Endocrinology Flashcards
Know Endocrinology
DM Type 1
Autoimmune pancreatic B-cell destruction leading to insulin deficiency and abnormal fuel metabolism
DM 1
Hx/ PE
Presents with
- Polyuria (especially nocturia)
- Polydipsia (drink a lot)
- Polyphagia (eat a lot)
- weight loss
Associated with HLA-DR 3
HLA-DR 4
DM 1
DX
Fasting (>8 hours) glucose of >126 mg / dl on 2 occasions
Random glucose >200 mm / dL plus symtoms
2 hour post prandial glucose of >200 after glucose tolerance test on 2 occasions
DM 1
Tx
Insulin
Self Monitor (Normal range 80-120 mg/dL)
Routine HbA1c Test (children goal <8)
Foot checks, dilated eye exams, kidney check and lipid profiles q 2 - 5 years.
DM 2
Dysfunction in glucose metabolism best characterized as varying degrees of insulin resistnace that can lead to B-cell burnout and insulin dependancy
DM 2
Dx / PE
Non-ketotic Hyperglycemia
Usually older adults with obesity
Strong Genetic disposition
Onset is insidious
DM 2
Dx
Criteria same as DM 1
Follow-up test
- Test at 45 years
- Retest every 3 years
- Impaired fasting glucose (>110 but <126 follow up with frequent retesting
Dm 2 Tx
Goal is tight control 80 - 120 mg/dl
HbA1c <130/80 Use ACE/ARBs
- ASA
- Screening CVA, Nephropathy, Retinopathy, Neuropathy
Thyroid
TFT Include:
TSH
RAIU
TSH measurement
- Single best test for assessing thyroid function
Radioactive Iodine Uptake (RAIU)
- determines level of iodine uptake. Determines thyrotoxic state
High TSH means?
Hypothyroidism
Low TSH means?
Thyrotoxicosis
Radioactive Iodine Uptake (RAIU)
Determines level of iodine uptake by thyroid.
Differentiates Thyrotoxic States
Limited role in determining malignancy
1 Hyperthyroidism
What way do arrows go?
TSH
T4
T3
TSH down
T4 up
T3 up
1 Hyperthyrodism causes (7)
Graves Toxic Multinodular goiter Toxic Adenoma Amiodarone Molar Pregnancy Postpartum Thyrotoxicosis Postviral thyroidits
1 Hypothyrodism
what ways arrows?
TSH
T4
T3
TSH up
T4 down
T3 down
1 Hypothyrodism Causes (7)
Hasimoto’s
Hypothyroid thyroiditis
Iatrogenci factors (radioactive iodine, Excision with in adequate supplementaions)
External radiation
Iodine deficiency
Infiltrative disease
Total T4 measurement
Not adequate screen test
90% T4 bound to TBG
T3 Resin uptake (T3RU)
Used with total T4 and T3 to correct for changes in TBG levels
Free thyroxine index = total T4 X T3RU
Free T4 Measurement
Preferred screening test for thyroidi hormone levels
Thyroid Storm
Acute, life threatening form of thyrotoxicosis
Present with A-fib
- Fever
- delirium
Admit to ICU
Hyperthyroidism
Refers to causes of Thyrotoxicosis (increase T3 / T4 due to any cause) in which the thyroid overproduces thyroid hormone.
- Graves
- Plummer’s
- Toxic Adenoma
Hyperthyroidism
Hx / PE
Weight loss Heat Intolerance nervousness palpitations increase bowel frequency insomnia menstrual abnormalities
Hyperthyroidism
Dx and Tx
Initial test
- TSH level
then T4 levels
Tx-
1- Radioactive I^131 thyroid ablation
- Antithyroid drugs (methimazole or propylthiouracil) if radioactive iodine is not indicated
- Give Propanalol for adrenergic symptoms
Hypothyroidism
Hashimoto’s Thyroiditis is most common cause
- Anti TPO antibodies are +
-2nd most common cause Iatrogenic
Hypothyrodism
Hx / PE
Weakness Fatigue Cold intolerance Constipation Weight Gain Depression Menstrual irregularities Hoarseness Bradycarda Cold skin Decrease DTR
Hypothyrodism
TX
Uncomplicated - Levothyroxine
Myxedema Coma- IV levothyroxine and Hydrocortisone
Thyroiditis
Inflammed Thyroid Gland
Subtypes
- Subacute
- Radiation-induced
- Autoimmune
- Postpartum
- Drug Induced
Thyroditis
Hx / PE
- Subacute form presents with TENDER thyroid
- URI
Other forms
- Painless goiter
Thyroiditis
DX and Tx
Thyroid Dysfunction
Decrease uptake on RAIU
Tx- BB for hyperthyrodism
- Levothyroxine for Hypothyrodism
- Subacute- NSAIDS and is self limited
Thyroid Neoplasms
name them (4)
- Papillary
- Follicular
- Medullary
- Anaplastic
Thyroid Neoplasms
Hx / PE
Usually Asymptomatic
Hyperfunctioning nodules
+ Family History (especially medullary)
“Cold” nodules on Radionuclide scan
- Firm and fixed solitary nodules
- 70 y/o
Thyroid Neoplasms
DX
1st test- Fine Needle Aspiration (FNA)
2nd- TFT
3rd- Ultrasound (cystic or solid)
4th- Radioactive scan determines if HOT or Cold
(Cancer is usually Cold and solid)
HOT nodules are NEVER cancer and NOT biopsied
Thyroid Neoplasms
Tx
Benign FNA
- Physical exam / ultrasound
- trial of levothyroxine suppresion treatment
