endocrinology Flashcards
0
Q
elevated prolactin levels cause amenorrhea because
A
LH and FSH will decrease
1
Q
Damage to the pituitary stalk will affect labs how
A
all levels will decrease except prolactin will increase
2
Q
prolactin has no stimulatory hormone, it has only
A
dopamine
3
Q
hypothyroidism will also cause increased prolactin due to
A
TRH -thyroid releasing hormone- acts on prolactin and TSH
4
Q
signs/symptoms of hyperprolactinemia in female
A
galactorrhea
amenorrhea
infertility
5
Q
signs/symptoms of hyperprolactinemia in male
A
impotence
decreased libido
infertility
6
Q
causes of hyperprolactinemia
A
hypothalamic dz-sarcoid, pituitary stalk dz,pregnancy, hypothyroid, renal failure, pituitary tumors,cirrhosis, acromegaly, idiopathic, drugs,
7
Q
drugs assoc with hyperprolactinemia
A
phenothiazine, metoclopramide,reserpine,methyldopa,, estrogen, opiates,cocaine, TCA, MAO inhib., verapamil, H2 blockers, SSRI’s
8
Q
prolactin level >150 in nonlactating and nonpregnant, think
A
prolactinoma
9
Q
macroadenoma
A
> 10mm
10
Q
microadenoma
A
<10mm
11
Q
rule out secondary causes hyperprolactinema by
A
MRI brain
12
Q
work up suprasellar macroadenoma, infrasellar macroadenomas
A
visual field testing, eval anterior pituitary function (TSH,ACTH,FSH,LH,IGF1)
infertility or amenorrhea tx with bromocriptine or caberrgoline
if no response to rx, may need surgery
13
Q
treatment of microadenamas
A
regular menses-no tx
infertility-bromocriptine
amenorrhea- bromo/cabergoline, OR estrogen/progesterone
14
Q
most common cause of acromegaly
A
GH producing tumor of the pituitary
15
Q
unique sign of acromegaly
A
enlarging glove and shoe size
16
Q
S/S acromegaly
A
enlarging shoe and glove size, widened teeth spacing, incr. soft tissue mass palms/soles, macroglossia, hyperhydrosis, prominent jaw, deep voice, hyperglycemia, arthritis
17
Q
best screening lab for acromegaly
A
IGF-1
18
Q
confirmation of acromegaly diagnosis
A
failure of growth hormone to suppress <1ug/L within 1-2 hours of 75G oral glucose load
19
Q
tx of acromegaly
A
surgery for pituitary adenoma, if no remission after surgery, add somatostatin (octreotide) +/- GH receptor antagonist pegvisomant +/- pituitary irradiation
20
Q
complications of acromegaly
A
sleep apnea, carpal tunnel, CHF, LVH, HTN, cardiomegaly, OA, DM, hyperprolactinemia, hypogonadism, visual field defects , giantism
21
Q
giantism in acromegaly occurs when
A
GH hyper secretion occurs prior to long bone epiphyseal closure
22
Q
**Surgery indicated in acromegaly for
A
pituitary adenomas secreting : ACTH,TSH,GH
adenomas assoc with mass effect, vision field defects or hypopituitarism
prolactinomas unresponsive to dopamine agonists
23
Q
20 year old presents with impotence, decreased libido, infertility, and anosmia. Lab: decreased testosterone, LH, FSH
Dx & Tx
A
Kallman’s syndrome-GnRH deficiency
Tx-testosterone
24
causes of GnRH deficiency
Kallman syndrome, mutation in GnRH receptor gene, hyperprolactinemia
acquired deficiency: long distance runners, anorexia nervosa, starvation, stress
25
Prolactin levels must be measured in all patients with....
