
volume contracted
volume expanded w/ edema
volume expanded w/out edema
52
SIADN -> hyponatremaia
acutely causes?
Chronicially
Acute - lethargy, somnolence, weakness
-Seizures**, coma death
Chronic- asymptomatic, anorexia, N/V, CNS symptoms less common, brain edema decreased
53
Dx SIADH by?
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
Symptoms of SIADH(6)
- hyponatremia,
- volume expansion w/o edema
- Naturesis
- hypouricemia and low BUN
- Normal/reduced serum Cr
- Normal thyroid and renal function
55
Tx SIADH
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
Features of hypoparathyroidism
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
Labs in hypophospahtemia
Ca
Phos
PTH
cAMP
LOW Ca
HIGH phos
LOW serum PTH
LOW urine cAMP
58
Primary hyperparathyroidism
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
Primary hyperparathyroidism
1+ glands gone crazy -> most common cause of hypercalcemia outpatient (NEED to r/o malignancy w/ high CA though)
60
Symptoms of hypercalcemia
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
osteitis fibrous cystic
brown tumor - seen w. hypercalcemia
predisposes to pathologic fxr
62
Calcium levels relation to albumin
if Ca is high what would be an appropriate lab value
Ca + 0.8(4-alb)=
PTH should be elevated to cause if in need of Ca, HIGH Ca suppresses PTH
63
Chloride to phos >33 diagnostic of what?
primary hyperparathyroidism; Cl is high secondarily to renal bicarb waisting (2/2 PTH)
64
Surgery for priamry hyperparathyroidism (5)
Age 400mg in 24 hrs
65
Secondary hyperparathyroidism is?
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
What diuretic is contraindicated in medical Tx of primary hyperparathyroidism
Thizaide(retains Ca)
Fluids + loops instead
67
Cushing syndrome vs Cushings Disease
Syndrome - results from excessive levels of glucocorticoid
Disease - Pituitary Cushing's syndrome (pituitary adenoma)
68
cortisol effects(4)
inpaired collagen production, enhanced catabolism
anti insulin effects-> glucose intolerance
impaired immunity
enhanced catecholane effects (HTN)
69
Most common cause of cushing syndrome
iatogenic (exogenous)
acth secreting adenoma (disease) second
Ectopic ACTH - small cell carcinoma, bronchial carcinoid, thyoma
70
Change in appearance, central obesity, rounding of the face, stare, langou hair, acne, bruising HTN, DM think of
Cushings
also lowered immunity, depression/mania/ proximal weakness
ACTH excess-> hyperpigmentism (addisons have pigment 2/2 low cortisol and feedback response)
71
Screens of Cushings
1. overnight low dose dexamethasone suppression screener- 1mgPM-> measure cortisol in am
- serum 5 has Cushings
24hr cortisol?
2. 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
Pheos arise from
chromatin cells of adrenal medulla or sympathetic ganglia if extra adrenal
73
hyperglycemia, hyperlipidemia an dhypokalemia w/ periodic tachycardia and HTN
Pheo
74
Features of pheo(8)
```
HTN - high and episodically super high
pounding HA
Severe sweating
Tachycardia
Palpitations
Anxiety
impending doom
Lab: hyperglycemia. hyperlipdemia, hypokalemia
```
75
Urine screen for pheo?
Meanephrine
| Vannillymandelic acid, homovanillic, normetanephrine
76
rule of 10 w/ pheos?
```
10% familial
10% biateral- MEN II
10% malignant
10% mtpl
10% kids
10% extrarenal
```
77
Tx prior to surgical intervention w/ pheo
beta blockade(HR) and alpha blockade(BP) 2-3 days prior
78
MEN Type I (3Ps)
parathyroid hyperplasia
pancreatic islet cells
pituitary tumors
79
MEN IIA (MPP)
medullary thyroid CA
Pheochomocytoma
hyperParathyroidism
80
MEN IIB (MMP)
Medullary thyroid CA
mucosa neuromas
pheochromocytoma
marfoid body
81
Hyperaldosterone - Primary
electrolytes and acid/base
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
HTN and low K think of?
Sep if not on diuretic
Conns- primary hyperaldosterone
83
Adrenal incidentaloma
common, determine if functional if not
resect if >6cm
84
Signs of Conn?(4)
HTN*
Ha/fatigue/weakness
polydypsia
Absence of peripheral edema
85
Screener of conns
| 3
Ratio of plasma aldosterone: renin
>30 eval further
Saline infusion, decreases aldosterone in normal Pts, unchanged if not
Aldosterone r/o
86
Dx of primary aldosteronism
and treatment- depends
adenoma/hyperplasia
- Adrenal venous sampling
- renin-aldosterone stim test
- Imaging - CT/MRI differentiate for need to bilateral w/ hyperplasia(spiranolactone)
87
Most common cause of addisons
adrenal insufficiency?
TB- wordwide(fungal, CMV, cryptococcus), toxo)
Autoimmune- western world
(primary)
rapid glucocorticoid withdrawal (secondary adrenal insufficiency)
88
Clinical findings of: weight loss, weak, pigmentation, anorexia, nausea, postural hypotension, ab pain, hypoglycemia
Addisons
ACTH ramped up-> pigmentation
low aldosterone -> Na loss and hypotension, shock, hyperkalemia
89
Dx of Addisons
1. decreased plasma cortisol
2. plasma ACTH level
ACTH synthetic given and measure response, (primary no response, secondary also no response initially)
MRI
90
Tx of addisions
daily oral glucocorticoid, (hydrocortizone, prednisone and daily fludrocortizone) may need stress dosing
91
Congenital adrenal hyperplasia - cause?