Malignant FNA
- Surgical resection
- radioiodine ablation following excision
Indeterminate FNA
- remove nodules by surgical excision
Anaplastic has a poor prognosis
Papillary Carcinoma
90% survive 10 years
75-80% of thyroid Cancers
Female-male Radio is 3:1
Slow growing tumor
Follicular Carcinoma
90% survive 10 years
17% of thyroid cancers
Medullary Carcinoma
80% survival at 10 years
6-8% of cancers
Found in Calcitonin- producing C cells
Anaplastic
10 % survival >3 years
<2% of thyroid cancers
Rapid enlarge and metastisizes
Multiple Endocrine Neoplasia (MEN)
MEN 1 (wermer's) MEN 2 (Sipple's) MEN 3 (Type 2B)
Autosomal-Dominant inheritance
MEN I
“P” Organs
Pancreas
Pituitary
Parathyroid
MEN Type 1 (Wermer’s)
- Pancreatic Islet Cell Tumors
- Parathyroid Hyperplasia
- Pituitary Adenomas
MEN 2
Sipple’s
- Medullary Carcinoma
- Pheochromocytoma
- Parathyroid Gland Hyperplasia
MEN 3
Or Men 2B
- Medullary Carcinoma
- Pheochromocytoma
- Neuromas
Marfanoid Habitus
Osteoporosis
Common metabolic bone disease
<2.5 bone mass
Osteoporosis
Dx
DEXA- GOLD Standard
- <2.5 SD below normal
Labs: markers of bone turnover
Xrays: global demineralization
Most common fracture- Vetebral
Osteoporosis
Tx
Calcium supplementation and Vit D
Weight bearing exercise
Bisphosphates
HyperParathyroidism
Primary cases- 80% cases due to Single Adenoma
15% parathyroid Hyperplasia
Secondary Cases- Phosphate Retention in kidney disease
Hyperparathyrodism
Hx / PE
most cases asymptomatic
Mild symptoms- Kidney stones (nephrolithiasis)
- bones
- abdominal groans
(Bones, stones and groans)
Psyciatric Overtones
- Fatigue
- depression
- anxiety
- Sleep issues
Hyperparathyroidism
Dx
Labs
- Hypercalcemia
- HypoPhosphatemia
- Hypercalciuria
Hyperparathyroidism
Tx
Parathyroidectomy if Symptomatic
HyperCalceimia - IV FLUIDS
- IV Bisphosphate & Calcitonin
Cushing’s Syndrome
Cause
- Hypersecretion of ACTH from pituitary adenoma
(HyperCortisolism)
Cushing’s Syndrome
Hx / PE
Presents with
- Hypertension
- Central Obesity
- Muscle Wasting
- Thin Skin
- Purple Striae
- Hirsutism
- Moon Facies
- Buffalo Hump
Exam
- Oligomenorrhea
- Growth Retard
- Depression
Cushing’s Dx
Begin with Screen
- 24 hr urine cortisol
or
- + low dose dexamethasone suppresion test is considered abnormal if A.M. cortisol is persistently elevated following overnight suppression
- Distinguish ACTH dependent from ACTH-independent causes
Cushing’s Tx
Surgical resection of hypersecretory source
HyperProlactinemia
Most common pituitary tumor
Hyperprolactinemia
Hx / PE
- Hypogonadism is manifested by infertility
- Oligomenorrhea or Amenorrhea
- Galactorrhea
- Gynecomastia
- Bitemporal Hemianopia
Dx- Serum prolactin >200 mg/mL
Hyperprolactinemia
Tx
1st line- Dopamine Agonist
(cabergoline or bromocriptine)
Surgery shoudl be considered when medical treatment failed
DI
Failure to concentrate urine as a result of central or nephrogenci ADH dysfunction
DI Subtypes? (2)
Central DI
Nephrogenic
Central DI
Posteriror pituitary fails to secrete ADH
Causes
- Tumor
- Ischemia (Sheehan)
- Traumatic cerebral injury
- Infection
Nephrogenic DI
Kidneys fail to respond to ADH
Causes
- Renal disease
- Drugs (Lithium, Demeclocycline)
DI
Hx / PE
Polydipsia
Polyuria
Persistent thirst (dilute urine)
Pt presents with Hypernatremia and Dehydration
DI Dx
Water deprivation test
Pt excrete high volume of dilute urine
Desmopression (DDAVP)- analog of ADH can be used to distinguish central from dephrogenic
- Central DDAVP will decrease urine outpoot and increase urine osmolarity
- Nephrogenic- DDAVP challenge will not significantly decrease urine output
DI Tx
Treat underlying cause
- Central DI- give DDAVP IV or oral
Nephrogenic- Salt restriction and water intake
SIADH
Hyponatremia that results from stimulated ADH release independent of serum osmolality
SIADH
Hx / PE
Associated with CNS disease (Head injury, tumor)
- pulmonary disease
- Ectopic tumor production
- Drugs
- Surgery
SIADH
Dx
Urine osmolality >50-100 mOsm/kg
Urinary sodium >20 mEq/L
SIADH
Tx
- Restrict fluid
- Hyponatremia <110 give hypertonic saline
- Demeclocycline - normalizes serum Na by antagonizing the action of ADH in collecting duct
Adrenal Managment
(Addisons)
4 S’s
Salt: 0.9% saline
Steroids: IV 100 mg q 8 h
Support
Search: for underlying conditions
Phenochromocytoma
Rule of 10’s
Dx
10% Extra-adrenal 10% Bilateral 10% Malignant 10% occur in children 10% familiar
Dx- Metanephrines (24 hr) and CT/MRI