hypogonadism and low LH/FSH
26
hypopituitarism leads to deficiency of
multiple hormones
27
hypopituitarism in young children see
growth retardation ( decreased growth hormone)
28
hypopituitarism in older children see
delayed puberty (decreased LH/FSH)
29
hypopituitarism in premeopausal see
amenorrhea (decr LH/FSH)
30
hypopituitarism in men see
hypogonadism (decr libido, infertility, impotence)
hypothyroidism
secondary hypocortisolism
31
growth hormone deficiency causes
increased fat mass
decreased lean body mass
decreased bone density
decreased quality of life
32
prolactin deficiency causes
inability to lactate following pregnancy
33
ACTH deficiency causes
secondary hypocortisolism: hypoglycemis, fatigue, anorexia
34
thyrotropin deficiency -TSH
wt gain, dry brittle hair, hair loss, dry skin, constipation, fatigue, cold intolerance, cognitive complaints
35
dx of hypopituitarism
low or inappropriately normal levels of pituitary hormones in the setting of low target hormone ie: low free T4 and normal TSH
36
initial tests for eval of hypopituitarism
MRI of pituitary
IGF-1,free t4, TSH, am cortisol, ACTH, testosterone, LH, FSH, prolactin
(TSH,LH,FSH may be normal or low in hypopituitarism)
37
common etiology of hypopituitarism
tumors, brain radiation
hemochromatosis, amyloidosis
sheehan syndrome, empty sella symdrome
lymphocytic hypophysitis
38
sheehan syndrome
seen after delivery baby, hypotension during labor causes pituitary necrosis
see: failure of lactation, failure to resume regular menses, and fatigue
39
Empty sell syndrome
decreased pituitary gland volume
| 10% may have hypopituitarism or increased prolactin
40
lymphocytic hypophysitis
symmetric and homogeneous sellar mass
usually occurs during or after pregnancy
adrenal insufficiency is common
41
treatment of hypopituitarism
** cortisol replacement before thyroid replacement
remember stress cortisol dose if ill, stress, surgery
testosterone replacement in males
estrogen/progesterone in females
GH replacement
42
polyuria, think
central diabetes insipidus
nephrogenic diabetes insipidus
psychogenic polydipsia
43
with central diabetes insipidus see
>50% urine osmolality after vasopressin or desmopressin
44
with psychogenic polydipsia see
hyponatremia
increases urine osmolality after water deprivation
45
50 y/o male with headache, decreased libido, sparse facial hair, lab:decreased testosterone,LH, and FSH. prolactin 2000. MRI large pituitary adenoma with suprasellar extension. visual exam-bitemporal heminopsia. Dx and Tx
macroadenoma
bromocriptine
46
in prior pt, if all same except prolactin 50, what dx and tx?
nonsecreting macroadenoma
TX*** nonsecreting large tumors need surgery!!!
47
same patient but free T4,TSH,am cortisol all decreased, prolactin 2000. Dx & Tx
hypopituitarism
| tx: cortisol, thyroid, testosterone if male, bromocriptine
48
30 y/o female,2mm pituitary adenoma on routine MRI. asymptomatic and menses and prolactin levels are normal. what to do next?
Dx: incidentiloma
Tx: measure IGF-1 and prolactin, if normal, recheck lab and MRI in 6 months
49
54 y/o male severe headache,nausea, vomiting, hypotension, altered consciousness. MRI show a hemorrhagic mass in the sella.
Dx & Tx
Pituitary Apoplexy (hemorrhage into tumor)
Tx hydrocortisone and surgery
50
patient to ER after head injury. he is polyuric, elevated BUN, Na 150, urine osmolality of 40.
Dx and how to confirm
central diabetes insipitis
IV desmopressine- should decrease urine volume
51
38 y/o female with diabetes, amenorrhea, and bronze pigmentation of skin. Lab: neg pregnancy, decreased FT4,TSH,FSH,LH.
