Endocrine/Metabolic Disorders Flashcards
Pathophysiology of alcoholic keto acidosis
*add pic from Q4 Exam 1
4 H’s of Scurvy
Hemorrhage - perifollicular hemorrhages, petechiae, bleeding gums
Hyperkeratosis - rough skin, loose teeth, poor wound healing, “corkscrew” appearance of hairs
Hypochondriasis - irritability, emotional changes
Hematologic abnormalities - easy bruising, hemolytic anemia
T/F: Vitamin C deficiency is often associated with iron deficiency
True
Symptoms of pituitary tumor
- Bitemporal hemianopsia, nonspecific headache, diplopia, ptosis, Horner’s syndrome, CSF rhinorrhea
- Prolactinoma: amenorrhea, impotence, infertility
- Growth hormone: gigantism (children), acromegaly (adults)
True or false: postpartum thyroiditis can occur after miscarriage
True
What is pituitary apoplexy?
Sudden hemorrhage into pituitary gland, often from pituitary tumors
Initial sx related to increased pressure in and around pituitary gland (sudden onset excruciating headache, diplopia, hypopituitarism
Tx for pituitary apoplexy
- Surgical decompression
- Corticosteroids (pt likely with adrenal insufficiency with hypotension, fatigue, abd pain, hyponatremia, hyperkalemia, hypoglycemia) -> hydrocortisone
- Dopamine agonist
Recognizing pheochromocytoma (sx and dx)
- Severe and intense headaches that abruptly resolve
- Diaphoresis, palpitations and tachycardia, HTN
- Urinary and plasma fractionated metanephrines and catecholamines
Tx pheochromocytoma
Surgical resection (phenoxybenzamine preop) - In acute hypertensive crisis - Phentolamine (first line) otherwise sodium nitroprusside or nicardipine
T/F: patients with COPD are often hyperchloremic
False; often hypochloremic
T2DM medications that have risk of causing hypoglycemia
- Sulfonylureas (glyburide, glipizide)
- Meglitinides (-glinide)
- Insulin
Which oral hypoglycemic agents are associated with euglycemic DKA?
Sodium-glucose cotransporter-2 inhibitors (canagliflozin, dapagliflozin, empagliflozin)
Symptoms of pellagra
Niacin (Vitamin B3) Deficiency
- Dermatitis (photosensitive, pigmented, scaling rash commonly around neck and referred to as “Casal’s necklace”)
- Diarrhea
- Dementia
- Bright red glossitis
Patients at risk for niacin deficiency
- Alcoholics
- Corn-based diets
- Pts taking isoniazid
- Congenital defects of intestinal or renal absorption of amino acid tryptophan
- Carcinoid syndrome where tryptophan converted to serotonin
Hyponatremia causes based on volume status, serum osm, urine Na
Q#386235
Symptoms of hypercalcemia
- Altered mental status
- Abdominal pain, n/v
- Weakness/lethargy
- Muscle aches
- Depression
Most common cause of hypercalcemia
Primary hyperparathyroidism
Tx for hypercalcemia
- IVF
- furosemide
- bisphosphonates
Chvostek sign
Twitching of ipsilateral facial muscles with tapping of facial nerve -> hypocalcemia
CRAB acronym of multiple myeloma
Calcium (high)
Renal insufficiency
Anemia
Bone lesions (lytic)
Labs for multiple myeloma
- Monoclonal antibody spike
- Peripheral blood smear with Rouleaux formations
- Serum protein electrophoresis: M spike
- Protein electrophoresis UA: Bence-Jones proteins
Pathophysiology of Diabetes Insipidus
Deficiency of ADH and inability to concentrate urine
Central DI: due to a decrease in release of ADH
Nephrogenic DI: due to a resistance to ADH at level of kidneys
Differences between central and nephrogenic DI (causes, findings, water deprivation test, treatment)
Central:
- causes: neurosurgery, trauma, tumors, ischemia, infiltrative diseases, idiopathic
- findings: decreased ADH, serum osm >290 mOsm/kg, hyperosmotic volume contraction