Auto recessive
90% 21 hydroxylase deficiency
2nd: 11 hydroxylase deficiency
92
Features of congenital hyperplasia
lower cortisol and aldosterone- precursors shunted towards androgens -> viralization of females (ambiguous genitalia w/ normal ovaries/uterus)
Males NO change
hyponatremia an dhyperkalemia
93
high levels of 17 hydroxyprogesterone is?
Tx?
congenital adrenal hyperplasia
medically w/ glucocorticoid and mineralcorticoid
surgically- genitalia correction for females
94
HLA is associated w/ what DM
Type 1 HLA DQ/DR
95
Ketosis is common in what DM?
Type 1
also has autoantibodies
96
Dawn and somogyi effect in DM management
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
Screens/tests for DM
```
A1c ACEi/ARB
BUN/Cr check
eye screening yearly
feet check
Statin
ASA
pneumococcal
```
98
DM diagnosed if
Hgb>6.5 (5.7-6.4)
FPG >126 2x (110-126)
oral glucose >200 2 hrs (140-200)
99
Sulfonureas - glyburide
stimulates pancreas to secrete Insulin
effective, inexpensive,
concern w/ weight gain and hypoglycemia
100
Metform
enhances sensitivity, blocks gluconeogenesis
mild weight old, no hypoglycemia
GI upset and lactic acidosis
101
Acarbose
reduces glucose absorbtion-> low calories
Low risk
Gi upset/diarrhea
102
thiasolidinedione - rosiglitazone and pioglitazone
reduce insulin resistance
reduces insulin levels
heptotoxicity, cardiac concerns
103
initial dosing of insulin for a PT
0.5U/kg (to 1U/kg)
60% long acting, 40% short
104
Macrovascular complication s of DM
Accelerated atherosclerosis-> stroke, MI, CHF
Peripheral vascular disease (60%)
105
Microvascular complications of DM(3)
```
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
Radiocontrast in DM Pts
generally a bad idea w/ AKI possible
give lots of fluid prior and hold metformin 48hrs after
107
UA will not pick up microalbuminuria
need to order separate . Does not become + until 300
Mcroalbuminuria is 30-300
108
CN complications w/ DM
CN III but also VI and IV
palsy of 3rd eye but pupils SPARED
109
Autonomic neuropathy in DM
impotencein men, neurogenic bladder, gastroparesis, constipation, postural hypotenison
110
Diabetic foot 2/2?
Comnined artery disease and nerve
increased susceptibility to infection ( cellulitis, candidiasis, pneumonia, osteomyelitis,)
111
DKA precipitating factors
Any stress - infectious, trauma, MI, stroke, surgery, sepsis, GI
Inadequate insulin
Have low insulin compounded by glucagon excess-> hyperglycemia and ketogenesis
112
Signs of DKA (8)
```
N/V
Kussmaul brealing
Ab pain
fruity breath
Dehydration -> orthostatic hypotension, tachy
Polydipsia, uria, phagia
Altered consciousness/drowzy
Occur w/in 24 hrs
```
113
DDx for DKA (5)
```
alcoholic ketoacidosis
hyperosmolar hyperglycemic nonketotic syndrome
hypoglycemia
sepsis
intoxification
```
114
Dx of DKA(3)
glucose
- >450, shift
Low phosphate and magnesium
115
Correction of Na w/ hyperglycemia
Na _ 1.6 (Glucose-100)
116
DKA Tx (3)
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
Hyperosmolar hyperglycemic nonketotic syndrome(3)
Pts?
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
Features of HHNS(4)
thirst, pyorrhea,
hypotension/tachy
CNS** siezures,
Lethargy/confusion
Hyperosmolar hyperglycemic nonketotic syndrome
119
TX w/Hyperosmolar hyperglycemic nonketotic syndrome(2)
```
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
Response to hypoglyemia
80s - insulin lowers
glucagon begins to increase
Epi and cortisol next
50s - > symptoms
121
Organ at risk w/ hypoglycemia?
Brain - can't use free fatty acids
122
Measure what in hypoglycemia of unknown cause (4)
plasma nsulin
c peptid
anti insulin antibodies
plasma and urine sulfonureal levels
123
causes of hypoglycemia
drug induced, factitious, insulinoma, ethanol ingestion, post op after gastric surgery, Adrenal insufficiency, liver failure, illness
124
features of hypoglycemia -
Around 40-50
Elvated epinephrine levels-> sweating, tremors, BP and pulse, anxiety
Neuroglycopenic -> irritability, behavioral change, weakness, drowsiness, HA, convulsions death.
125
Whipples triad
hypoglycemic by fasting
blood glucose <50 during symptomatic attack
glucsoe admin brings relief
126
Insolinoma
what is it?
Test?
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
ZOllinger ellison syndrome
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
Glucagonoma
clinically necrotizing migratory erythema - below the waist
glossitis, stomatitis, DM, hyperglycemia
Tx w/ surgery
129
Somatostatinoma
rare
poor prognosis
Triad of gallstones, DM and steatorrhea
130
VIPoma
rare pancreatic tumor
Water diarrhea!!-> dehydration and hypokalemia
achlorhydria - low gastric acid secretion
hyperglycemia and hypercalcemia
Surgical resetion