Dx and what to do next
dx: hemochromatosis
do iron studies
replace her hormones and thyroid
52
24 y/o female with polyuria and polydipsia, urine osm is 60 and does NOT change with water deprivation. after vasopressin, osmolality increases to 100. Dx?
central diabetes insipidus
53
19 y/o female with syncope and has K+ 2.5, HCO3 34, urine K 8
Dx?
dx-bulemia
| ** #1 cause of metabolic alkalosis in young female- vomiting caues lose of acid from the GI tract
54
same 19 y/o patient but HCO3 of 20
| whats dx now/
laxative abuse, mild acidosis
55
same 19 y/o but K+ 2.5 and urine K 50
| whats diagnosis
diuretic abuse or Barter syndrome (lose K in urine)
56
most common cause of diabetes insipidus
autoimmune
57
patient with polyuria and sodium 128, likely cause
psychogenic polydipsia
58
a few days post op a patient develops Na+ 120. why
pain increases ADH
| also use of hypotonic fluids
59
patient on lithium presents with polyuria
urine osm 50, Na+145
Dx & Tx
lithium induced DI
tx-thiazide or amiloride
** do not stop lithium
60
patient with thyrotoxicosis and enlarged thyroid
increased: FT4, T3,TSH,RAI
what next
pituitary tumor-do MRI
| TSH should be decreased with thyrotoxicosis but since it is increased pituitary is the problem
61
pt w hashimoto for many yrs now has rapidly enlarging neck mass, engorged neck veins,, hoarseness, dysphagia. ultrasound shows enlarged thyroid and cervical glands. Dx
Primary thyroid lymphoma
high incidence with hashimoto's
62
disorders associated with increased risk of thrombosis
```
prothrombin 20210 mutation
ATIII deficiency
Protein C deficiency
antiphospholipid syndrome
resistance to activated protein C
```
63
T3 produced by
TSH in pituitary or conversion of T4->T3
64
conditions that impair peripheral conversion of T4 to T3
systemic illness
malnutrition
old age
drugs:propranolol, PTU, iodine contrast
65
with impaired conversion of T4 to T3, see
increased rT3
66
low T3
not used in dx hypothyroidism
low T3 doe not always indicate hypothyroidism
no role in eval of hypothyroidism, so dont measure total T3
67
only time free T3 us ckecked is eval for
thyroitoxicosis
68
labs with thyrotoxicosis (hyperthyroid)
^Total T3 &T4, ^ free T3 & T4
decreased TSH
RAI uptake >30%
^except on thyrotoxicosis factitia
69
hypothyroidism lab
decreased T4 & T3, total and free levels, increased TSH
70
TPO Ab -thyroid peroxidase antibodies and thyroglobulin antibodies seen in
hashimoto thyroiditis
*presence in euthyroid or subclinical hypothyroidism confer an increased risk of developing overt hypothyroidism
71
thyroid stimulating immunoglobulin (TSI) seen in
Graves' disease
72
TSH binding inhibitor immunoglobulin (TBII)
Graves' disease or Hashimoto's thyroiditis
73
a patient with thyrotoxicosis with enlarged thyroid, incr free T4 and free T3, ^TSH, ^RAI. what test to do next?
do pituitary MRI-pituitary tumor
74
pt with hashimoto thyroiditis for years presents with rapidly enlg neck mass, engorged neck veins, hoarse, dysphagia.Likely dx
primary thyroid lymphoma-high incident with hashimotos
75
thyroid binding globulin increased in
pregnancy
estrogen,tamoxifen,methadone
genetic
hepatitis, biliary cirrhosis
76
thyroid binding globulin decreased in
```
androgens, glucocorticoids
nephrotic syndr, chronic liver disease
severe systemic illness
acromegaly
genetic
```
77
if suspect thyroid dx, measure
TSH , Free T4
78
high FT4
hyperthyroidism
79
high FT4 and TSH low
primary hyperthyroidism
| test RAI uptake
80
RAI uptake with diffuse increase
Graves' disease
81
RAI uptake with focal increase
toxic adenoma
82
RAI uptake with decreased uptake
subacute or lymphocytic thyroiditis
factitious thyrotoxicosis
iodine excess
struma ovarii-teratoma produces thyroid hormone
83
High FT4 and TSH normal or elevated
secondary hypothyroidism-rare-can be due to:
TSH producing tumor
thyroid hormone resistance syndrome
84
Low FT4
hypothyroidism
85
low FT4 and TSH elevated
primary hypothyroidism, check TPO Ab:
(+) Hashimoto
(-) other causes
86
FT4 low and TSH normal or low
secondary hypothyroidism.