- water deprivation test: >50% increase in urine osmolality only after administration of ADH analog (DDAVP)
- Tx: intranasal desmopressin acetate, hydration
Nephrogenic:
- causes: hereditary, 2/2 hypercalcemia, lithium, demeclocycline
- findings: normal ADH levels, serum osm > 290 mOsm/kg, hyperosmotic volume contraction
- water deprivation test: minimal change in urine osmolality, even after administration of ADH analog
- Tx: HCTZ, indomethacin, amiloride, hydration
SIADH vs. dehydration vs. diabetes insipidus
Serum Na, serum osm, urine osm
Q678786
Clinical manifestations of hypercalcemia
Bones - abnormal bone remodeling and fracture risk
Stones - increased risk of kidney stones
Groans - abdominal cramping, nausea, ileus, constipation
Psychiatric overtones - lethargy, depressed mood, psychosis, cognitive dysfunction
Tx of hypercalcemia
- IV NS
- Bisphosphonates (inhibit calcium release from bones)
- Calcitonin (inhibits bone resorption and enhances renal excretion of Ca)
- Steroids (chronic granulomatous disease)
- Parathyroidectomy (for hyperparathyroidism)
- Dialysis (severe hypercalcemia >18 mg/dL
AVOID THIAZIDES - increase calcium resorption
Associated side effect of bisphosphonates
Jaw osteonecrosis
EKG finding of hypercalcemia
Shortened QT interval
Administration of IV calcium can precipitate dysrhythmia in patients taking what medication?
Digitalis
ECG changes due to hyperkalemia
- Peaked T waves
- Dropped p wave
- Widened QRS complex
- Sine wave
What is the approximate duration of action of calcium on cardiac membrane stabilization?
30-60 minutes
Five I’s of DKA
Infection Ischemia Infarction Insulin deficit Intoxication
Tx of pheo
- Surgical resection
- Phenoxybenzamine (preop)
- Phentolamine (acute hypertensive crisis)
- Sodium nitroprusside (acute hypertensive crisis)
- Nicardipine (acute hypertensive crisis)
Alpha-blockade must precede b-blockade
Describe Cushing syndrome
- Moon face (facial plethora)
- Resistant hypertension
- Irregular menstrual cycles
- Cutaneous findings (easy bruising, striae)
- Androgen excess (hirsutism)
- Enlarged supraclavicular fat pads
- Proximal muscular atrophy and weakness
- Osteoporosis
- Cardiac hypertrophy
- Poor wound healing
- Obesity
- Glucose intolerance
- Thromboembolic events
Q184365 with visual
Cause of Cushing syndrome
Pituitary adenoma in most non-iatrogenic cases - increases amplitude and duration of ACTH secretion
Causes of hypernatremia
Q165006
What irreversible neurologic illness can be the manifestation of salt poisoning
Osmotic demyelination syndrome
Signs of hypocalcemia
- Chvostek sign: contraction of ipsilateral facial muscles elicited by tapping facial nerve just anterior to the ear
- Trousseau sign: induction of carpopedal spasm characterized by adduction of thumb, flexion of MCP joints, extension of interphalangeal joints, flexion of wrist caused by inflation of BP cuff
- Hyperreflexia
- Prolonged QT interval
When is Ca replaced via IV?
Ca = 7.5
Tetany, seizure, carpopedal spasm, prolonged QT
Clinical presentation of Sheehan Syndrome
- Inability to lactate
- Amenorrhea or oligomenorrhea
- Fatigue
- Cold intolerance
- Lethargy
- Weight loss
- Hypotension
Lab results in Sheehan Syndrome
Consistent with adrenal insufficiency (hyponatremia) and hypogonadism
- Growth hormone deficiency
- Prolactin deficiency
- TSH deficiency
- ACTH deficiency
- FSH and LH deficiency
What ECG abnormality is associated with hypocalcemia?
Prolonged QT interval
Labs in hypoparathyroidism
Low PTH
Low Calcium
High Phosphorus
What steroid is recommended for the tx of adrenal insufficiency?