| get CT,MRI, measure other hormones
87
sick euthyroid syndrome
acute systemic illness can affect thyroid function
88
apathetic thyrotoxicosis
FT4 normal TSH decreased: see apathy rather than hyperacitvity:
lethargy, depression, wt gain, droopy eyelids, constipation . A fib, CHF
89
types of thyroiditis
```
Hashimoto
painless postpartum, sporadic, subacute
suppurative
drug induced
Riedels
```
90
hashimoto thyroiditis
#1 cause of hypothyroidism
thyroid firm, lumpy, painless
+ TPO or thyroglobulin antibodies
91
Painless postpartum (lymphocytic) thyroiditis
thyroid enlarged and nontender
thyrotoxicosis at first then hypothyroid, lasts 4-6 months
Tx thyrotoxicosis with beta blockers, hypothyroid with synthroid
92
painful subacute thyroiditis
follows URI,tender and enlarged thyroid, incr sed rate
thyrotoxicosis early->transient hypothyroid->recovery 6-12 month
Tx NSAIDS,steroids if severe pain
B blockers for toxicosis, synthroid for hypothyroid
93
suppurative thyroiditis
fever, chills, tender nodule
| tx-drainage and anibiotics
94
drug-induced thyroiditis
amiodarone, lithium, interferon alpha, interleukin 2
95
riedels thyroiditis
rock hard, fixed, painless goiter
negative antibodies
may cause esophageal or tracheal compression
96
indications for RAI (radioactive iodine)
severe hyperthyroidism
very large goiter (>4 x normal)
T3:T4 ratio >20
elevated antithyrotropin antibody
97
contraindications of RAI
pregnant, lactating
unable to comply with safety regulations:
no contact children or pregnant for 1 week
avoid close contact >2 hours at 6 feet or closer for 5 days
98
RAI pretreatment
Bblocker for symptoms
High risk patient tx with antithyroid meds for several weeks prior, stop them 2-3 days before and resume 3-7 days after tx:
elderly, underlying CV dz, severe hyper symptoms,or hormone >2-3 times normal
99
indications for antithyroid drug therapy (PTU,methimazole)
children, preg/lactating
initial tx in adult with severe eye dz, mild-mod hyperthyrodism, small goiter,T3:T4 <20, (-)antithyrotropin antibody
PTU not used as first line except in first trimester pregnancy, and thyroid storm tx
100
antithyroid drug tx for 12-18 months and
if adult relapses->tx with RAI
| if child, give second round of antithyroid meds
101
side effects of anti thyroid drugs
agranulocytosis-stop if neutrophil count <1000
arthralgias, polyarthritis
ANCA + vasculitis, immunoallergic hepatitis (PTU)
severe hepatic necrosis)PTU),cholestasis (methimazole)
hypoglycemia-insulin autoimmune syndr (methimazole)
102
Thyroid storm
rare, life threatening condition with severe clinical manifestations of thyrotoxicosis
mortality 15-20%
103
clinical features of thyroid storm
hyperpyrexia
CNS:agitation, delirium,confusion, psychosis, sz, stupor, coma
GI: N/V, diarrhea, abd pain, jaundice
CVS: tachycardia, heart failure, atrial fib
104
causes of thyroid storm
graves dz #1
toxic adenoma
multinodular goiter
105
precipitating factors of thyroid storm
surgery, infection, trauma, parturition, acute iodine exposure, RAI therapy, ingestion of salicylates and pseudoephedrine
106
treatment of thyroid storm
large doses of PTU and SSKI (start 1 hour after PTU) plus propranolol to control heartrate, plus IV hydrocortisone
107
features of Graves opthalmopathy, moderate to severe
spont. retrobulbar pain, pain w eye movement, redness of eyelids, conjuncitva, swelling of eyelids, caruncle and conjunctival edema
eyelid retraction >2mm,exopth>3mm, mod to severe soft tissue involvement, extraocular muscle involvement (diplopia), moderate corneal involvement
108
tx of mod-severe graves opthalmopathy
weekly infusion methylprednisone 500mg X 6 weeks then 250mg weekly for 6 weeks. if no improvement in 3-4 months, give 2nd course of IV steroids with orbital radiation
109
rare manifestations of hypothyroidism
```
pericardial effusion, CHF, sinus brady, prolong QT, torsades
hypoventilation
increased CPK and +MB fraction
hyperprolactinemia
diffuse pituitary enlargement
```
110
clinical features of myxedema coma
decr LOC,psychosis, seizures
Hypothermia, hypoventilation leading to hypoxia and incr PCO2
hyponatremia, hypotension, hypoglycemia
sinus bradycardia
111
must rule this out in any patient with coma and has low heartrate
myxedema coma
112
precipitating factors in myxedema coma
cold weather
sedatives
infections
113
tx of myxedema coma
high doses of both levothyroxine and glucocorticoid
114
multinodular goiter with normal FT4,normal TSH
observe
115
multinodular goiter with normal FT4 and low TSH, treatment
symptomatic-RAI
asymptomatic-observe
116
multinodular goiter with increased FT4 and Low TSH Tx
RAI
117
Jod-Basedow phenomenon
patient with multinodular goiter that develop thyrotoxicosis on exposure to iodine containing contrast agents
118
tx of papillary and follicular thyroid carcinoma
near total thyroidectomy
RAI after 6 weeks when TSh >50-ablates thyroid remnants/mets
thyroid hormone replacement
repeat scan 6-12 month
follow serial thyroglobulin levels, repeat scan if increase levels
119
indications of RAI tx after thyroidectomy for cancer
all with distant mets
extrathyroidal extension of tumor regardless of size
primary tumor >4cm even with no high risk features
1-4cm w lymph node mets or high risk features
120
thyroid nodules with high suspicion of thyroid cancer
```
nodule firm/hard/fixed to adjacent structures
rapid growth
regional or distant lymphadenopathy
paralysis of vocal cords
family Hx medullary ca or MEN syndrome
```
121
thyroid nodules with moderate suspicion of thyroid Cancer
male, age 70
hx of head and neck radiation
dysphagia, hoarse, dyspnea, cough
U/S: >3cm, speckled calcification w/in nodule, high vasc flow in center, hypoechogenicity,irreg border, taller than wide
122
thyroid nodules indications for biopsy
nodule >1cm or smaller if risk factors
| if nodule >3cm and FNA is (-), consider repeat
123
effects of amiodarone on thyroid functions
hypothyroidism--dont stop drug, tx with synthroid
hyperthyroid in pt w prior graves or multinodular goiter-discontinue amiodarone, may need antithyroid meds
impaired T4 to T3 conversion
124
intensive therapy to achieve near-normal glucose delays onset and slows the progression of
microvascular complications of diabetes (retinopathy,nephropathy,neuropathy). but NOT the macrovascular complications (MI, CVA)
125
microalbuminuria - 30-300mg/gm of cr on random urine sample
risks: increase risk of overt renal failure and CAD
Tx: control BP <130/80, ACE/ARB
intense bs control
126
types of diabetes
Type I
Type II
genetic defects
secondary causes
127
type I diabetes is
autoimmune destruction of pancreatic beta cells, insulin deficiency, ketosis prone, positive islet cell or glutamic acid decarboxylate antibody
128
type II diabetes is
impaired insulin secretion
increased insulin resistance
excessive hepatic glucose production
129
genetic defect as cause of diabetes
MODY-maturity onset diabetes of the young
130
secondary causes of diabetes
chronic pancreatitis, CF, hemochromatosis, acromegaly, cushings,pheochromocytoma,hyperthyroidism, gestational
Crugs: niacin, glucocorticoids, thiazides, protease inhibitors, clozapine, cyclosporine
131
diagnosis of DM
symptoms + random blood glucose >/= 200
2 hr glucose >/=200 after 75gm glucose tol test
8 hr fasting plasma glucose >/= 126 on 2 occasions
HgbA1c >/= 6.5
132
prediabetes
fasting plasma glucose 100-125
2 hour plasma glucose 140-199 after 75gm glucose
HgbA1c 5.7-6.4
133
what is risk of coronary event in pt with diabetes?