Hydrocortisone
Some causes of B12 deficiency
Veganism
Use of metformin
Causes of hypophosphatemia
- DKA
- Malabsorption/Malnutrition
- Alkalosis
- Hyperparathyroidism
- Chronic diuretic or antacid therapy
- Sepsis
- Chronic alcoholism
How does DKA cause severe hypophosphatemia?
Metabolic acidosis
Osmotic diuresis
Mobilization of intracellular phosphate stores leading to urinary losses
Clinical manifestations of hypophosphatemia
- Myocardial Depression
- Hypotension
- Respiratory insufficiency
Diagnosing Cushing Syndrome
- 24-hr urinary cortisol excretion
- Low-dose dexamethasone suppression test
- Late-night salivary cortisol
Which classic symptoms of Cushing syndrome are generally absent in patients with physiologic hypercortisolism (pseudo-Cushing syndrome)?
- Cutaneous symptoms such as easy bruising and thinning
- Muscular involvement such as weakness and atrophy
Initial treatment for patient with severe hyponatremia presenting with neurologic symptoms
3% hypertonic saline 100-150 mL over 15-20 minutes - stop infusion when sx either resolve or a target of 5 mEq/L increase in serum sodium is achieved
May repeat bolus up to a total of 3 doses or total of 450 mL
Serum sodium level should not increase by more than what during first 24 hours?
8-12 mEq/L
What is an indication fo discontinue an insulin pump in a patient with type 1 DM?
Ketoacidosis - assumes pump has failed (could be due to a kink, empty reservoir, disconnection, mechanical malfunction, or errors in priming the pump)
Red flags for Thyroid Nodule
- Male sex
- Age <20 or >65 years
- H/O head/neck irradiation
- FHx of thyroid cancer
- Hard, fixed nodule >4cm
- Rapid growth of nodule
- Sx related to local invasion (dysphagia, hoarseness)
Most common type of radiation-related thyroid cancer
Papillary
Correct order of medications in thyroid storm
- B-blocker
- Thionamide (propylthiouracil and methimazole)
- Hydrocortisone
- (1 hr after thionamide) iodine-containing agent (lugol solution, supersaturated KI, Iopanoic acid, Ipodate)
- Cholestyramine (ion-exchange resin which prevents enterohepatic recirculation of thyroid hormone and facilitates elimination from body)
What primary acid-base disorder does acetazolamide induce?
Metabolic acidosis
How should acute hypernatremia be corrected?
Rapidly with goal of normalizing serum sodium to 140 within 24 hours
How does MEN type 2A present?
- Medullary thyroid cancer
- Parathyroid neoplasms
- Pheochromocytoma
How does MEN 2B present?
- Medullary thyroid cancer
- Mucosal neuromas
- Pheochromocytoma
How does MEN 1 present?
- Parathyroid tumors (primary hyperthyroidism)
- Pancreatic tumors
- Pituitary adenoma
Major causes of metabolic alkalosis
Caused by either gain of bicarb ion or loss of acid in form of hydrogen ion
GI HYDROGEN LOSS
- vomiting/NG suction
- congenital chloride diarrhea (cystic fibrosis)
RENAL HYDROGEN LOSS
- Primary mineralcorticoid excess
- Mineralcorticoid excess-like states (licorice ingestion, Liddle syndrome)
- Loop or thiazide diuretics
- Barter or Gitelman syndrome
- Posthypercapnic alkalosis
- Hypercalcemia and milk-alkali syndrome
INTRACELLULAR SHIFT OF HYDROGEN
- Severe hypokalemia
- Villous adenoma
- Laxative abuse
Alkali administration with reduced renal function
Contraction alkalosis
Pathogenesis of Refeeding Syndrome
Starvation -> low glucose = low insulin/high glucagon = increased gluconeogenesis -> depletion of phosphate stores -> hypophosphatemia
Refeeding -> high glucose = high insulin = increased cellular uptake of phosphate
Hypophosphatemia from starvation + phosphate demand -> severe hypophosphatemia
What is an adverse effect of IV phosphorus therapy?
Hypocalcemia