same as those with KNOWN CAD
134
patient with Type I DM has acute pancreatitis. BS 500, TG 5000. what is best tx of the TG in this patient?
IV insulin
135
54y/o with FBS 115, 2 hr glucose TT 130, HgbA1c 6, BMI 36.
| DX and TX
prediabetes
| diet and exercise
136
how to differentiate T.I and T.II diabetes?
(+) GAB antibodies in Type I
137
where should you maintain blood glucose in critically ill patient?
140-180
138
preferred initial agent in diabetic if no contraindication
metformin
139
actions of metformin
decrease glucose production in the liverr
increase uptake & util. of glucose by adipose ad muscle
no effect on insulin release
promotes wt loss and lowers lipids
decreases macrovasc. complications (MI,CVA)
140
metformin toxicity
```
lactic acidosis
metalic taste
nausea
diarrhea
abdominal pain
```
141
contraindications of metformin
renal dz:male cr >1.5, female >1.4, GFR <60
impaired liver function, chronic alcoholism or binge drinking
CHF
severe hypoxia
142
discontinue/hold metformin
prior to radiographic contrast material
prior to surgery or in critically ill patients
if pt develops N/V
143
rapid acting insulin
humalog-insulin lispro
novolog-aspart
apidra-glulisine
inhaled insulin
144
short acting insulin
regular-given 30 min before meal
145
intermediate acting
NPH
| Lente
146
long acting insulin
lantus-once a day-insulin glargine
| detemir-given BID
147
premixed insulin
NPH/regular- 70/30, 50/50
protamine aspart/aspart 70/30
protamine lispro/lispro 75/25, 50/50
148
management type 2 DM-lifestyle intervention and metformin, if HbA1c > or = 7% do one of below
add basal insulin-most effective
add sulfonylurea-least expensive, add below if not controlled
add glitazone-avoid hypoglycemia-add sulfonyl if still not control then basal insulin etc.
149
insulin tx in type 2 DM:hs NPH or daily lantus (10units or 0.2u/kg starting dose)->FBS daily, inc dose by 2units every 3 days (4 units if FBS.180)until target range 70-130. after 3 mo if HbA1c.=or > 7%, FBS ac and hs.
if glucose incr still, add rapid acting insulin:
pre lunch bs incr-add insulin before breakfast
pre dinner incr bs- add insulin before lunch
if incr at hs-add insulin before dinner
150
goals for tx of diabetes
HbA1c 40 in male, >50 female,TG50,female>60
151
insulin dosing
total dose .2-0.4 unit/kg/d one-half dose as basal insulin, other half give rapid acting (humalog, novolog) divided equally before each meal
152
ideally prandial insulin is determinedby amount of carbs about to be consumed ( 1 unit for 10-15gm carb) plus a correction factor predicated on preprandial glucose ( 1 extra unit for every 40-50mg/dl above 100)
see above
153
diabetic ketoacidosis
insulin deficiency and glucagon excess
incr gluconeogenesis & decr peripheral glucose utilization
release of fatty acids from adipose tissue
accelerated fatty acid oxidation in the liver
incr ketones (beta hydroxybutyrate/acetoacetic acid)
154
precipitating factors of diabetic ketoacidosis
```
inadequate insulin administration
infection,MI,CVA
surgery, trauma
pregnancy
cocaine
```
155
clinical features of diabetic ketoacidosis:
anorexia, N/V, polyuria, polydipsia
altered mental status,focal deficits, coma , Kussmaul respiraions, acetone odor on breath, diffuse abd pain
tachycardia, hypotension, dehydration
Lab: increased WBC,TG,amylase
decreased sodium (1.6 meq decr for each 100 rise in serum glucose) decreased HCO3, decr K+.
+ ketones
156
Tx of DKA
1. severe hypovolemia-normal saline at 1 liter/hour
mild dehydration-correct Na: high-0.45% Nacl 250-500ml/h.when serum glucose
2. insulin-regular 0.1 u/kg IV bolus then 0.1u/kg/hr IV continuous infusion until glucose 200, decrease insulin to 0.05-0.1u/kg/h to maintain glucose 150-200.
3. potassium-,3.3-hold insulin, give K 40-0meq/hr until K .3.3, if K+ is 3.3-3.5-repl K at 10meq/hr, if K+>5.3 hold K
4. HCO3-given only if pH ,7.0or HCO3
157
complications during tx of DKA
accelerated coagulopathy
cerebral edema- more common kids, progressive neuro deterioration-IV mannitol
hyperchloreic acidosis, hypophosphatemia(rhabdo, cardiomyopathy,hemolytic anemia), hypoglycemia, hypokalemia
158
in noncritical inpatients, goal fasting glucose
90-140 and random or postprandial levels 150 (graded scale 1-4 units for each 50 mg/dl
159
autonomic neuropathies in diabetes
gastroparesis, alternating diarrhea and constipation, impotence, urinary incontinence or retention, orthostatic hypotension without reflex tachycardia, persistent sinus tachycardia
160
gastroparesis in diabetes symptoms
early saiety
N/V
dyspepsia
postprandial abd fullness
161
Dx gastroparesis in diabetes and tx
Dx-gastric emptying scan
| Tx-metoclopramide or erythromycin
162
risk factors for diabetic foot ulcers
```
increased formation of keratin
loss of pressure sensation
loss of pain and temperature sensation
weakness of intrinsic muscles
loss of sweating
```
163
clinical features of hyperglycemic hyperosmolar state
profound dehydration, hypotension, incr HR, alt mental status
NO-N/V,abd pain, Kussmauls are NOT present
often precipitated by serious illness:MI,CVA,sepsis, pneumonia
164
labs in hyperglycemic hyperosmolar state
marked hyperglycemia (600-1200)
hyperosmolality (330-380)
Na+ normal to mild decr-correct add 1.6 meq to measured Na for every 100mg rise in glucose
small anion gap acidosis due to lactic acidosis, serum ketones +/-
165
Tx hyperglycemic hyperosmolar state
NS initially and change to 1/2 NS after hemodyn. stable. water deficit is 9-10 liters and should be replaced over 2-3 days.
insulin bolus 0.1 unit/kg then drip 0.1unit/kg/hr
when glucose 200-300 add D5 and reduce insulinto 0.05-0.1unit/kg
166
manifestations of vit D deficiency
osteomalacia, ricketts in children, osteopenia/osteoporosis
muscle weakness and incr risk of falls
incr risk of: cancer(breast,colon,prostate), HTN, CV dz,diabetes, metabolic syndr, MS, schizophrenia, depression
167
Osteomalacia-manifestation of vit D deficiency see
bone pains/tenderness, fracture after minimal trauma, pseudofractures
Lab: calcium-normal or decreased
phosphorous-normal to decreased
increased alk phos
168
vitamin D testing
measure 25(OH)D2 and D3
normal 30-60
<20 tx 50,000u D2 weekly for 6- weeks then 800u/d of D3
20-30 tx vit D3 800u/d
169
causes of vit D deficiency
reduced skin synthesis-decr sun exposure, sunscreens,skin pigmentation,aging
decreased bioavailability-malabsorption, obesity
increased catabolism-anticonvulsants, glucocorticoids, HAART
breastfeeding, pregnancy, lactation
170
cont causes of vit D deficiency
decr synthesis of 25(OH)D-liver disease
incr urinary loss of 25(OH)D-nephrotic syndrome
decr synthesis of 1-25(OH)2-chronic kidney disease
tumor induced osteomalacia-phosphaturia
primary hyperparathyroidism-decr 25(OH)D, incr 25(OH)2D
171
cont causes of vit D deficiency
granulomatous diseases-decr 25(OH)D incr 1-25(OH)2D
thyrotoxicosis-incr metabolism of 25(OH)D
heritable disorders-ricketts
172
hypercalcemia with high or normal PTH
hyperparathyroidism
lithium
familial hypocalciuric hypercalcemia
173
hypercalcemia with lor or undetected PTH-
if chronic:sarcoid,thyrotoxicosis, adrenal insuff., immobilization, drugs(thiazides, vit A&D, calcium carbonate.
if acute:MALIGNANCY-if incr Ca, decr P-humoral
-if incr Ca, P normal-metastatic myeloma
174
Multiple endocrine neoplasia
MEN1, MEN IIa, MEN IIb
175
MEN I
hyperparathyroidism
pituitary
pancreatic tumors
176
MEN IIa
hyperparathyroidism
pheochromocytoma
medullary carcinoma
177
MEN IIb
pheochromocytoma
medullary carcinoma
mucosal neuromas
marfanoid habitus
178
familial hypocalciuric hypercalcemia
autosomal dominant
decr calcium excretion<0.1
parathyroidectomy DOES NOT correct calcium
179
hyperparathyroidism-indications for surgery
age 400,hx life threat hypercalcemia
symptomatic hypercalcemia
renal stones , Ca >1 above normal , decr bone mass (T score<60
180
hyperparathyroidism procedures
sestamibi parathyroid scanning (best),neck ultrasound
| indicated if minimally invasive surgery is planned
181
hyperparathyroidism-medical treatment
avoid thiazides, normal calcium intake, maint 25(OH)D>20
bisphosphonates if low bone mass
Cinacalcet(calcimimetic agent) use in symptomatic pt not surgical candidates
monitor calcium and cratinine annually and bone density 1-2 years
182
hypercalcemia of malignancy
```
humoral
metastatic
osteoclast activating factors
ectopic PTH secretion (rare)
coexisting primary hyperparathyroidism
```
183
hypercalcemia of malignancy-humoral
PTHrP increased Ca, decreased P
squamous cell ca of the lung and other sites
other tumors:renal, breast, ovary, endometrium
184
hypercalcemia of malignancy-metastatic
```
breast
prostate
thyroid
lung
kidney
```
185
hypercalcemia of malignancy-osteoclast activating factors
interleukin-1
TNF
1-25(OH)2 vit D
186
tx of hypercalcemia
hydrate with NS, loop diuretics, phosphate repletion if P <3.0
Meds: first line-IV bisphosphonates (Pamidronate, Zoledronate)
2nd line-glucocortioids, Mithramycin,calcitonin, gallium nitrate
187
Hypoparathyroidism
diseases assoc with: addisons, premature ovarian failure, autoimmune thyroid disease, pernicious anemia, mucocutaneous candidiasis
LAB: decr Ca++.decr PTH, incr P
188
hypocalcemia
```
PTH absent (decr Ca++,decr PTH, incr P)-hypoparathyroidism, hypomagnesenia (leads to decr Ca++, decr K)
PTH ineffective (decr Ca++,incr P & PTH)-end organ resistance to PTH-short 4th and 5th metacarpals and metatarsals
PTH overwhelmed-severe acute hyperphosphatemia(tumor lysis, rhabdomyolysis, ARF, hungry bone syndrome(after surgery for hyperparathyroidism)
```
189
tx of hypocalcemia
oral calcium and Vit D to keep calcium 8-8.5
| IV calcium gluconate for acute symptomatic hypocalcemia
